Immunization recommendations for kids involve a variety of health experts

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center.

I'm your host, Amber Smith.

Recommended childhood vaccines start soon after birth and continue into the teens. Today I am talking about the childhood vaccination schedule with a pediatrician who's been in practice for 40 years. Dr. Steven Blatt is a professor of pediatrics at Upstate and the medical director of the general pediatrics division.

Welcome back to "The Informed Patient," Dr. Blatt.

Steven Blatt, MD: Thank you Amber, and thanks for inviting me.

Host Amber Smith: Can you start by telling us how the childhood vaccination schedule is created and maintained? Is it the government or is it the American Academy of Pediatrics?

Steven Blatt, MD: I think that's a crucial question because everybody's worried, where do these recommendations come from? And over the years, the various groups in the country developed what I think is a great way to develop a schedule.

First of all, the organizer of all this is the federal government, the Centers for Disease Control, the CDC, and they have the Advisory Committee on Immunization Practices. And that's comprised of experts not only from the CDC, but also expert representatives from all of the major health care providers in the country. So that includes the AAP, the American Academy of Pediatrics, as well as our colleagues from the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, or ACOG, the American College of Nurse-Midwives, the American Academy of Physician Associates and the National Association of Pediatric Nurse Practitioners. And I think I left out the group representing the internal medicine specialists (the American College of Physicians). So it's representatives from all of the specialties who actually do the work and administer vaccines.

Host Amber Smith: How did it begin and when did it begin?

Steven Blatt, MD: I think many years ago it was more like the Wild West, where each group decided what their specialists were going to do and came up with recommendations. And I think the unified schedule and this unified group came out probably about 25 years ago, and it's grown in membership. Our colleagues from nurse practitioners' and physician associates' and nurse-midwives' organizations are somewhat newer, so they were incorporated more recently, but I think over the years it's been meant to be an inclusive group for a few reasons.

One was to get the best expertise from everybody, because everybody does things a little differently and has a little bit different view of patient care, but also to be inclusive. And I think most importantly, we wanted to send one message. We didn't want the pediatricians to say one thing, and the family practitioners or the obstetricians to do something a little bit differently.

We wanted the medical profession as much as possible to speak with one voice, and I think we've been very successful in this.

Host Amber Smith: Do you know how many vaccines were on the first schedule 25 years ago?

Steven Blatt, MD: When I was a resident (doctor in training), and I started my residency, my internship, here at Upstate in 1983, there were just a handful of vaccines we had. In one needle we had diphtheria, tetanus and pertussis, DTP, and then we had polio vaccine, and then measles, mumps and rubella. So back when I was a student and resident, it was very easy to pass a test on what vaccines do we have to give, because there were just a handful of them. Now, there's a lot, lot more.

Host Amber Smith: A lot, lot more. It looks like it's a full chart. I mean, it goes on to a whole page.

Steven Blatt, MD: Yeah. And not only that, it gets very confusing. The actual number of vaccines that a child will get from birth to kindergarten varies a little bit from office to office because there are some different preparations that people could use and different combinations.

But in our office, it would be 21 different administrations of vaccines over 16 visits. So there's a lot of immunizations and a lot of visits.

Host Amber Smith: Does the schedule change every year or potentially change every year?

Steven Blatt, MD: It's more the latter. It potentially changes every year. The biggest changes in the last 10 or 15 years have been when there've been new vaccines that have come online which didn't exist in the past.

About 15 years or so ago, we started using meningococcal vaccine, and meningococcus causes a terrible, terrible infection, causing meningitis. It could lead to just horrific morbidity, which means really bad illness and even death. So when that came out, we added meningococcal vaccine. Rotavirus, which is an oral vaccine, it's been a wonderful addition that came out about 10, 15 years ago. It's oral, it's given to young infants and prevents this terrible, terrible diarrhea that would cause a lot of hospitalization throughout the country. And rotavirus is one of the leading causes of childhood death in the world, but not in this country because we have the rotavirus vaccine.

Host Amber Smith: What is the first vaccine? Because babies get vaccinated before they go home from the hospital, right? What do they get before they go home?

Steven Blatt, MD: There are two immunizations that we now offer in the nursery. The first one is hepatitis B vaccine, and hepatitis means an infection or an inflammation of the liver. And the first one is given at birth. And the reason for that is scientific, medically scientific, and that is, there are women that have hepatitis B, and so you want to protect the baby immediately at birth. And we know it's safest to start just giving it to all babies at birth. Some parents defer the immunization to a little bit later, and we do that.

And then about a year and a half ago, we have a new immunization called nirsevimab. Amber, you're probably familiar with nirsevimab because one of the, I think the very first patient in the world to get it, were patients of (Upstate's) Dr. Joe Domachowske, who was one of the lead researchers in it. And nirsevimab prevents respiratory syncytial virus.

So RSV, people may be familiar with it because there are commercials for adults, for the elderly, to get RSV vaccine. This is a different immunization. This one is meant for infants up to 8 months of age. And RSV is the biggest reason why infants get admitted to the hospital in the first year of life.

So we give that in the nursery because the time where they get the sickest is in the first two months of life. So we want to give that right away.

Host Amber Smith: And then there's some in the late teens too, right?

Steven Blatt, MD: I mentioned one of them, the meningococcal vaccine, and that's given before the teen years, but the second dose is given after age 16. And then there's another meningococcal vaccine, a different strain, called meningococcus B, and that is the type of meningitis that every so often there are outbreaks, typically in colleges, where college students, there'll be six cases in one university where they'll get meningitis.

So those are two that are for younger kids and then going up in the later teens. And then there's another vaccine called human papillomavirus vaccine, or HPV. And the thing that is, I think, pretty amazing about HPV vaccine is, it prevents a virus that could cause cancer, and it could cause cancer more often in women. It could cause cervical cancer, but it could also cause cancer in males. And when that vaccine first came out about 20 years ago, we didn't start it until after age 15, but we've always known it worked better in younger kids. So now we start giving HPV vaccine, the current recommendation is at age 11, but a lot of the medical experts say to give it even earlier, down to age 9, so many offices, including ours, we are giving the HPV vaccine, the first dose, at age 9, and we anticipate that the vaccine schedule will change in the near future to also say, down at age 9.

Host Amber Smith: Do these childhood vaccines confer lifelong immunity against all of these diseases?

Steven Blatt, MD: That is often the key, key question.

Many of them are lifelong immunity, but not all of them. I think people are very familiar with the idea that you need a tetanus shot every so often. And the first tetanus vaccine we start giving at 2 months of age. Pertussis vaccine, or whooping cough, that vaccine in the '90s was purposely reformulated because the old formulation had a lot of extraneous parts of the pertussis bacteria that were left in the vaccine, and that would cause a lot of side effects, such as fevers and pain and some other things.

So that vaccine was purified, and those side effects pretty much disappeared. The downside is the protection doesn't last that long. It's only a number of years, five years, maybe 10 years. So what happens now is that with some of the vaccines, like the tetanus shot, we give a little bit of pertussis in there to give people a boost of the pertussis, or whooping cough, vaccine.

And also, when mothers-to-be are pregnant, they get a pertussis vaccine to protect their newborn baby. And not only that, but the recommendation is that the other adults in the home, such as the father or the grandparents, they also get a pertussis vaccine, so it'll prevent that adult from getting pertussis and giving it to the baby.

So not all of the vaccines are lifelong, but many of them have very good immunity for a long time.

Host Amber Smith: This is Upstate's The Informed Patient" podcast I'm your host, Amber Smith. . I'm talking with professor of pediatrics Dr. Steven Blatt, who oversees Upstate's general pediatrics division. We're talking about childhood vaccines.

So let's talk about vaccine development. How does a vaccine make its way onto the vaccine schedule?

Steven Blatt, MD: There's a lot that goes on. You could spend a couple hours talking about that, but I don't think anybody would be around at the end of the broadcast for that one. But, very briefly, the vaccine manufacturers come up with a new vaccine that they think is going to work, and then, eventually, it'll go to the FDA, the Food and Drug Administration, and then when they approve it and say, yes, this is a vaccine, it works, it's safe, then it'll go on to that committee from the CDC, the Advisory Committee on Immunization Practices, and that committee will look at the vaccine to see: Does this work as well as we think it does? Does it protect against important diseases? Is it cost-effective to use?

And then once it's all agreed, it will be put on the vaccine schedule. So there is a long process, and again, It has to pass a lot of scientific examination By people really focusing on the science to make sure it's good science, to make sure the vaccine does what the manufacturer wants it to do and it does so with minimal side effects. And then it goes to a committee, which includes scientists, but also more of a clinical look at it from people who are looking at the patient and the disease to see how it fits in.

Host Amber Smith: So it's already been vetted for safety before it ever comes to this committee to be put on the schedule.

Steven Blatt, MD: It's been vetted for safety. But I do want to be clear: I think everyone, every group of people in the whole process for vaccines, going from the creation of the vaccine to implementation, want it to work, and they want it to be safe, but the reality is, when there's a study that's done, it might have a large study, might have 10,000 subjects, which seems like a lot of people, but it's not until a vaccine is put into use and given out to tens of thousands, hundreds of thousands and even millions of people that we really know for sure how safe it is, because if you're 10,000 people that get the vaccine, and there's no side effects, well, there could be a side effect on the next dose. And it's still one in 10,000, which may not sound like a lot unless it happens to you.

I always like to make it local. So in Syracuse there are approximately 100,000 kids, a little more, a little less. So, if something is one in 10,000, that means 10 kids would have a side effect from the vaccine, and you know, that's 10 kids too many, but we are not able to detect those uncommon and rare events until it's given out to hundreds of thousands of patients. And you may need millions for even rarer events. So even after the vaccine is in use, there's a lot of post-marketing surveillance. There are different safety systems.

One is the Vaccine Adverse Event Reporting System, or VAERS, V-A-E-R-S. And that's so that pediatricians or family practitioners or others could report to this website and say, "I had a patient who may have had a side effect or an event from a vaccine," and it could be investigated. And that's one of the ways we know when something unexpected has happened. And that does pick up problems from time to time. So there's a lot of effort to make things safe, but there's nothing 100% safe. One of the things that people on the Advisory Committee for Immunization Practices do is, they look at the potential for side effects, but they also look to see how bad the actual disease is. So if you look at meningitis, that's a devastating illness, and it often leads to death. So we want a vaccine for that, and that's what the balance is. We also want them to be safe, and we don't want them to cause problems down the road. So it's a complicated process, and there's a lot of time and energy spent on it to try to get it correct, right, as much as possible.

Host Amber Smith: Let me ask you, what's the difference between live and killed virus vaccines?

Steven Blatt, MD:

A lot of the vaccines that we have have nothing living inside of it. So for example, a hepatitis B vaccine. That vaccine is made actually in a lab. It doesn't come from anything live. It's just made from different components. And we know that's a very safe vaccine.

Steven Blatt, MD: If people were to talk to their grandparents, my grandparents' age and my parents' age, people who were around in the '50s and before, the biggest fear of any parent back then was to contract polio, and polio was from a virus. President Roosevelt, Franklin Roosevelt, contracted polio as a young man, left him partially paralyzed.

And polio vaccine came out in two different types. One was a killed polio vaccine, and the other was a live vaccine. The killed polio vaccine was very effective against polio, but everybody had to get a shot, and people don't like shots, so we had the oral polio vaccine, which they took the polio virus, and they weakened it, so you give a few drops of the polio vaccine to somebody to drink, and it would cause a very low-level infection and then protect them against polio. And polio vaccine, the oral variety, worked very well, except there were about 10 cases a year in this country where somebody would get polio from the polio vaccine. And that was unacceptable, so probably about 20 years ago or so, we stopped using oral polio in this country. We only use the killed vaccine. We no longer use the live vaccine.

So currently we do have some live vaccines and that includes chicken pox vaccine and measles right now is in the news. The measles vaccine is a live vaccine and those vaccines, are very safe. And yet there are times where people will get a chicken pox vaccine, which is live. It's a very weakened chicken pox virus vaccine, and sometimes the kids will get a couple of chicken pox (spots), like three chicken pox (spots), and it's very protective and it doesn't cause any problems.

But just to be safe for those live virus vaccines, we don't give them to people who are immunocompromised. So for example, if there was a child who had cancer and was immunocompromised from the cancer treatment, or there was an adult in the house who was immunocompromised, we wouldn't use, perhaps, depending on the circumstance, the measles vaccine or the chicken pox vaccine because it may cause disease.

The rotavirus vaccine that we use is live, but that doesn't really cause anything significant in terms of side effects.

So we do have some live vaccines, but even though they're live, they're still safe. Although I do want to point out the live polio vaccine, which we no longer use, did cause some real problems in rare cases.

Host Amber Smith: Are you, as a pediatrician, seeing parents who don't want their kids to be vaccinated?

Steven Blatt, MD: We have always had parents that question our medical advice, and that's good.

We should be able to explain what we want to do, no matter what the condition is, or what the proposed treatment is, and vaccines are no different, and I think things kind of wax and wane, and certainly nowadays, especially after COVID, there was a lot of resistance to some vaccines. There's been resistance to the measles vaccine.

So yes, we do have some parents that don't want their children to be vaccinated. And it varies from parent to parent. It varies in different parts of the country. And another important thing, which I think will be one of your future questions, so I'm just going to answer it right now, and that is what vaccines do you need to go to school or to go to day care?

And that also varies state by state. So in New York state, for a child to go to a New York state-certified day care or to go to school, pre-kindergarten and then all the way up through kindergarten, there's a vaccine schedule, and the kids need to get those vaccines to participate unless there's a medical exemption.

So we have parents that come in and we say, these are the vaccines that you need. And they say, well, I don't want them. I don't want my child to get that. And we say fine, and we talk about it and try to answer their questions and share our knowledge. It's our job to give the parent the knowledge. It's the parent's job to make the decision.

And then there's some parents that say, no, I don't want the vaccines. And we say, OK, but just so you know, when your child goes to day care , they're going to need the vaccine. Or when they go to school, they're going to need the vaccine. And there are some parents that will homeschool their children. There may be different reasons. One of the reasons for some of them is that they don't want them to have to get the vaccines. So yes, we do have parents that don't want vaccines. There's some parents that say, "Well, you could give some vaccines now, and I'll come back in another two weeks, and you give some more later," that don't want them all at once.

And our office, we're fine with that. In other offices there may be more pushback, but yes, there's a lot of parents who, are hesitant, concerned about their child getting vaccines.

Host Amber Smith: At what age can a child overrule their parents' decision about vaccines? Do they have to be 18 or 21?

Steven Blatt, MD: It's a great question and is, a field of bioethics now and a whole bunch of lawyers to help us answer those questions. So my answer, I'll try to be as precise and correct as I can, but I may be off a little bit. So, in general, in New York state, someone could consent to their own health care at age 18.

So prior to 18, it would be, it's probably hard for a child to override his or her parents' wishes. HPV vaccine, which is human papillomavirus, and as I mentioned before, helps prevent cervical cancer, cancer for part of the uterus. HPV is considered a sexually transmitted disease. So when it comes to sex, some kids or young adolescents are able to get treatment without their parents' permission.

So I think, technically, a child could get an HPV vaccine against their parents' wishes. The last thing we as pediatricians want is for children and parents to be in conflict over these things, so it doesn't happen in our office very often. I can't even remember the last time, but if it did come up, I think we would work very much, to try to get the parents and the child aligned to one another, so they can make a decision together, and sometimes it causes conflict.

I will note though, and it happened today, I had a young man in the office, and we're talking about vaccines that he was eligible for. He was an older teen, and I looked at both the father and the patient. I said, "We have these vaccines. Would you like them?"

And the father said to his child, "Well, what do you think? Do you want them?"

And he said, "Yes."

And for me, as a pediatrician, I think that's great because it's the parent empowering his own child to learn how to make his own health care decisions.

And even if the child said no, I think it's great because again, he's making his own decisions. We never want to tell someone, "This is what you have to do." We want to communicate, "This is our medical advice, and you're going to make the decision." We want our patients, our families, to be educated and make good decisions for themselves, which may be different than the next family making good decisions for themselves.

We never want to be in an adversarial position. We want to be collaborative with our patients, so they could decide what's right for them. We're a source of information and advice, and I could tell you that when we give information and advice, we do it because to the best of our medical knowledge and experience, this is what we think is correct. But time has shown us that things that we thought were correct today may be shown to be incorrect in the future. We're not perfect. You have to make a decision, either yes or no. This is the best way we come to making a decision.

Host Amber Smith: So a public health question for you. What happens when people refuse vaccines?

Steven Blatt, MD: So again, especially today, and if somebody is listening to this in the future, we're on March 6th in 2025, and we are in the midst of a measles endemic in a couple counties in Texas bordering New Mexico. And in Texas, they have different laws about what vaccines are needed to go to school. And in these particular counties, the immunization rates for measles vaccine is about 82%, and in New York state for kids in school, it's I think 97%, and it should be 100%.

And for measles as an example, if the rate of people who are immunized falls below 95%, it's a setup for an outbreak, and that's what's happening right now in Texas. There's a low immunization rate. There is measles out there; somebody came in contact with it. Measles is probably the most infectious organism out there. It's more contagious than Ebola. It is so contagious that if somebody had measles and walked from one end of a plane to the other, and the plane was filled with people who were not immunized, 90% of those people would be infected with measles at the end of the plane ride. It is that contagious.

You asked, what's the public health view on this? And the thing about public health is that if the population, and in this case of children, but of anybody, if the population of un-immunized children gets low, we're going to have an outbreak.

We do have measles in New York now. A few years ago we had outbreaks of measles in Brooklyn and also up north of New York City because they were in populations of people that were not getting immunized, and there was an outbreak. And many years ago there was an outbreak at Disneyland in California, and as long as we have people that are not getting immunized, there will be outbreaks.

There are different communities in Central New York, that don't believe in immunizations, and periodically we see outbreaks in those communities also. These are diseases that are easily prevented by vaccines, but not everybody wants to get vaccines.

Host Amber Smith: Have you cared for children who've become sick with vaccine-preventable illnesses?

Steven Blatt, MD: I cared for more children than I'd like to remember, but for two different reasons. So when I was a resident, we didn't have that many vaccines, and there were lots of illnesses that we saw routinely. We had kids with hemophilus influenza B, meningitis and pneumococcal meningitis, and these kids would come in, and not all of them would leave the hospital alive.

It was incredibly sad to see these kids suffer and die and see what it did to their families and also to us as health care professionals. And then we have these new vaccines, so those diseases we don't see very much anymore, but we still see them. We had in our office, over the last six months, we had a case in measles. We had chicken pox. We've had whooping cough, so just walking in our front door. we still have these cases, and that's a different type of sadness.

So when I was a resident, it was sad because we had nothing to do, and we would see this all the time. Now we have ways to prevent it, and we still see these cases, not as often, luckily, but we still see them. and it's heartbreaking. Luckily, the ones that we've seen have recovered fine. But I do want to point out, there was a young child in Western New York about two weeks ago who died of influenza virus, and there's a child down in Texas who died of measles. Those are two childhood deaths from vaccine-preventable illnesses.

Down in Texas, I think it's about 20% of the kids infected have been admitted to the hospital, which is not a good thing. And the other thing is that the vast majority of people infected in Texas are kids, and almost none of them were immunized. Immunization works. If you get immunized with these vaccines, you are not guaranteed, but almost guaranteed, to never get those illnesses. And if you do get them, you won't get all that sick.

Host Amber Smith: How are vaccines paid for?

Steven Blatt, MD: Many years ago, when I started my practice, practicing medicine, vaccines were paid out of pocket. It was burdensome for young families, who don't have a lot of money to begin with, and they had to pay for vaccines. In New York state in the 1990s, it became a law that your health insurance has to cover the vaccines that are on that schedule from the CDC.

So one mechanism is people that have private health insurance, commercial health insurance, that'll pay for the vaccines. About half of the kids in the country get their vaccines from a federal program called Vaccines for Children, and this came about in the 1990s. And Vaccines for Children will purchase vaccines from the manufacturer, and then they go to the state, in our case it goes to New York state, and then for an office, it'll sign up with the state. And here at Upstate, we have two primary care offices and family medicine offices, and we all participate, and they send us vaccine. And that's used primarily for our kids that are either on Medicaid or kids that don't have insurance at all, so they get their vaccines at no cost.

There's no cost to the health care provider, to the physician or nurse practitioner. They give it to us, and we give it to them, and we don't charge for anything. We just kind of pass it through. There's a very small administration fee. That the office gets, it's 10 or $15 just, to pay for the nurse to give it and the alcohol swab. It's no money changing hands. It's just a good thing to get the vaccine into the child's arm.

For the ones that come from commercial insurance, that's about half. Of the kids also, the vaccines are at no charge. And again, the pediatricians and the family practitioners make a negligible amount of money. Nobody's making money off of this, is my point. Nobody's doing this for the money. And in fact, given all the time it costs, we do it because it's the right thing to do.

Host Amber Smith: So cost then is not a barrier to families or parents that come in and say they don't want their kids vaccinated. What are some of the reasons that they give you?

Steven Blatt, MD: I ask every parent who says they don't want vaccine. I say, could you share with me why you don't want it? And I tell them, I'm just interested. I want to learn about my patients. And there are a number of categories why people don't want it. There are people who, are worried about side effects, and if they say that's what they're worried about, then we talk about the side effects.

There are people who say they know somebody who got that vaccine, and they had something terrible happen to them. And I say, let's talk about it. And I know when people tell me that, I'm usually not going to change their mind. Because people say, "Well, my sister's kid got the vaccine, and something happened."

And it's like, when people experience something, they experience something, but I like to talk to them anyway. Then, there are people that say, "I don't think it's important. It's not a big deal if I get the flu or if I get COVID. You know, it's just a bad cold." And I tell them my perspective on that. Like today, I would say somebody, a young child, recently died from the flu. It can be a big thing.

There are people who don't trust the government, and they don't trust the vaccine manufacturers. And for a lot of people, it's for good reason. And I think the most well-known good reason, and this happened to African Americans, so it's a belief much more commonly held in my patients from the African American community. Is that back from the '30s to the '60s, there was the Tuskegee experiments, where there was research being done, supported by the federal government, that had to do with black men with syphilis not being treated, even although treatment was available and they were told they were treated and everything was fine. And that was a horrific thing and never should have happened. And there are people distrustful because of that and I certainly understand it. It's interesting to note that when COVID occurred, and COVID vaccine was out there, there's a group of, descendants of those men who were victims of the Tuskegee experiments, and they got together and they said, yes, the Tuskegee experiments was an evil thing that happened to our fathers and our grandfathers and our uncles, but we still think you should get COVID vaccine because it's a different time, and we think it's safe.

But be that as it may, there are people that just don't trust the government and they'll tell me, they say, "Dr. Blatt, I trust you, but I don't trust them."

And I say, "OK, well, I'm still your doctor. I'll support you."

So there are different reasons, but I do talk to people, and most people have reasons, and sometimes people say, "Well, I read something."

And I say, "Bring it in and we'll talk about it."

And they can never find what they read, but everybody makes up their mind different ways, and I try to find out why and then discuss it.

And sometimes, I explain my reason, and people understand it and go ahead and get the vaccine, and other times they don't. And then, we move on, and that's OK. People are people. Not everybody's going to do the same thing. Every time somebody tells me why, at the end, I thank them for listening to my answer, because a lot of times I'm telling people what I want to say, and I know they're not interested, but they're very nice and listen to me, and I appreciate that, and I appreciate what they do for me.

Host Amber Smith: Well, I appreciate you making time to share your knowledge about vaccines with us. This is very complicated, really, when you look at it closely.

So thank you for laying it out.

Steven Blatt, MD: Well, you're welcome. And let me tell you why, very briefly. I know I go on with long answers, but very briefly, the reason why I wanted to talk to you about it is, I think, and others do too, that after good nutrition and clean water, vaccines is the biggest advancement in civilization in the history of the world.

It has saved more people from death, has prevented more illness, than anything after proper nutrition and clean water. As a pediatrician, it is one of my favorite things because it is so helpful to my patients, so I'm so happy to share it, what I have to say, with anybody who wants to listen to me.

Host Amber Smith: My guest has been Dr. Steven Blatt. He's a professor of pediatrics, and he oversees the general pediatrics division at Upstate.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe, with sound engineering by Bill Broeckel and graphic design by Dan Cameron.

Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please invite a friend to listen. You can also rate and review "The Informed Patient" podcast on Spotify, Apple Podcasts, YouTube or wherever you tune in.

This is your host, Amber Smith, thanking you for listening.