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InflaRx CEO Niels Riedemann, MD, discusses the issue that arose and cost the company some of its data for its investigational therapy being studied for SARS-CoV-2-induced acute respiratory distress syndrome (ARDS).

Cautionary Tale Associated in Trial With Rare Error in Cox Regression 

Along with a 1 reported case in Massachusetts, the

New Hampshire Department of Health and Human Services (DHHS) has confirmed a person infected with eastern equine encephalitis (EEE) has died. The public health agency said the person was hospitalized due to severe central nervous system disease. The last reported human EEEV infection in New Hampshire was in 2014, when DHHS identified 3 human infections, including 2 fatalities. In the same statement, DHHS mentions there has been 1 confirmed case in Vermont this summer.

On August 16, the Massachusetts Department of Public Health (MDPH) released a statement discussing the confirmation of the first human case of EEE in the state this year. The confirmed case was discovered in an 80 year old man who was exposed to the vector borne disease in Worcester County. As a result, the risk level in the local communities of Douglas, Oxford, Sutton, and Webster has been raised to critical, and in Dudley, Northbridge, and Uxbridge the risk is increased to high.

Additionally, the neighboring communities of Auburn, Charlton, Grafton, Leicester, Mendon, Millbury, Millville, Southbridge, and Upton are now considered at moderate risk according to MDPH.

“This is the first time we have seen a person infected with EEE in Massachusetts since 2020,” Public Health Commissioner Robbie Goldstein, MD, PhD, said in a statement. “EEE is a rare but serious disease and a public health concern. We want to remind residents of the need to protect themselves from mosquito bites, especially in areas of the state where we are seeing EEE activity.

Though very rare, EEE is serious and a potentially fatal disease that can affect people of all ages. EEE is generally spread to humans through the bite of an infected mosquito. There were 12 human cases of EEE in Massachusetts in 2019 with 6 deaths, and 5 human cases with 1 death in 2020. There were no human cases of EEE in Massachusetts in 2021, 2022, or 2023.

EEE has a fatality rate of 33% to 70%, with most deaths occurring 2–10 days after the onset of symptoms.

In addition to a high mortality rate, long-term physical and mental complications, including permanent neurological deficits have been identified in many people who survive EEE.

Plymouth is approximately 40 miles south of Boston along the coast, and Worcester County is in the middle of the state, so the 2 areas are not in close proximity, but due to the elevated risk locally, the town of Plymouth decided to take action in response to outdoor parks. As of last Friday, all town public parks and fields are close daily from dusk until dawn.

“As Mass DPH has now elevated Plymouth’s EEE risk status to high, it is important to take extra precautions when outdoors and follow state and local health guidelines to avoid unnecessary risk to exposure to EEE. The health and safety of our community, residents, and visitors remain our priority,” Plymouth’s Commissioner of Health and Human Services, Michelle Bratti, said in a statement.

According to the Centers for Disease Control and Prevention (CDC) most people who are infected with the virus do not develop symptoms; however, for those that do, the date from the bite to the onset of the illness is 4 to 10 days. EEE can also result in fever or neurologic disease. The type of illness will depend on the age of the person and other factors. Those who are infected can develop meningitis.

There are no FDA-approved treatments for EEE and for patients who develop severe cases, they can be hospitalized to receive supportive treatment.

Over the weekend, MDPH detailed plans of spraying for mosquitos including aerially in areas of Plymouth County, and truck-mounted spraying in parts of Worcester County. As of Saturday, 10 communities in Massachusetts were raised to high or critical risk for EEE virus.

“The risk from EEE is high in parts of Plymouth County and critical in parts of Worcester County,” State Epidemiologist Catherine M. Brown, DVM, said in a statement. “In addition to recommending that people use mosquito repellent with an EPA-registered active ingredient and clothing to reduce exposed skin, we also recommend that evening outdoor events be rescheduled to avoid the hours between dusk and dawn. The mosquitoes most likely to spread EEE are most active during the dusk to dawn hours.”

There are preventative strategies to avoid EEE, and the MDPH has listed such measures 

For those who live in Massachusetts and want more information on EEE, it can be found 

 or by calling the DPH Division of Epidemiology at 617-983-6800.

1.NH DHHS Identifies Person Infected with Eastern Equine Encephalitis Virus in New Hampshire.The New Hampshire Department of Health and Human Services. August 27, 2024. Accessed August 28, 2024.
https://www.dhhs.nh.gov/news-and-media/nh-dhhs-identifies-person-infected-eastern-equine-encephalitis-virus-new-hampshire
2. State health officials announce season’s first human case of Eastern Equine Encephalitis in Massachusetts. MDPH. August 16, 2024. Accessed August 27, 2024.
https://www.mass.gov/news/state-health-officials-announce-seasons-first-human-case-of-eastern-equine-encephalitis-in-massachusetts
3.Plymouth to Close all Public Parks and Fields from Dusk to Dawn. Town of Plymouth. August 23, 2024. Accessed August 27, 2024. PDF.
4. Eastern Equine Encephalitis: Symptoms, Diagnosis, and Treatment. CDC. May 15, 2024. Accessed August 27, 2024.
https://www.cdc.gov/eastern-equine-encephalitis/symptoms-diagnosis-treatment/index.html
5. State officials announce plans to spray for mosquitoes in sections of Worcester and Plymouth counties due to EEE. MDPH. August 24, 2024. Accessed August 27, 2024. 
https://www.mass.gov/news/state-officials-announce-plans-to-spray-for-mosquitoes-in-sections-of-worcester-and-plymouth-counties-due-to-eee



The town of Plymouth decided to prohibit people from using the parks from dusk to dawn due to concerns over eastern equine encephalitis after a man contracted the rare disease in the state.

Concerns Over Mosquito-Borne Illness Causes Massachusetts Town to Create Curfew for Parks, Spraying in Counties

Last week, 20 HIV and hepatitis organizations filed an amicus brief with the Supreme Court in support of the US government’s position in Kennedy v. Braidwood Management, which challenges the Affordable Care Act’s (ACA) preventive services coverage requirement.

The preventative services coverage requires private insurers to include a range of testing, including for HIV and hepatitis B and C, as well as preventative offerings, including PrEP for HIV and vaccinations for hepatitis A and B, and counseling for sexually transmitted infection prevention.

This court case originated in 2023 when 6 Christian-owned businesses in Texas challenged the ACA's preventive services requirement, arguing that the PrEP coverage requirement violated their religious rights.

"Removing access to evidence-based preventive measures will have a devastating impact, not only on those at risk for acquiring HIV and hepatitis but also the population at large,” the HIV and hepatitis organizations wrote in the brief. 

One of the organizations who filed the brief, the HIV+Hepatitis Policy Institute,

“Coverage of no-cost preventive services, including HIV and hepatitis testing, along with PrEP, now rests with the highest court in the land. In our brief, we laid out the critical role testing plays in linking people to life-saving medications and, in the case of hepatitis C, curative treatment, along with the importance of people knowing if they have an infectious disease. We describe the growing importance of PrEP in preventing HIV, including long-acting PrEP drugs, which are almost 100 percent effective in preventing HIV,” Carl Schmid, executive director of the HIV+Hepatitis Policy Institute, said in a statement.

 "We emphasize that coverage of preventive services by private insurers will help end HIV and hepatitis, and losing them would certainly damage the public health of our country and increase medical costs.”

According to HIV.gov, PrEP is highly effective at preventing HIV when taken as indicated. In fact, this form of prevention has been shown to reduce the risk of HIV infection from sex by about 99% when taken as prescribed. And even among people who inject drugs, it reduces the risk by at least 74% when taken as indicated.

Along with the HIV + Hep Policy Institute, the other groups signing on to the brief are: ADAP Advocacy Association, AIDS Alabama, American Academy of HIV Medicine, Caring Ambassadors Program, Community Access National Network, Community Liver Alliance, Community Resource Initiative, Fast Track Cities Institute, Frannie Peabody Center, Georgia AIDS Coalition, Global Liver Institute, Hepatitis B Foundation, Hep B United, Housing Works, International Association of Providers of AIDS Care, Latino Commission on AIDS, NMAC, SIECUS, and Vivent Health.

References
1. 20 HIV & hepatitis organizations urge the U.S. Supreme Court to protect preventive services coverage.HIV and Hep Policy Institute. February 25, 2025. Accessed March 4, 2025.
https://hivhep.org/press-releases/20-hiv-hepatitis-organizations-urge-the-u-s-supreme-court-to-protect-preventive-services-coverage/
2. Preventative Care Benefits for Adults. Healthcare.gov. Accessed March 4, 2025.
 https://www.healthcare.gov/preventive-care-adults/
3. Pre-Exposure Prophylaxis. HIV.gov February 7, 2025. Accessed March 4, 2025.
https://www.hiv.gov/hiv-basics/hiv-prevention/using-hiv-medication-to-reduce-risk/pre-exposure-prophylaxis

Twenty organizations asked the high court to consider the federal government’s position on pre-exposure prophylaxis (PrEP) and HIV and hepatitis testing. 

HIV and Hepatitis Groups Ask Supreme Court to Protect PrEP, Testing

Robert Allen, MD, discussed how Pemgarda continues to offer protection for immunocompromised individuals against emerging SARS-CoV-2 variants.

Invivyd's Pemgarda Neutralizes Leading SARS-CoV-2 Variants

Invivyd announced that new in vitro data confirms Pemgarda (pemivibart) continues to effectively neutralize the dominant SARS-CoV-2 variant XEC. This underscores the monoclonal antibody's ongoing effectiveness despite the virus’s evolving variants.

The CDC reports that XEC and KP311 now account for 69% of circulating SARS-CoV-2 variants in the US as of December 21, 2024. Invivyd’s findings highlight the potential of Pemgarda as a crucial preventive treatment, especially for immunocompromised individuals who remain vulnerable to severe illness from COVID-19.

In our interview with Robert Allen, PhD, Invivyd's chief scientific officer, he discussed how Pemgarda continues to target the stable receptor-binding domain (RBD) of the spike protein of SARS-CoV-2, despite the virus's ongoing mutation, "The antibody binds to a specific region of the target, the spike protein’s receptor-binding domain (RBD). This region has remained largely unchanged, even after the emergence of Omicron about three years ago. Because this region hasn’t changed significantly, we are able to continue binding and neutralizing the virus, even with the rise of new variants like XEC."

This stability makes Pemgarda effective in neutralizing the current XEC variant and particularly valuable for immunocompromised individuals, who may not generate a strong immune response to vaccines, "Pemgarda remains effective for immunocompromised individuals because the antibody can access the virus and neutralize it, reducing the clinical impact on these individuals,” Allen said

Immunocompromised individuals can struggle to respond to traditional COVID-19 vaccines. As a result, they remain at a higher risk for severe illness. Pemgarda provides a crucial alternative by offering direct protection through an external antibody response. Allen said, "Immunocompromised patients typically cannot generate a strong immune response like immunocompetent individuals. For example, if their B cells, which are responsible for producing antibodies, aren’t functioning properly, they can’t produce a robust response to a vaccine."
In these cases, Pemgarda steps in to provide that protection, "Pemgarda is an antibody that protects against the pathogen, in this case, SARS-CoV-2. In the absence of a fully functional immune response, Pemgarda can step in and neutralize the virus."

This approach augments the compromised immune system, offering essential protection to those who cannot generate it on their own, "Even without a fully functioning immune system, Pemgarda supplies an antibody that neutralizes the pathogen, providing critical protection for immunocompromised individuals."

As new SARS-CoV-2 variants continue to emerge, Pemgarda remains a crucial tool for protecting vulnerable populations, particularly those who are immunocompromised. With consistent neutralizing activity against variants like XEC, Pemgarda offers an important option for individuals who may not respond to vaccines, ensuring they are better protected against severe COVID-19 outcomes.

In part 2 of this interview, we discussed the ongoing efforts to monitor the virus’s impact and Invivyd's next antibody: 

Invivyd Tracks SARS-CoV-2 Evolution, Prepares for Future Variants

Press Release. Invivyd Announces Continued Neutralizing Activity of PEMGARDA™ (pemivibart) Against Dominant SARS-CoV-2 Variant XEC. January 10, 2025. Accessed February 3, 2025. https://investors.invivyd.com/news-releases/news-release-details/invivyd-announces-continued-neutralizing-activity-pemgardatm-0 

Robert Allen, PhD, discusses how Pemgarda’s stability in targeting the spike protein's receptor-binding domain offers crucial protection, including immunocompromised individuals.





Pemgarda Maintains Effectiveness Against Evolving SARS-CoV-2 Variants

In this week’s Centers for Disease Control’s (CDC) 

 data show limited efficacy in preventing emergency department visits for adults and a better efficacy in immunocompromised adults.

“Vaccine effectiveness (VE) of 2024–2025 COVID-19 vaccine was 33% against COVID-19–associated emergency department (ED) or urgent care (UC) visits among adults aged ≥18 years and 45%–46% against hospitalizations among immunocompetent adults aged ≥65 years, compared with not receiving a 2024–2025 vaccine dose. VE against hospitalizations in immunocompromised adults aged ≥65 years was 40%,” the authors wrote.

Last year, the CDC’s Advisory Committee on Immunization Practices (ACIP) recommended 2024–2025 COVID-19 vaccination with an FDA-authorized or approved vaccine for all persons aged 6 months or older. Subsequently, the FDA approved monovalent 2024–2025 COVID-19 vaccines by Moderna and Pfizer-BioNTech and authorized a monovalent 2024–2025 COVID-19 vaccine by Novavax for persons aged 12 years of age and older.

ACIP recommended a second vaccine dose for all adults aged ≥65 years and for persons aged 6 months–64 years who were moderately or severely immunocompromised and were 6 months removed from their last dose of the 2024–2025 COVID-19 vaccine. Additionally, ACIP recommended that persons aged ≥6 months who are moderately or severely immunocompromised may receive additional doses of 2024–2025 COVID-19 vaccine.

groups: the Virtual SARS-CoV-2, Influenza, and Other Respiratory Viruses Network (VISION), and the Investigating Respiratory Viruses in the Acutely Ill (IVY) Network.

VISION is a multisite electronic health care records (EHR)–based network that encompasses 373 ED/UCs and 241 hospitals across 8 states. Eligible patients are those who have received molecular or antigen testing for SARS-CoV-2 during the 10 days preceding, or ≤72 hours after, an eligible ED/UC encounter or hospital admission. COVID-19 vaccination history is ascertained from state or jurisdictional registries, EHRs, and, in a subset of sites, medical claims data.

The IVY network consists of 26 hospitals in 20 states. They enroll adults aged ≥18 years with COVID-19–like illness

 who also receive molecular or antigen testing for SARS-CoV-2 within 10 days of illness onset and within 3 days of hospital admission.

The investigators point out that individuals who received the latest vaccine ≥7 days before the encounter index date (VISION) or illness onset date (IVY) were considered vaccinated. Conversely, those who had not received the 2024-2025 vaccine—regardless of previous COVID-19 vaccination or infection history—were considered not vaccinated and served as comparators.

The investigators point out that COVID-19–associated hospitalizations were relatively low compared with those during previous years, precluding estimation of vaccine efficacy against critical illness such as admission to the intensive care unit, invasive mechanical ventilation, or death. They explained that VE against these outcomes has been higher and more sustained than that against less severe outcomes in past years. 

With both lower hospitalization and vaccination rates, vaccine effectiveness could not be estimated for children and adolescents between the ages of 5–17 years for either outcome, and for adults aged 18–64 years against hospitalization.

Despite the aforementioned study limitations and these lower VE rates, the investigators do see some protection afforded as a positive benefit.

“In this analysis, receipt of a 2024–2025 COVID-19 vaccine dose provided additional protection against COVID-19–associated ED/UC visits and hospitalization among adults with and without immunocompromise. These results support CDC and ACIP recommendations for 2024–2025 COVID-19 vaccination,” they wrote.

Reference
Link-Gelles R, Chickery S, Webber A, et al. Interim Estimates of 2024–2025 COVID-19 Vaccine Effectiveness Among Adults Aged ≥18 Years — VISION and IVY Networks, September 2024–January 2025. MMWR Morb Mortal Wkly Rep 2025;74:73–82. DOI: http://dx.doi.org/10.15585/mmwr.mm7406a1

The interim results demonstrated a slightly better vaccine effectiveness in individuals who are immunocompetent vs immunocompromised individuals. 

The 2024-2025 COVID-19 Vaccines Show Limited Efficacy in Adults 

Paul Offit, MD, says measles outbreaks are the first sign that childhood vaccination rates are starting to decline. 

Measles: The Canary in the Coalmine for Childhood Vaccine Decline

In the fall of 1990, the city of Philadelphia started seeing cases of measles. It eventually became an epicenter for a major measles outbreak that went well into 1991. It caused more than 1400 cases, with a majority in unvaccinated children, and led to 9 children dying.

Paul Offit, MD, the director of the Vaccine Education Center and an attending physician in the Division of Infectious Diseases at Children's Hospital of Philadelphia (CHOP), treated several children involved in that outbreak.

“Both children's hospitals [in Philadelphia] were utterly overwhelmed with that virus. You had to make decisions about who would or wouldn't come into the hospital,” Offit told 

.

Within that outbreak, 486 cases and 6 measles-associated deaths were reported to the Philadelphia Health Department from members of 2 fundamentalist church communities. The 2 communities promoted "a reliance on prayer, not medical care, to cure disease."

Flash forward to today, and Texas is in the midst of a measles outbreak largely amongst the Mennonite community.

 On February 25, the Texas Department of State Health Services announced that there are now 124 cases that have been identified since late January. Eighteen of those patients have been hospitalized, and 5 of those cases are in vaccinated individuals. The rest are unvaccinated, or their vaccination status is unknown.

Additionally, there are 9 cases in New Mexico.

“[Measles] is not a disease you want to get. Every year, before there was a vaccine, about 50,000 children would be hospitalized and 500 would die."


“I do expect to see greater amounts of measles outbreaks in the coming year for this reason: the CDC recently reported that more parents are choosing nonmedical vaccine exemptions for their children than ever before," Offit said. "There are a number of jurisdictions where the number of children who are now at risk for measles has become so great that we have lost herd immunity. So, I think what you're seeing in West Texas right now that has spilled over into New Mexico is probably a sign of more to come.”

Offit points out that for the younger generation of clinicians, who have little to no experience in seeing and treating measles, there are some clinical care nuances and considerations when dealing with measles.

“Young doctors really haven't seen measles, and so they may not be so quick to diagnose it," he explained. "The other thing that I worry about is that they may be quick to bring children into the hospital who don't necessarily need to be hospitalized because you don't want the measles virus in your hospital,” Offit said. “It's very hard to contain measles. It has a contagious index—meaning how many people you infect during a typical day—that is 5 times greater than COVID... When you bring measles into the hospital, there are a lot of children who are immune-compromised and, therefore, may be at greater risk of measles.”

Offit does understand parents’ concerns around the number of childhood vaccines but cautions families about not getting these vital immunizations. “We ask a lot of parents in this country; we ask them to get vaccines against 14 different diseases in the first few years of life, which can mean as many as 25 shots during that time. It can mean as many as 5 shots at 1 time to prevent diseases that most people don't see, using biological fluids that most people don't understand. So, I think pushback on vaccines is understandable, but know this: the canary in the coal mine—whenever you start to see vaccine rates erode—is measles. It's always the first one to come back, because it's not only the most contagious vaccine-preventable disease; it is the most contagious infectious disease.”

He stresses that measles can make children very sick, causing a high fever, photophobia, and dehydration, and it can lead to more serious health issues, including pneumonia and a rare chronic measles disorder, subacute sclerosing panencephalitis (SSPE), a neurological disease that can be fatal.

“This is not a disease you want to get. Every year, before there was a vaccine, about 50,000 children would be hospitalized and 500 would die,” he said.

Measles is a highly contagious respiratory illness that can be life-threatening. During an outbreak, estimates suggest that 1 in 5 infected people will be hospitalized, and 1 in 20 will develop pneumonia. In rare cases, measles can lead to swelling of the brain and death, and can cause pregnancy complications.

Measles can be transmitted via direct contact with infectious droplets and/or by airborne spread via breaths, coughs, or sneezes. Those infected experience symptoms onset within 1-2 weeks post-exposure, with early symptoms including high fever, cough, runny nose, and red, watery eyes. A telltale rash will often break out with flat, red facial spots that spread down the neck and torso. The contagious period tends to be approximately 4 days prior to the rash and lasts until 4 days post-rash. Those who believe they have measles or may have been exposed should isolate themselves and call their health care provider before arriving to be tested, according to state and federal guidance.

Reference
1. 1990–1991 Philadelphia measles outbreak. Wikipedia. Accessed February 26, 2025.
https://en.wikipedia.org/wiki/1990%E2%80%931991_Philadelphia_measles_outbreak
2. Texas announces first death in measles outbreak. Texas Department of State Health Services. February 26, 2025. Accessed February 26, 2025. https://www.dshs.texas.gov/news-alerts/texas-announces-first-death-measles-outbreak
3. Measles Outbreak – Feb. 25, 2025. Texas Department of State Health Services. February 25, 2025. Accessed February 26, 2025.
https://www.dshs.texas.gov/news-alerts/measles-outbreak-feb-25-2025




On the heels of the first death in an ongoing US-based measles outbreak, Paul Offit, MD, discusses how outbreaks are the first sign that childhood vaccination rates are starting to decline.

Measles: The Canary in the Coal Mine for Childhood Vaccine Decline

Researchers have identified measles virus genotype D8 in wastewater samples from Brussels, Belgium, raising concerns about silent transmission in the region. The findings highlight the growing role of wastewater surveillance in tracking viral circulation and informing public health interventions. The study analyzed wastewater from Belgian treatment plants and detected measles virus in samples collected from Brussels North. Genetic sequencing confirmed a match with 15 known regional measles cases, suggesting broader virus circulation beyond reported infections.

According to the studies researcher and lab manager at Clinical & Epidemiological Virology at KU Leuven, Elke Wollants, “Wastewater surveillance offers a non-invasive way to monitor virus circulation within a population, independent of clinical testing. This is especially valuable for diseases like measles, where not all cases are reported.” By combining wastewater surveillance with viral genotyping, scientists can trace the origins of a virus and its transmission pathways. “Last year, it was D8 from Romania; this year, we have B3 from Morocco,” Wollants noted.

The ability to detect outbreaks early enables more targeted public health responses. “Integrating wastewater surveillance into public health strategies allows for early detection of outbreaks, enabling targeted responses such as localized vaccination campaigns to prevent further spread,” Wollants added.

Challenges in Estimating Cases from Wastewater Data

Despite its potential, accurately estimating the number of active measles cases from wastewater remains a challenge. “The main challenge is quantifying the number of infected individuals based on viral concentrations in wastewater. There is limited data on how much measles virus an infected person sheds and through which bodily fluids,” Wollants explained. Factors such as dilution effects and variations in sewer networks can further complicate measurements. Advancements in research, including improved models and better understanding of viral shedding patterns, are needed to refine these estimates.

The detection of measles virus in wastewater provided an early warning before a significant increase in confirmed cases. “This allowed public health authorities to respond more quickly by alerting general practitioners and launching targeted awareness campaigns,” Wollants said. Identifying genotype D8, already circulating in Europe, emphasized the need to boost vaccination efforts among at-risk populations.

As part of the response, additional vaccination campaigns were organized, and awareness initiatives were expanded. “To further raise awareness, our findings were shared on X, and the message was immediately picked up by local newspapers, TV, and radio,” Wollants noted. The media coverage significantly increased public engagement, prompting many people to check their immune status and seek vaccination where needed.

The study on measles virus genotype D8 detected in Brussels wastewater relates to the measles outbreak in 

 by highlighting the potential for undetected transmission. In Belgium, researchers identified D8 in wastewater samples and confirmed a match with 15 known cases, suggesting broader circulation. In Texas, cases reached 58 total, with 13 hospitalizations and four cases in vaccinated individuals.

 Wastewater surveillance detected the virus before major case spikes in Belgium, showing how early warning systems could support targeted interventions in Texas.

Wollants also mentions, "Measles is making a comeback in Europe," showing that this is a global issue. These findings underscore the role of wastewater surveillance in infectious disease monitoring, offering an approach to preventing outbreaks before they escalate.

1. Rector A, Bloemen M, Hoorelbeke B, Van Ranst M, Wollants E. Detection of measles virus genotype D8 in wastewater of the Brussels Capital Region, Belgium. 

 February 17, 2025. Accessed February 19, 2025. doi:10.1002/jmv.70251 

2. Abene S. Measles Outbreak in Texas Expands to 58 Cases, Hospitalizations Increase. 

Published February 18, 2025. Accessed February 19, 2025. 

https://www.contagionlive.com/view/measles-outbreak-in-texas-expands-to-58-cases-hospitalizations-increase

Elke Wollants explains how wastewater surveillance in Belgium provided an early warning for measles outbreaks, offering insights into broader virus circulation.

Niels Riedemann, MD

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