Inflammatory Bowel Disease

Not an actual patient.

The incidence of inflammatory bowel disease (IBD) has increased in recent years.1

Approximately 1.6 million Americans have IBD,1,2 which is comprised of 2 major types: ulcerative colitis (UC), characterized by continuous, mucosal inflammation limited to the innermost lining of the colon and rectum, and Crohn’s disease (CD), defined by patchy, transmural inflammation which can affect any part of the gastrointestinal (GI) tract, from the mouth to the perianal area.1,3,4

Inflammatory bowel disease illustration

Epidemiology

Population-based studies in the U.S. suggest that the incidence of IBD is most common in patients aged 15 to 35 years.1 IBD can also present in childhood, including up to 20% of children who are diagnosed before the age of 10 years.5 It is more common in Whites (vs other racial groups) and in adults, UC is more common in males.1,6

Diagnosis

Symptoms of IBD depend on the disease location, and can range from mild to moderate to severe.2,4 Diarrhea and rectal bleeding are characteristic with UC. Patients can experience weight loss and fever (although it can be less common than with CD), and abdominal pain varies depending on the patient. For CD, weight loss, fever, and abdominal pain are more predominant, although these patients can also experience diarrhea and rectal bleeding.4

Irritable bowel syndrome (IBS), the most common GI condition diagnosed by gastroenterologists, may be mistaken for IBD since IBS symptoms may mimic those seen in a patient with mild IBD, but history and additional diagnostic tests can help rule it out of the differential diagnosis.7 Endoscopy combined with biopsies of the affected area(s) of the GI tract will also establish the diagnosis and differentiate between UC and CD.4,8

Pathophysiology

The etiology of IBD most likely involves a complex interaction between genetic and environmental factors, microbiome, and the immune system.3,4 T cells, which are activated by antigen-presenting cells in the peripheral lymphoid tissue, migrate to the site of inflammation and play a role in recruitment and activation of additional inflammatory cells in the GI tract.9,10

Navigating IBD

IBD is a chronic disease, with significant impact on a patient’s general health.3 While the Crohn’s Disease Activity Index (for CD) and Mayo Score (for UC) are the most frequently used instruments for scoring and monitoring disease activity in clinical trials, researchers are working to improve the measures of disease activity and severity through assessment of impact of disease on the patient, disease burden, and disease course, including structural damage with a goal of improving disease management for patients.11

  1. Shivashankar R, Tremaine WJ, Harmsen WS, et al. Clin Gastroenterol Hepatol. 2017;15(6): 857-863.
  2. Crohn’s and Colitis Foundation of America. Factbook. 2014. Available at: 
    https://www.crohnscolitisfoundation.org/sites/default/files/2019-02/Updated%20IBD%20Factbook.pdf. Last accessed September 2, 2021.
  3. Latella G and Papi C. World J Gastroenterol. 2012;18(29):3790-3799.
  4. Podolsky DK. N Engl J Med. 2002;347(6):417-429.
  5. Abramson O, Durant M, Mow W, et al. J Pediatr. 2010;157(2):233-239.
  6. Dahlhamer JM, Zammitti EP, Ward BW, et al. MMWR. 2016;65(42):1166-1169.
  7. Burgmann T, Clara I, Graff L, et al. Clin Gastroenterol Hepatol. 2006;4(5):614-620.
  8. Andresen V, Whorwell P, Fortea J, et al. United Eur Gastroenterol J. 2015;3(1):39-52.
  9. Ley K and Kansas GS. Nat Rev Immunol. 2004;4:1-11.
  10. Sheridan BS and Lefrançois L. Nat Immunol. 2011;12(6):485-491.
  11. Peyrin-Biroulet L, Panés J, Sandborn WJ, et al. Clin Gastroenterol Hepatol. 2016;14(3):348-354.

Upcoming & Past Conferences in Gastroenterology

  • Upcoming

  • Past

Professional Society for Health Economics and Outcomes Research (ISPOR Europe), 2024

November 17 - 20, 2024 | Link to Event

The conference program centers on the importance of scientific evidence in understanding and improving the health and well-being of people across the globe.

World Congress of Pediatric Gastroenterology, Hepatology and Nutrition (WCPGHAN), 2024

December 4 - 7, 2024 | Link to Event

Annual forum for participants to learn about the latest advances in pediatric gastroenterology, hepatology, and nutrition, and to discuss current topics in clinical applications.

Advances in Inflammatory Bowel Diseases (AIBD), 2024

December 9 - 11, 2024 | Link to Event

An all-encompassing event providing real-world clinical education, case studies and new evidence-based approaches in IBD management.

Crohn's & Colitis Congress (CCC), 2025

February 6 - 8, 2025 | Link to Event

Annual conference for a multidisciplinary community of practitioners and researchers focusing on inflammatory bowel disease (IBD) by pairing best practices in clinical care with innovative research.

European Crohn's and Colitis Organisation (ECCO), 2025

February 19 - 22, 2025 | Link to Event

Annual global congress structured around basic science, traditional medicine and clinical sessions given by some of the world's top GI specialists.

Annual Meeting American Academy of Allergy Asthma and Immunology (AAAAI), 2025

February 28 - March 3, 2025 | Link to Event

Premier global educational event for allergists and immunologists, with thousands of attendees each year, discussing allergies, asthma, and immune deficiency disorders.

American Society for Parenteral and Enteral Nutrition (ASPEN), 2025

March 22 - 25, 2025 | Link to Event

Annual global conference for interdisciplinary, clinical nutrition leaders, providing the latest in clinical nutrition research, education, and products.

Digestive Disease Week (DDW), 2025

May 3 - 6, 2025 | Link to Event

Global meeting for physicians, researchers, and industry in the fields of gastroenterology, hepatology, endoscopy, and gastrointestinal surgery.

North American Society For Pediatric Gastroenterology, Hepatology & Nutrition (NASPGHAN), 2024

November 6 - 9, 2024

Annual forum for participants to learn about the latest advances in pediatric gastroenterology, hepatology, and nutrition, and to discuss current topics in clinical applications.

American College of Gastroenterology (ACG), 2024

October 25 - 30, 2024

Premier event for clinicians and the general public about digestive disorders and the latest trends in GI technology and therapeutics.

American College of Allergy, Asthma & Immunology (ACAAI), 2024

October 24 - 28, 2024

Global meeting featuring thought leaders from around the world focused on advancing patient care in allergy and immunology.

Academy of Managed Care Pharmacy Nexus (AMCP Nexus), 2024

October 14 - 17, 2024

Annual event with more than 2,500 members and non-members of the AMCP to engage on the latest innovations and most intentional networking in managed care pharmacy.

American College of Clinical Pharmacy (ACCP), 2024

October 12 - 15, 2024

Annual event dedicated to excellence in clinical pharmacy practice, research, and education.

United European Gastroenterology Week (UEGW), 2024

October 12 - 15, 2024

Global congress for researchers from around the world to present their findings on gastroenterology and digestive health.

Pediatric Intestinal Failure and Rehabilitation Symposium (PIFRS), 2024

September 26 - 28, 2024

Global meeting designed to bring together international and national experts in the multidisciplinary care of the intestinal failure patient.

Gattex® (teduglutide)

  • Long-term Use of Teduglutide in Children with Short Bowel Syndrome: A Multi-Center Post-Marketing Cohort Study
  • Long-term Safety & Effectiveness of Teduglutide in Pediatric Patients with Short Bowel Syndrome-Associated Intestinal Failure: A Multicenter Registry

Gastroenterology and Hematology Advanced Practice Providers (GHAAP), 2024

September 12 - 14, 2024

Conference specifically designed by advanced practice providers (APPs) for the purpose of meeting the educational needs of APPs who specialize in the management of patients with GI disorders and chronic liver disease.

Entyvio® (vedolizumab)

  • Proactive Patient Engagement to Promote Representative Patient Populations for Future Trials of Dual Targeted Therapies in Inflammatory Bowel Diseases

Eohilia® (budensonide)

  • Safety of Short-Term Therapy with Budesonide Oral Suspension for Eosinophilic Esophagitis: an Integrated Safety Analysis of Phase 2 and 3 Clinical Studies

European Society for Clinical Nutrition & Metabolism Congress (ESPEN), 2024

September 7 - 10, 2024

Annual global congress dedicated to clinical nutrition and metabolism, including basic and clinical research, education, and organization of consensus statements about clinical care.

Gattex® (teduglutide)

  • Long-term Safety of Teduglutide in Paediatric Patients with Short Bowel Syndrome-Associated Intestinal Failure: an Observational, Prospective, Multicentre Registry
  • Long-term Effectiveness of Teduglutide in Paediatric Patients with Short Bowel Syndrome-Associated Intestinal Failure: an Observational, Prospective, Multicentre Registry

Digestive Disease Week (DDW), 2024

May 18 - 21, 2024

Global meeting for physicians, researchers, and industry in the fields of gastroenterology, hepatology, endoscopy, and gastrointestinal surgery.

Gattex® (teduglutide)

  • Short bowel syndrome patient experience: a mixed-method study leveraging Inspire, an online community platform.

Entyvio® (vedolizumab)

  • Proactive patient engagement to promote representative patient populations for future trials of dual targeted therapies in inflammatory bowel diseases.
  • Machine Learning-Based Precision Medicine Approach Identifies Specific Responder Sub-Populations in the Vedolizumab treated patients by Dynamic Clustering of PRO Data: Post Hoc Analysis of VARSITY and GEMINI Dataset.
  • Biologic Therapy Sequencing in Ulcerative Colitis: A Real-World Observational Study of Second-Line Therapy After Vedolizumab [encore].
  • Real-world clinical effectiveness and safety of vedolizumab and ustekinumab in biologic- naïve patients with Crohn's disease by disease location: Results from the EVOLVE Expansion study [encore].
  • Disease Clearance After 16 Weeks of Treatment With Vedolizumab in Patients With Moderate to Severe Ulcerative Colitis: An Interim Analysis From the VERDICT Trial [encore].

Eohilia® (budensonide)

  • Safety of short-term therapy with budesonide oral suspension for eosinophilic esophagitis: an integrated safety analysis of four phase 1–3 clinical studies.

Motegrity® (prucalopride)

  • Diagnostic journey of patients with chronic idiopathic constipation in the USA: analysis from a cross-sectional observational study.

Professional Society for Health Economics and Outcomes Research (ISPOR), 2024

May 5 - 8, 2024

Leading global conference discussing how to establish, incentivize, and share value sustainable for health systems, patients, and technology developers.

Academy of Managed Care Pharmacy (AMCP), 2024

April 15 - 18, 2024

Large assembly of pharmacy and healthcare professionals dedicated to the issues of managed care pharmacy, offering immersive education sessions and keynote presentations.

Campaign Urging Research for Eosinophilic Disease (CURED), 2024

April 4 - 7, 2024

International meeting concerning the field of Eosinophilic Gastrointestinal Disorders, including EoE and other eosinophilic diseases.

Eohilia® (budensonide)

  • Improved histopathologic features in patients with eosinophilic esophagitis: data from a phase 3, randomized, placebo-controlled trial of budesonide oral suspension

American Society for Parenteral and Enteral Nutrition (ASPEN), 2024

March 2 - 5, 2024

Annual global conference for interdisciplinary, clinical nutrition leaders, providing the latest in clinical nutrition research, education, and products.

Annual Meeting American Academy of Allergy Asthma and Immunology (AAAAI), 2024

February 23 - 26, 2024

Premier global educational event for allergists and immunologists, with thousands of attendees each year, discussing allergies, asthma, and immune deficiency disorders.

European Crohn's and Colitis Organisation

February 21 - 24, 2024

Annual global congress structured around basic science, traditional medicine and clinical sessions given by some of the world's top GI specialists.

Crohn's & Colitis Congress (CCC), 2024

January 25 - 25, 2024

Annual conference for a multidisciplinary community of practitioners and researchers focusing on inflammatory bowel disease (IBD) by pairing best practices in clinical care with innovative research.

Advances in Inflammatory Bowel Diseases (AIBD), 2023

December 14 - 16, 2023

An all-encompassing event providing real-world clinical education, case studies and new evidence-based approaches in IBD management.

Entyvio® (vedolizumab)

  • Biologic Therapy Sequencing in Ulcerative Colitis: A Real-World Observational Study of Second-Line Therapy After Vedolizumab

Medication Resources

Entyvio®

(vedolizumab)

Videos

 

Watch videos focused on inflammatory bowel disease (IBD).

Focus on the Intestinal Immune System in IBD

Learn about how inflammation in the intestinal tract can lead to inflammatory bowel disease (IBD).

The incidence of inflammatory bowel disease (IBD) has increased in recent years.1

Approximately 2.4 million Americans have IBD, which consists of 2 major types: ulcerative colitis (UC), which involves diffuse inflammation typically limited to the colonic mucosa, and Crohn’s disease (CD), characteristically causing transmural inflammation that can affect any part of the GI tract from the mouth to the anus.1,2

Inflammatory bowel disease illustration

Epidemiology

The prevalence of IBD in the U.S. is among the highest in the world.1 A 2023 epidemiology studied showed that the Northeast and South regions of the U.S. have higher rates of IBD compared to the West and Midwest.1,3,4 Additionally, prevalence is slightly higher in males among children and females among adults.1 There has been an observed significant rise in cases in the pediatric population, driven mainly by patients aged between 10 and 17 years old.5

Incidence and prevalence rates of IBD are higher in White patients compared with patients of other races.1 However, a 2017 study demonstrated that between 1970 and 2010, there was an 39% increase in IBD incidence rates for White patients and 134% increase for patients of other races (African American, Asian, American Indian, and Other), suggesting that the future of IBD in the U.S. may experience a shift in racial diversity.6

Pathophysiology

The pathophysiology of IBD has yet to be fully defined but is known to include a combination of genetic, environmental, microbiological, and immunological factors.7-9 The interplay between these factors can compromise the intestinal mucosa and epithelial barrier.  The subsequent influx of antigens and microorganisms into the lamina propria of the gut is associated with activation of the innate immune response, and a persistent, adaptive immune response.10-13

Diagnosis

Symptoms of IBD depend on the disease location and can range from mild to moderate to severe.14 Common symptoms of CD include diarrhea, abdominal pain, and fatigue; weight loss, fever, growth failure, anemia, recurrent fistulas, or extraintestinal manifestations can also be presenting features.15 For UC, the main symptom is bloody diarrhea, with or without mucus; other symptoms include urgency or tenesmus, abdominal pain, malaise, weight loss, and fever, depending on the extent and severity of disease.16

Irritable bowel syndrome (IBS), the most common GI condition diagnosed by gastroenterologists, may be mistaken for IBD since IBS symptoms may mimic those seen in a patient with mild IBD, but history and additional diagnostic tests can help rule it out of the differential diagnosis.17 Diagnosis of IBD is a multistage process including physical examination and medical history, endoscopy, lab testing, and cross-sectional imaging.18

Navigating IBD

IBD can substantially compromise the physical, psychological, familial, and social dimensions of life, with secondary effects evident in the increased rates of anxiety, depression, and other emotional effects.20 As chronic IBDs, CD and UC can lead to disabling bowel symptoms and progressive bowel damage throughout a patient’s life, resulting in prominent disability, reduced QoL, and increased morbidity.20,21 Patients with IBD expect to be informed about their disease, enabling shared decision making that ultimately leads to symptom control and improved quality of life.22

  1. Lewis JD, et al. Gastroenterology. 2023;165:1197–1205.e1192.
  2. McDowell C, et al. Inflammatory Bowel Disease. [Updated 2022 Jun 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan.
  3. Betteridge JD, et al. Inflamm Bowel Dis. 2013;19:1421–1427.
  4. Xu F, et al. MMWR Morb Mortal Wkly Rep. 2021;70:698–701.
  5. Ye Y, et al. Inflamm Bowel Dis. 2020;26:619–625.
  6. Aniwan S, et al. Therap Adv Gastroenterol. 2019;12:1756284819827692.
  7. Torres J, et al. Lancet 2017;389:1741–55. 
  8. Choy MC, et al. Inflamm Bowel Dis 2017;23:2–13. 
  9. de Souza HSP, et al. Nat Rev Gastroenterol Hepatol 2017;14:739–49.
  10. Bamias G, et al.. Clin Gastroenterol Hepatol 2021;19:2469–80.
  11. Dotan I et al. Med Res Rev 2020;40:245–62. 
  12. Takiishi T et al. Tissue Barriers 2017;5:e1373208.
  13. Neurath MF. Mucosal Immunol 2014;7:6–19.
  14. Podolsky DK. N Engl J Med. 2002;347(6):417-429.
  15. Lichtenstein GR et al. Am J Gastroenterol 2018;113:481–517.
  16. Lynch WD et al. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan.
  17. Burgmann T, et al. Clin Gastroenterol Hepatol. 2006;4(5):614-620.
  18. Plevris N, Lees CW. Gastroenterology. 2022;162:1456–75.
  19. Andresen V, et al. United Eur Gastroenterol J. 2015;3(1):39-52.
  20. GBD 2017 Inflammatory Bowel Disease Collaborators. Lancet Gastroenterol Hepatol 2020;5:17–30
  21. Revés J, et al. Curr Res Pharmacol Drug Discov. 2021;2:100070
  22. Al Khoury A, et al. Dig Dis Sci 2022;67:1956–74.

Health Equity Resources

 

Find materials to help foster a deeper understanding of health equity in Inflammatory Bowel Disease.

Infographic: Addressing Inequities in Inflammatory Bowel Disease

 

 

 

 

Health Equity Knowledge Check

 

Test your understanding of health equity in Inflammatory Bowel Disease.

 

 

We Believe That Everyone Deserves Equity in Healthcare

“Improving our understanding of differences in the epidemiology and features of IBD in patients of different races and ethnicities is an essential goal as we aim to improve health outcomes for all patients.”

— Barnes, et al1

START

 

 

IBD = inflammatory bowel disease
1. Barnes EL, Loftus EV Jr, Kappelman MD. Gastroenterology. 2021;160(3):677-689.

 

 

 

Health Equity Knowledge Check

 

 

 
 

 

 

According to the 2015 National Health Interview Survey, what percentage of U.S. adults (aged ≥18) diagnosed with IBD are either Hispanic or Black?

 

 

IBD = inflammatory bowel disease

U.S. = United States

 

 

 

 

 

 

 

 

 

Health Equity Knowledge Check

 

 

 
 

 

 

According to the 2015 National Health Interview Survey, what percentage of U.S. adults (aged ≥18) diagnosed with IBD are either Hispanic or Black?

 

IBD = inflammatory bowel disease

U.S. = United States

1. Dahlhamer JM, Zammitti EP, Ward BW et al. MMWR Morb Mortal Wkly Rep. 2016;65(42):1166-1169.

 

 

 

 

 

 

 

 

Health Equity Knowledge Check

 

 

 
 

 

 

Are racial health disparities a contributing factor of delayed IBD diagnosis?

 

 

 

IBD = inflammatory bowel disease

 

 

 

 

 

 

 

 

 

 

Health Equity Knowledge Check

 

 

 
 

 

 

Are racial health disparities a contributing factor of delayed IBD diagnosis?

 

 

IBD = inflammatory bowel disease

 

1. Odufalu FD, et al. Curr Opin Gastroenterol. 2022;38(4):321–327; 2. Sofia MA et al. Dig Dis Sci. 2014;59(9):2228–2235; 3. Damas OM et al. Am J Gastroenterol. 2013;108(2):231–239; 4. Barnes EL, et al. Inflamm Bowel Dis. 2018;24(12):2634–2640; 5. Nguyen GC, LaVeist TA, Harris ML et al. Am J Gastroenterol. 2010;105(10):2202–2208.

 

 

 

 

 

 

 

 

Health Equity Knowledge Check

 

 

 
 

 

 

A population-based cohort study of U.S. patients with newly diagnosed IBD between 1970 and 2010 reported that the incidence rate for Non-White populations increased by              % compared to a 39% increase for White patients.1

 

 

 

IBD = inflammatory bowel disease

U.S. = United States

 

1. Aniwan S, Harmsen WS, Tremaine WJ et al. Therap Adv Gastroenterol. 2019 Feb 6;12:1756284819827692. doi: 10.1177/1756284819827692

 

 

 

 

 

 

 

 

Health Equity Knowledge Check

 

 

 
 

 

 

A population-based cohort study of U.S. patients with newly diagnosed IBD between 1970 and 2010 reported that the incidence rate for Non-White populations increased by              % compared to a 39% increase for White patients.1

 

 

IBD = inflammatory bowel disease

MN = Minnesota

U.S. = United States

 

1. Aniwan S, Harmsen WS, Tremaine WJ et al. Therap Adv Gastroenterol. 2019 Feb 6;12:1756284819827692. doi: 10.1177/1756284819827692

 

 

 

 

 

 

 

 

Health Equity Knowledge Check

 

 
 

 

 

A cross-sectional study evaluating the use of IBD specialist services, emergency department services, and medications found that racial disparities may affect healthcare utilization.*1

When compared to White patients, Black patients with IBD were found to be              .

 

 

 

*Cross-sectional study included Black (n=137) and White (n=149) patients with IBD who were recruited from an outpatient IBD clinic in the U.S.

 

IBD = inflammatory bowel disease

U.S. = United States

 

1. Nguyen GC, LaVeist TA, Harris ML, et al. Am J Gastroenterol. 2010;105(10):2202–2208.

 

 

 

 

 

 

 

 

Health Equity Knowledge Check

 

 

 
 

 

 

A cross-sectional study evaluating the use of IBD specialist services, emergency department services, and medications found that racial disparities may affect healthcare utilization.*1

When compared to White patients, Black patients with IBD were found to be              .

 

 

*Cross-sectional study included Black (n=137) and White (n=149) patients with IBD who were recruited from an outpatient IBD clinic in the U.S.

 

ED = emergency department

IBD = inflammatory bowel disease

U.S. = United States

 

1. Nguyen GC, LaVeist TA, Harris ML, et al. Am J Gastroenterol. 2010;105(10):2202–2208.

 

 

 

 

 

 

 

 

Health Equity Knowledge Check

 

 
 

 

 

IBD disease location and behavior are uniform across racial groups.

 

 

 

IBD = inflammatory bowel disease

 

 

 

 

 

 

 

 

 

 

Health Equity Knowledge Check

 

 

 
 

 

 

IBD disease location and behavior are uniform across racial groups.

 

 

IBD = inflammatory bowel disease

 

1. Shi HY, Levy AN, Trivedi HD et al. Clin Gastroenterol Hepatol. 2018;16(2):190-197; 2. Louis E, Collard A, Oger AF et al. Gut. 2001;49(6):777-782.

 

 

 

 

 

 

 

 

Health Equity Knowledge Check

 

 

 
 

 

 

A study conducted by the University of North Carolina reported Black patients with Crohn's disease, when compared to White patients, were               times as likely to be treated with steroids.

 

 

 

 

 

 

 

 

 

 

 

Health Equity Knowledge Check

 

 

 
 

 

 

A study conducted by the University of North Carolina reported Black patients with Crohn's disease, when compared to White patients, were               times as likely to be treated with steroids.

 

 

CD = Crohn's disease

 

1. Odufalu FD, et al. Curr Opin Gastroenterol. 2022 Jul 1;38(4):321-327; 2. Nguyen GC, LaVeist TA, Harris ML et al. Am J Gastroenterol. 2010 Oct;105(10):2202-2208,

 

 

 

 

 

 

 

 

Health Equity Knowledge Check

 

 

 
 

 

 

Between 1994 and 2019, what was the percentage of minority inclusion in all U.S. published randomized clinical trials?

 

 

U.S. = United States

 

 

 

 

 

 

 

 

 

Health Equity Knowledge Check

 

 

 
 

 

 

Between 1994 and 2019, what was the percentage of minority inclusion in all U.S. published randomized clinical trials?

 

FDA = Food and Drug Administration

IBD = inflammatory bowel disease

U.S. = United States

 

1. Ma MA, Gutiérrez DE, Frausto JM, et al. Mayo Clin Proc. 2021;96:264–266; 2. United States Census Bureau. Quick facts. 2021. Accessed August 2024. https://www.census.gov/quickfacts/; 3. Cohen NA, Silfen A, Rubin DT. Gastroenterology. 2022;162:17–21; 4. Johnson C, Barnes EL, Zhang X, et al. Crohn's Colitis 360. 2020 Apr;2(2):otaa023. doi: 10.1093/crocol/otaa023.

 

 

 

 

 

 

 

 

Health Equity Knowledge Check

 

 

 
 

 

 

How can we close the IBD health equity gap?

What are the top 3 barriers of care for minorities with IBD that you would like to see further addressed?

Please select up to 3

 

 

IBD = inflammatory bowel disease

 

 

 

 

 

 

 

 

Health Equity Knowledge Check

 

 

 
 

 

 

Thank you

for participating.

 

 

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