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Syneos Health, Inc. (SYNH) Q4 2020 Earnings Call Transcript

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SYNH earnings call for the period ending December 31, 2020.

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Syneos Health, Inc. (SYNH 1.63%)
Q4 2020 Earnings Call
Feb 18, 2021, 8:00 a.m. ET

Contents:

  • Prepared Remarks
  • Questions and Answers
  • Call Participants

Prepared Remarks:

Operator

Good morning, and welcome to the Syneos Health Fourth quarter and full-year 2020 Earnings Conference Call. [Operator Instructions].

I would like to hand the conference over to Ronnie Speight, Senior Vice President of Investor Relations. Please go ahead, sir.

Ronnie Speight -- Senior Vice President, Investor Relations

Good morning, everyone. With me on the call today are Alistair Macdonald, our Chief Executive Officer, Jason Meggs, our Chief Financial Officer, Michelle Keefe, our President of Commercial Solutions, and Paul Colvin, our President of Clinical Solutions. In addition to the press release, a slide presentation corresponding to our prepared remarks is available on our website at investor.syneoshealth.com. Remarks that we make about future expectations, plans, growth, anticipated financial results and prospects, and our expectations regarding the COVID-19 pandemic constitute forward-looking statements for purposes of the Safe Harbor Provisions under the Private Securities Litigation Reform Act of 1995 and we disclaim any obligation to update them. Actual results may differ materially from those indicated by these forward-looking statements as a result of various important factors. These factors are discussed in the Risk Factors section of our Form 10-K for the year ended December 31, 2020.

During this call, we will discuss certain non-GAAP financial measures, which exclude the effects of events and transactions we consider to be outside of our core operations. These non-GAAP measures should be considered a supplement to and not a replacement for measures prepared in accordance with GAAP. For a reconciliation of non-GAAP financial measures with the most directly comparable GAAP measures, please refer to the appendix of our presentation.

I would now like to turn the call over to Alistair Macdonald. Alistair?

Alistair Macdonald -- Chief Executive Officer

Thanks. Ronnie. Good morning everyone and thank you for joining us today. I hope you and your families are safe and in good health. I am pleased to report that we delivered a solid fourth quarter and full-year financial results, as we continue our recovery from the impacts of COVID-19. As demonstrated by our strong sales performance in the quarter which capped off a record year of awards our growing portfolio of innovative and integrated product development solution continues to resonate with customers of all sizes. Revenue across both segments grew sequentially. Overall profitability was also strong growing both sequentially and on a year-over-year basis. We continue to deliver on the value creation plan outlined at our investor event in December executing on our key growth strategies of further penetrating large pharma, enhancing our leadership position with SMID customers and accelerating our innovative Syneos One and full-service commercial offering. We expect strong growth in both our segments in 2021 which will become most apparent from the second quarter onwards, primarily driven by the robust new awards added to our backlog since late 2019 beginning to ramp along with our COVID vaccine trial. Our robust backlog now exceed $10 billion, providing us with a consistent revenue pipeline and highlighting our confidence in the long-term strength of our business. We have maintained our balanced approach to capital deployment, remaining focused on strategic M&A activity that will help expand our access to new markets and add key services to our portfolio. During the fourth quarter, we closed the acquisition of Synteract, which provides us with an expanded presence in the emerging biopharma market where strong biotech funding and innovation are driving double-digit growth.

We are also excited about our more recent acquisition of the and Illingworth Research Group, a leading global provider of clinical research home health services which covers 46 countries and enables clinical trial participation from the comfort and safety of the patient's own home. COVID-19 has accelerated the decentralization of healthcare delivery and the need for in-home clinical trial services and we believe this trend is favorable as it relates to demand for Illingworth's services. Illingworth expands the scale and capabilities of our decentralized solutions allowing our customers to realize efficiencies in patient recruitment and engagement with improved patient access and diversity.

Now for other key highlights from the quarter. First, we closed Q4 with strong net new business awards resulting in a book-to-bill ratios of 1.52 times for Clinical Solutions 1.63 times for Commercial Solutions, and 1.55 times in total. During full year 2020, we achieved a record $5.9 billion of net awards and an aggregate book-to-bill ratio of 1.33 times resulting in robust backlog growth and record ending backlog.

Second, we experienced strong profitability for the fourth quarter with 3.3% year-over-year. adjusted EBITDA growth and a 160-basis point adjusted EBITDA margin increase to 17.1%. This brings our full-year adjusted EBITDA margins of 14.3%, a 50 basis point increase over 2019.

And third, we generated another quarter of robust operating cash flow at a $114.3 million resulting in a record total of $425.5 million for the full year 2020, further strengthening our overall financial position and liquidity.

Now getting into the detail of our results. During the fourth quarter, we continued to sequentially recover from the impact of COVID-19 with total revenue growth of 3.7% compared to the 3rd quarter. Clinical Solutions revenue continued its sequential recovery growing 3.3% over the 3rd quarter. Our clinical team also delivered a strong fourth quarter of net awards, resulting in net awards growth of 13.3% for the full year. Full-year clinical net awards were a record $4.7 billion resulting in a strong TTM book-to-bill ratio of 1.42 times and year-over-year backlog growth of 24.6% including the impact of acquisitions. Clinical Solutions is well positioned to see accelerating revenue growth in 2021 as a result of the strong backlog growth and robust pipeline. We also won over 80 COVID related clinical projects during 2020. These represent approximately 7% of our gross awards for 2020 and we continue to see a substantial pipeline of additional COVID related opportunities. While we continue to see some operational delays in studies, we have not experienced any meaningful cancellations as a consequence of COVID-19. The pandemic continues to drive a high utilization of remote monitoring and lower patient enrollment in some therapy areas, although we anticipate a return to normal levels as we progress through 2021.

Turning now Commercial Solutions, revenue grew 5.4% compared to the 3rd quarter including sequential growth across all businesses. Our commercial team once again had a strong fourth quarter in awards resulting in a $1.16 billion of net awards and a book-to-bill ratio of 1.05 times for full year 2020. Importantly, our full-service commercial awards more than doubled in 2020 compared to 2019 demonstrating that our integrated delivery model is increasingly penetrating the market, particularly with our SMID customer base. This awards performance drove Deployment Solutions backlog to a record level with growth of 4% compared to the fourth quarter of 2019. Deployment Solutions also executed a record number of new team start in 2020 spanning our diverse field team resources and our virtual engagement center. Although net awards and book-to-bill for 2020 were impacted by higher cancellations during the first half of the year, our commercial pipeline remains robust given the growing complexity of customer product strategy and the rapid pace of FDA new drug approval.

We continue to deliver high levels of innovation to our customer base, including the evolution of Kinetic, our modern customer engagement capability. Kinetic combines insights, intelligence, and omni-channel expertise to strengthen relationship between field teams and HCPs via targeted digital messaging. PM360, a leading publication for marketing decision makers, recently recognized Digital Amplifier, a key component of Kinetic as an innovative 2020 service. An example of Kinetic's powerful impact includes enabling a customer to reach 80% of targeted HCPs despite the fact that personal access was not possible due to COVID-19. It also created subsequent double digit prescription growth for those HCPs who receive digital messaging that complemented personal messaging. Kinetic results are increasingly driving new business with our customers who are looking to transition to a more digital footprint contributing to 14% of our commercial gross awards during 2020. Additionally, as we continue to deliver innovation across the lab to life spectrum, we are now leveraging Kinetic in our clinical programs to fuel innovation in patient outreach and recruitment for our customers. While originally designed to optimize HCP outreach for our commercial field teams, we are now working with our clinical customers to apply kinetic for their active clinical projects. We are seeing very positive early results in patient engagement and enrollment by using kinetic Digital Amplification capabilities to enhance patient outreach and referrals through targeted physicians. We are accessing our dynamic assembly network to optimize a variety of data sources, media type and advanced analytics to customize the Kinetic program for any given clinical therapy. These innovations are further accelerating uptake of our insights driven product development model.

With that broader context, let me provide an update on some of the key operating metrics we have highlighted in recent discussion. Our clinical teams continue to see gradual improvement in their physical access to investigative sites with about 70% of sites permitting some level of physical visit. Similar to the 3rd quarter, some of these sites are facing capacity constraint requiring a higher mix of remote monitoring visits than we previously anticipated. Another 25% of our sites are now accessible only via some level of remote monitoring activity, while about 5% of sites remain inaccessible. While sites generally continue to be somewhat cautious that made localized increases in COVID-19 cases, we believe they are much better prepared to operate in this environment than they were in early 2020. Therefore, we expect site access to continue to improve gradually through the first half of 2021.

Our clinical teams are also experiencing continued improvement in the pace of both patient enrollment and the start-up of new clinical trials. By early February new patient enrollment rates approached 120% of pre-COVID levels and new site activations are trending at about 150% of pre-COVID level. We expect this strength in site activations and enrollment to drive the ramp of our core backlog along with our COVID vaccine trials creating year-over-year organic growth in the first quarter when excluding the impact of reimbursable expenses in our 2020 divestiture of contingent staffing.

Further, we expect Clinical Solutions year-over-year organic revenue growth to accelerate in the second quarter of 2021 and for the balance of the year as we lapped the initial 2020 impact of the pandemic. Within Commercial Solutions, our Deployment Solutions field teams are executing on their omni-channel strategy while experiencing a gradual return to in-person visit, currently in about 65% of our territories. The pace of this return to physical visit varies by customer with some of our large pharma customers taking a more cautious stance on allowing their teams back into the field. However, we continue to leverage our innovative Kinetic capabilities to optimize HCP engagement through a combination of face-to-face and virtual field team activities. With total contact volume trending well above pre-COVID levels, importantly we are seeing significant improvements in the average weekly productivity of our ramp through the utilization of Kinetic and/or the virtual capabilities. The primary impact of COVID-19 has been reduced revenue from reimbursable expenses along with increased cancellations and the delayed start up of new customer programs. However, as we have helped customers adapt to their current environment with our virtual capabilities, new program start-ups have begun to accelerate, which we expect to continue in 2021.

Our Communications business continues to see increased demand for strategic integrated program. Our unique combination of services across advertising, public relations, and medical communications enable customers to navigate the dynamic modern landscape, including the [Phonetic] ENI and CRO programs, COVID-19 response, virtual engagement and another timely issues. This comprehensive approach is fueling growth in our full-service commercial services, particularly with our SMID customers. In addition, the performance of our diverse consulting practices remains strong, delivering double-digit revenue growth in 2020 while building a record backlog of work entering 2021. We expect to see year-over-year Commercial Solutions growth in the first quarter when excluding the impact of reimbursable expenses on the medication adherence divestiture primarily driven by continued new team start-ups in Deployment Solutions. We expect to see this year-over-year growth accelerate in the second quarter of 2021 as we begin to lap the impact of our elevated 2020 cancellations.

Before I turn the call over to Jason, I want to welcome our new colleagues from Synteract and Illingworth Research Group to the Syneos Health team. I again want to offer my heartfelt thanks to the entire Syneos Health community for their ongoing resilience, focus, and collaboration as they continue to provide superior execution for our customers on the very challenging circumstances.

Jason will now provide additional comments on our financial performance and guidance. Jason?

Jason Meggs -- Chief Financial Officer

Thank you, Alistair, and good morning everyone. Our total revenue for the fourth quarter of 2020 was $1.14 billion, down 6.1% and 7% in constant currency compared to the fourth quarter of 2019 on an adjusted basis. Our Clinical Solutions revenue for the fourth quarter was $855.6 million, down 5% or 5.9% in constant currency compared to the fourth quarter of 2019 on an adjusted basis. These declines include a contribution of 140 basis points from acquisitions partially offset by headwind of 120 basis points from the second quarter divestiture of our contingent staffing business. Clinical Solutions revenue growth included a 470 basis point headwind from the slow recovery in reimbursable expenses as more of our site visit activity remained remote and patient enrollment continue to recover. Our fourth quarter Commercial Solutions revenue was $284.5 million down 9.3% or 9.9% in constant currency. The decline in commercial revenue was primarily due to the impact of elevated cancellations during the first half 2020 as well as the impact of COVID-19 including a disproportionate decline in reimbursable expenses and delays in program starts. This decline in reimbursable expenses represented a 660 basis point headwind to commercial Solutions year-over-year revenue growth in the fourth quarter. Commercial Solutions revenue for the fourth quarter outperformed our expectations despite being negatively impacted by our divestiture of the medication adherence business. In addition to the strengthening performance, we also have a robust pipeline of commercial opportunities highlighting the demand for our innovative solutions. Adjusted EBITDA increased 3.3% year-over-year to $194.8 million representing an adjusted EBITDA margin of 17.1% an increase of 160 basis points. The increase in adjusted EBITDA margin for the fourth quarter was primarily a result of our synergies, cost management initiatives including ForwardBound and lower reimbursable expenses.

For the full year 2020, adjusted EBITDA was $633.6 million, a decrease of 1.8% with margin increasing 50 basis points to 14.3%. With 2020 being our final year of measurement, we realized our targeted $140 million in total merger synergies prior to the impact of our strategic reinvestments. In addition, it is important to note that our unadjusted EBITDA grew by 10.8% in 2020. This was primarily driven by a reduction in restructuring transaction and integration-related expenses as we wind down the bulk of our merger-related costs. We expect this trend to continue in 2021 with faster growth in unadjusted EBITDA as we continue our focus on cash flow conversion.

Adjusted diluted EPS of $1.11 for the fourth quarter increased by 7.8% year-over-year, primarily driven by the increase in adjusted EBITDA and lower interest expense. For the full year 2020, we generated adjusted diluted EPS of $3.41, up 5.6% compared to 2019, primarily driven by lower interest expense. Our operations generated $114.3 million in cash flow for the fourth quarter bringing the full year to a record $425.5 million. DSO for the quarter improved to 44.5 days. We ended the quarter with $271.9 million of unrestricted cash and total debt outstanding of $2.97 billion, resulting in net leverage of 4.3 times. Although net leverage increased primarily due to the financing of Synteract and Illingworth acquisitions, we remain committed to achieving our net leverage target of 3 times to 3.5 times by the end of this year. During the quarter, we repaid $13.5 million of our Term Loan A and $200 million of our Term Loan B and repurchased $8.1 million of our outstanding shares. Further, we issued $600 million of senior notes bearing interest at 3.625%. These notes mature in 2029, providing additional flexibility in our capital structure.

For the fourth quarter, the issuance of these notes resulted in an incremental $2 million of interest expense compared to our guidance. Our non-GAAP effective tax rate for the fourth quarter and full year 2020 was 24%. Given the benefit of our NOL deductions our actual net cash outlay for income taxes in 2020 was approximately $23 million.

Turning now to our 2021 guidance. This guidance contemplates our current view of the estimated impact of COVID-19 on our business, Recognizing that factors related to COVID-19 are outside of the company's control. Since we issued our initial guidance, we have seen some movement in foreign exchange rates that has resulted in incremental revenue tailwind for the full year while also generating and partially offsetting headwind to our adjusted EBITDA. Given that we are still early in the year and have seen only a limited potential impact, we are maintaining our existing guidance ranges. We continue to expect full year 2021 revenue in the range of $5.13 billion to 5.33 billion representing growth of 16.1% to 20.6%. This growth includes an estimated contribution from acquisitions of 540 basis points to 580 basis points and the headwind from our 2020 divestitures of approximately 110 basis points. With this strong revenue growth and the success of our ForwardBound programs, partially offset by headwind from the expiration of our temporary cost saving measures in 2020, we expect total adjusted EBITDA in the range of $745 million to $785 million. This represents an adjusted EBITDA margin of 14.5% to 14.7% up 30 basis points from 2020 at the midpoint.

Lastly, we expect adjusted diluted EPS of $4.09 to $4.38 or year-over-year growth of 19.9% to 28.4%. As noted on slide 8, our guidance incorporates interest expense of $94 million and non-GAAP effective tax rate of 24% and an estimated diluted share count of 106.7 million shares.

Further for 2021, we expect our net cash outlay for income taxes to range from $50 million to $60 million.

I also want to provide you with some commentary for the first quarter given our normal seasonality and current expectations for the continued pace of the recovery from COVID-19. As Alistair highlighted, we expect year-over-year growth to accelerate in the second quarter in both businesses, as we begin to lap the 2020 impact of the pandemic. For Clinical Solutions, we expect this to be powered by the ramp in our core backlog conversion along with our COVID vaccine trials. For Commercial Solutions, we expect this growth to be driven by robust new team starts in Deployment Solutions along with continued strength in communications and consulting.

We expect first quarter revenue of $1.17 billion to $1.21 billion and total adjusted EBITDA of $141 million to $151 million. This reflects, as reported growth of 0.6% to 4% compared to the first quarter of 2020. This revenue growth includes an estimated contribution from acquisitions of approximately 490 basis points and a headwind from our 2020 divestitures of approximately 170 basis points. This growth is also net of an expected headwind of approximately 210 basis points due to the continued slow recovery in reimbursable expenses. This completes our prepared remarks and we would be happy to answer any questions. Operator?

Questions and Answers:

Operator

[Operator Instructions] And our first question coming from the line of Eric Coldwell with Baird. Your line is now open.

Eric Coldwell -- Baird -- Analyst

Thanks very much and good morning. I was hoping to dig into these commercial bookings a little bit, you always have fourth quarter favorable seasonality or at least that is the expectation, but this was obviously a very good number. I'm curious if some of these awards were related to anything you'd call out as sort of unique, whether it's COVID related therapies or maybe something interesting happening in Syneos One with some of the projects you've talked about in your recent presentations or if it was really just broad based. So just was hoping to dig in a little bit more on the bookings strength. Thanks so much.

Alistair Macdonald -- Chief Executive Officer

Okay. Good morning, Eric. Alistair here. Yeah, we're very pleased with that obviously 1.6 -- in excess of 1.6 times book to bill for Commercial is a great result. Yes, it is seasonality but we're always pleased to see the growth in that number. And I think it's a little bit of all the things you suggested to a certain degree -- there is some COVID work in there, there is -- which we are starting to see more and more of coming through into the Commercial realm. There is a broad-based efforts around the Kinetic platform, we are winning a lot of work with that platform now as people look for more digital approach to field teams and HCP engagement. So the investments we have made in that technology and the processes and people that sits around that are important. I think we are seeing good traction in full-service commercial and that's work that's coming in from Syneos One as you said, but also just integrated full-service commercial on its own, so people buying the whole package from Michelle and her team as we go. And I do think there's also a sense of optimism in that commercial space around the recovery from COVID, so we're seeing vacancy management come back, we're seeing teams launched here and we had a record year in 2020 because the number of teams launched and that a lot of that work is coming from our SMID sector where there it's more teams but smaller, which helps us to continue to diversify the backlog. So really very, very broad -- a very broad base and with -- Eric to now you follow-on question with a robust pipeline going into Q1 of this year, so very pleased with how that's shaping up.

Eric Coldwell -- Baird -- Analyst

I like how you read my thought there a little bit, but actually my real follow-on question was a little bit different angle. I think last year we saw if memory serves, the second best or tied for second best year of FDA approvals for new drugs. And there was -- there has been the sense that pharma is really weren't launching their new products the way they historically did and that there were maybe delays in that traditional if you go back, years ago the original Blitzkrieg that you get upon -- upon approval. I'm just curious, what is the -- what is the backlog or the pipeline look for these newer products and what, what kind of decisions are clients making around these launches and is it-is it really a pig in the python situation or is it -- no we are -- we're changing the game and we're just, we are, as you said, maybe smaller teams maybe more omni-channel we're going forward, but don't expect the Blitzkrieg of the past.

Alistair Macdonald -- Chief Executive Officer

Yeah, I think -- I think some of those bigger efforts will be there. We've seen that little bit in 2020, some of the more strategic partnerships that we've won certainly includes some of those. But I do think it's the nature of the products that are coming through, it's more specialty, it's higher science, less boots on the ground, more educational more support through MSLs and those educators to make sure that the physicians that seeing the specialty patients are -- supports it very strongly in the field with everything that they need in a more omnichannel way, I think omnichannel one of the legacies of COVID that we see is really that shift over to -- a more permanent shift over to a digital footprint in commercial launches, in commercial detailing and the support that we give around that with the Kinetic platform, I think is really -- has been a great recent driver for us. So yeah that innovation needs to be there. I mean, Michelle, your thoughts on the style of launches now compared to where we were just a few years ago.

Michelle Keefe -- President, Commercial Solutions

Yeah, that's a great question and I totally reiterate everything that Alistair said. But what I would add is that I think that customers are getting very smart about how they communicate with all their stakeholders, right. And it's really about data and insights around your different customer mix, whether it's HCPs or payers or patients and creating a very personalized experience for that individual. And so I think what we're finding is that it's not one strategy anymore right, it's not these large sales teams that go out at launch and a bunch of tactics and effort early on, it's really very focused around creating the right message at the right time to the right customer and that those customers-the ROI on those individual customers are different and the relationship you need to have those different customers is different. So I think it's great for the Commercial business because it diversifies the type of solutions we're bringing forward and diversifies our backlog, so I do think it's something that we're uniquely positioned to address, because of the breadth of our capabilities, so it also creates what I think we all want to see which is a more diversified backlog.

Eric Coldwell -- Baird -- Analyst

Thanks very much guys. I appreciate it.

Operator

Our next question coming from the line of Robert Jones with Goldman Sachs. Your line is open.

Robert Jones -- Goldman Sachs -- Analyst

Yeah, thanks, good morning. Thanks for taking the questions. I guess maybe just one on clinical Alistair. You and your peers have consistently talked about delays but not cancellations as it relates to COVID, and COVID work and COVID complications from conducting trials. I guess just given that dynamic, could you talk a little bit more about to what degree there is really pent-up clinical trial demand and as it relates to that, anything you could share on how we should be thinking about backlog burn as we get into 2021.

Alistair Macdonald -- Chief Executive Officer

Yeah, good morning, Bob. Thanks for the question. I think you see a little bit of that pent-up demand starting to flow through. Not just our Q4 book to bill, but those have reported ahead of us all that pretty strong book-to-bills across the space. So we're starting to see that flow come again, the SMID pipeline is very strong and the pipeline the lagged a little bit still is large pharma and I think they're are very cautious to come out, making sure that they're not going to put people in harm's way, etc. So we are seeing that pipeline recovery, which indicates that that pent-up demand is there. Some of it is still COVID driven as well we see, we still see a fairly healthy pipeline of COVID in our overall pipeline, treatment trials as well as some vaccine trials though. So we see that coming through, I think as we -- we start to recover from the lack of sight kind of participation because of COVID, right, because of the -- the site closures, you will see that burn rate pick up for us, our burn rate starts to pick up kind of as we go through Q2 and then accelerates into the back half of the year as those COVID restrictions come off but also as the work that we won kind of from the end of ' 19 onwards, in 2020 for it has been a record year in sales and it helps us to bring that backlog through close on top of that, you've got the COVID, our COVID trials are slightly -- we are probably a quarter behind where some of the others were some of the others were in terms of the COVID vaccine trials coming through. So you kind of get that double acceleration for us where our backlog ex-COVID starts to burn again a higher clip because of site access, etc. and enrollment picking up. We got new trials obviously to go on top of those going through start-up of now. I mean, we talked about our start-up figures were 150% of site activations compared to pre-COVID. We weren't exactly hanging around before COVID, now we've got this massive pile of start-up work that's starting to work its way through the model, those trials will come on to enroll Q2 and onwards. And then you've got COVID that's kind of driving a little bit extra on top. So a lot of growth this year. It's the slope is a little bit steeper because of the recovery rate from COVID than we'd normally expect to see, but we've been preparing for that and recruiting slightly ahead of the curve to make sure that we can handle the growth. So it's an unusual year in that -- in that sense of the growth. it is so quick, but it's got 3 or 4 elements in that are really all tailwind.

Robert Jones -- Goldman Sachs -- Analyst

Yeah, No, that's helpful. And some of this might tie into my follow, but Jason, if I heard the 1Q numbers correctly, it looks like the EBITDA margin at the enterprise level somewhere around 12% at the midpoint. I know 4Q seasonally high but even looking back at 2Q 3Q, that's kind of in line to below, anything specific and it might actually obviously relates to some of the things Alistair just shared. But any specific dynamics that you would point to as far as why 1Q EBITDA margin might be a little lower.

Jason Meggs -- Chief Financial Officer

Hey, Bob, good morning. Yeah, I mean, typically if you go back and look we're in that sort of 12%, 12.5% range in quarter 1, come out of a very strong quarter 4, from a margin percentage basis and dollars frankly, because of the push of everyone to get all their change orders finished, all the taxes have capped out for the year, and on the payroll side you have your PTO vacation reversals where things really just drive that quarter 4 high and then all that resets and starts over and you have sort of this double [Phonetic] whammy to quarter 1 there on the cost side. So it's really in line with what we typically see from those seasonal -- seasonal items and nothing really to point out that's different.

Robert Jones -- Goldman Sachs -- Analyst

Okay, got it. Thanks so much.

Jason Meggs -- Chief Financial Officer

Thanks a lot.

Operator

Our next question is coming from the line of Tycho Peterson from JPMorgan. Your line is open.

Tycho Peterson -- JPMorgan -- Analyst

Hey, thanks. Actually one follow-up on one about questions about the recovery trend, Alistair you talked about said activations net 150% of pre-COVID levels enrollment 120% of pre-COVID levels but obviously you're only at 70% of site accessibility. So I'm curious how you think about kind of resolving the bottlenecks there is the answer, leveraging Illingworth and doing more remote monitoring and making investments there to try to kind of leverage that channel more or other ways to kind of free up the bottleneck.

Alistair Macdonald -- Chief Executive Officer

Yeah, yeah, they're all. I mean, you obviously have to get the approvals in place to be able to do the Illingworth piece -- that home health piece. So there are steps to get through that and also one of the factors in those numbers obviously is though COVID work starts to ramp, we've got a lot of COVID patients and lot COVID sites coming through those start-up numbers. So it's skews the overall a bit. So if you look at that-- just keep that in mind when you think about those numbers that -- that acceleration does have a bit of COVID in it, but I think sites -- so handling issues on a local level through PPE and local kind of protocols, they are engaging more, getting back into enrollment phase. You will see COVID starting to clear in a lot of different countries. I was on a call on Tuesday this week with a customer in India, who was talking about the COVID rates there dropping down to that in the US, we're seeing now in Europe with, there's a lot of optimism I think in the sites so they can get patients back in and get moving forward quicker, so yeah those bottlenecks needs to be managed carefully. One of the real bottlenecks is actually the amount of time people on site can spend on each project. So getting CRAs on site can be a little bit more difficult, but that's where the remote monitoring access comes into clear our backlogs, so you don't have to spend so much time on site. So a lot of different strategies to deal with it, but yes certainly will be leveraging Illingworth to do that wherever we can.

Tycho Peterson -- JPMorgan -- Analyst

And then you talked about FSP we're doubling, obviously Syneos One helping there now that you've got Synteract. Can you talk a little bit more about how that may help drive more FSP in the SMID Cap Biotech base.

Alistair Macdonald -- Chief Executive Officer

Yeah, well, we don't really think about FSP from Synteract. They're more full service model for the emerging biotech, but yeah, I mean overall we are very pleased with our FSP growth, continues to be a tool that we use with our large pharma partners and anybody really with scale to support either a hybrid model or just full FSP's. It is a lot of interest in that. But on the Synteract side, that's really about full service, there are a few little biometrics management FSP's that they have that we've already rolled into our major I mean FSP efforts.

Tycho Peterson -- JPMorgan -- Analyst

Okay. And then last one, you just mentioned the opportunity to leverage Kinetic into the clinical side, how do you think about that is -- that really just to drive faster enrollment or maybe what's the opportunity there.

Alistair Macdonald -- Chief Executive Officer

It's, we're really excited about using Kinetic in clinical, we've used it now probably a half a dozen times or so in big trials and the impact that has is quite -- very marked. So we're very pleased with that as a new tool for us, it really helps to the -- the clue is really in the name of Digital Amplifier something that helps to identify trials on a broader -- in a broader way to people and referring physicians, networks of physicians, so we can target in a way that the technology works to make sure that folks with potential patients are actually seeing the information around trials or in their vicinity in general or in the specialty. So we've seen a lot of referrals through that to actually investigative sites and that's been a great kind of proof point of the model using our insights from commercial -- we use this platform on HCPs to communicate to them and it's really -- it's a really about audience engagement, the patients, referring physicians, etc. are all an audience and this helps us to get the right materials in front of them at the right time when they are receptive to finding out information that could be useful for their patients. So it is a great to, we've got a lot of interest in it from our large pharma clients, about using it kind of across their platforms already. And that's pretty significant if you -- we know slowly some of our customers move some times, but some of them views this tool and they want it for everything. So we're very, very excited about that.

Tycho Peterson -- JPMorgan -- Analyst

Great. Yeah. Thank you,

Jason Meggs -- Chief Financial Officer

Tycho. I just want to hop back on the -- on the FSP question, the full service, I think. Alistair is prepared remarks, he mentioned that we've seen a doubling of our full-service commercial awards in 2020 which is the model we've been driving over the last several years, which things like Kinetic and other investments we've made put the services together. So think of it, FSP on the clinical side has moved to full service and we have a combination of both businesses, we are driving that way on the commercial side as well. Point solutions in the past, we are driving more toward a full-service commercial and overall commercial services and we have seen a doubling of those awards during 2020.

Tycho Peterson -- JPMorgan -- Analyst

Got it. Thank you.

Jason Meggs -- Chief Financial Officer

Thanks.

Operator

Our next question is coming from the line of David Windley with Jefferies. Your line is open.

David Windley -- Jefferies -- Analyst

Hi, thanks for taking my questions. Good morning. First, I wanted to just a clarification, kind of a housekeeping one around backlog where I was looking at the role and it looks like there is a fairly substantial add of some sort. Maybe it's -- maybe it's Synteract backlog or an FX adjustment or both. Is that -- is that the kind of a plug I need to get to the $10.2 billion at the end of the year, looks like bookings by themselves would do it.

Jason Meggs -- Chief Financial Officer

That's right now. So you would add the Synteract and the Illingworth backlog to the core Syneos Health backlog and that's how you would get to the full $10.2 billion.

David Windley -- Jefferies -- Analyst

Do you have numbers for those or I guess I can just back into the back end of the total.

Jason Meggs -- Chief Financial Officer

Yeah, I mean it's. It's roughly, I think you know in half billion range for the combined.

David Windley -- Jefferies -- Analyst

Okay and then Alistair really both of you have talked about comp ramp to Bob's question about first quarter ramp of revenue backlog burn rate kicking in in the second quarter. Just I wanted understand that a little bit better in that I think you're telling us that your site activation activity is running hot because at least in part because of COVID, which sounds to me like those are already starting to contribute in the first quarter, but the burn rate not really grow until the second quarter. So if you could just kind of flush that out a little more, I'd appreciate it.

Alistair Macdonald -- Chief Executive Officer

Yeah, sure, and good Dave for me it's, yeah, you're exactly right, so you get the results of activities going now, end of Q4 into in and through Q1 and then the real revenue starts to flow out of these trials when those patients are enrolling the monitoring is being done and the business being captured. So that really starts to come on stream end of Q1, Q2 for us because that's when the COVID, we got that COVID acceleration coming through from the vaccine trials that we're running and remember a lot of the work that we won in COVID is -- the majority of our work in COVID is on the treatment side, which we're on a bit more like regular trials. So they're not starting up in one month and enrolled in the next. They are a bit more slow and steady, takes a couple of months to get opened up and then enrollments a bit slow. So that spreads it out a little bit, which is why our backlog accelerates through Q2 and into Q3 and not immediately as we hit Q1.

David Windley -- Jefferies -- Analyst

Okay. Final question from me. Jason, you mentioned in your prepared remarks continued focus on improvement in cash flow conversion. And wanted to understand if you're thinking on that say capex declining or just further improvement in DSOs what do you think your levers are there to improve that percentage.

Jason Meggs -- Chief Financial Officer

Yes. So all those things absolutely Dave, in terms of continuing to focus on improvement of our DSO accounts, which is very important and you can see some of that coming through end of the year here, particularly if you look at deferred revenue and what we have done there on the DSO. We are, and will continue to pay close attention to capex, but not, we're not trying to under-invest in the business by any stretch. And then the below the line items over the years as we've put the companies together right, we have had to spent money to do that and launching ForwardBound and we are just focused on all of those, those areas as well.

David Windley -- Jefferies -- Analyst

Okay, thank you.

Operator

And our next question is coming from John Kreger from William Blair. Your line is open.

John Kreger -- William Blair -- Analyst

Hi, thanks very much. Alistair just following up on the comment you made about some of the COVID work a few minutes ago, what is the duration of those awards that you're seeing now across both Clinical and Commercial. For Clinical, can we think of those as sort of 2 to 3 years sort of typical study or will they burn faster from your impression.

Alistair Macdonald -- Chief Executive Officer

That is a good question. I will pass you over to Paul for some specifics in a second. But yeah, they are all faster, particularly the vaccine trials, I think typically obviously going to run a lot faster. The treatment trials tend to have a bit more of a follow up on them to see the overall, the long-term impact, talking about people with hepatic failure or ongoing long breathing respiratory issues that would need to be followed for a longer period. So they are a little bit more graceful in terms of timeline. So, but Paul your thoughts on the overall kind of timeline for those trials.

Paul Colvin -- President, Clinical Solutions

Yeah, no, I think you're spot on there. Alistair that again the treatment trials -- our experiences are more aligned to our normal burn rate. But certainly when you have the -- the vaccine trials there is a faster enrollment in both indirect and direct spend on those. So I think that's the typical that we've seen. I'd say the bigger mix issues will just be around therapeutic area, when you think about burn rate.

John Kreger -- William Blair -- Analyst

Great, thanks. And Jason in the '21 guidance that you've given us for the top line, can you give us a sense about what you expect COVID work to contribute both in Clinical and Commercial.

Jason Meggs -- Chief Financial Officer

Yeah. Hey, John. Good morning. So, yeah, when we, if you look at the, we'll start with Commercial. If you go back to one of the earlier questions. I think it was Eric's question on our quarter for bookings in commercial. We have seen some bookings on the COVID work that we've talked about in prior quarters, but nothing major yet from that, those are, those are still out for approvals. So we're doing some pre-launch work that's coming through. But, it's immaterial but the larger bookings in the revenue from that would be, I would say more second quarter even second half of '21. So, Q2 much there in addition to some of the work we've done, which has been less than probably $25 million and Communications and consulting for kind in 2020. So nothing material there. And on the Clinical side, not material in 2020. We talked about the awards being less than 7%, backlogs even less than 5%, close to 4% if even that and the revenue has been quite low in 2020 as well, again probably less than $25 million that does go up quite a bit as we go through the trials that are now launching, starting, we haven't guided exactly or provided insight into that, but it is a substantial part of the ramp from 2Q onwards. But we just haven't provided specific numbers on that.

John Kreger -- William Blair -- Analyst

Great, thanks and then Alistair maybe one more last quick one with another year under your belt post merger, what are your latest experience around sort of integrated wins, are you seeing those go up or down as a percentage of the total. And are you still seeing those primarily in your sort of SMID client base.

Alistair Macdonald -- Chief Executive Officer

Yeah. It's good question. So integrated wins to me fall into a couple of categories now, broad based large client kind of cross sells where we are penetrating customers in clinical with commercial, particularly around communications and consulting and vice versa, but then obviously the Syneos One platform continues to gain traction in the SMID base certainly, we've got one big partner who uses that model as well which is exciting. And then I think the area that we've seen the most growth which is it goes back to Tycho's question a little bit about where we saw this double is full-service commercial. We saw a full-service commercial packages double in 2020 over what we've done in 2019. And I think that's a model that will gain traction more and more as we move into that more kind of full-service commercial launch phase. So yeah, very excited about those thing.

John Kreger -- William Blair -- Analyst

Great, thank you.

Alistair Macdonald -- Chief Executive Officer

Thanks John.

Operator

Our next question coming from the line of Patrick Donnelly with Citi. Your line is open.

Patrick Donnelly -- Citi -- Analyst

Great, thanks for taking the questions guys. Maybe, Jason, just on the reimbursable expenses part. I know you talked about remaining a headwind in 1Q, can you just talk about that sequentially and also kind of split between commercial and clinical as it is still somewhere in between.

Jason Meggs -- Chief Financial Officer

Yeah, hey Patrick, it's difficult to hear. You're cutting in and out, do not know if your smartphone or not, but the reimbursables. Yeah, I mean it's been disproportionately impacting commercial, but it's been impacting both businesses. Sequentially, when you think about just an organic basis, we've seen a step-up quarter 2, quarter 3, quarter 4, and we expect to see that again in quarter 1 in terms of the sequential reimbursables. But both business is still being impacted year-on-year from quarter 1 of last year where we were pre-COVID. So that's a big driver. If you sort of back out the reimbursable expense impacts in quarter 1, I mean the business is largely flat. So it's a pretty big impact as we, as we outlined. And then we expect to see that continue to grow throughout the year to when we get hopefully through everything first half, and we'll see it continue to go up in the back half. But we don't anticipate, as we've said earlier and I guess in the quarter 3 call that we'll ever see it back to the percentage of our total revenue that it was pre-COVID just given the changes and remote monitoring and remote detailing etc. and the digital capabilities that are now in the commercial business.

Patrick Donnelly -- Citi -- Analyst

Okay, that's helpful and then Alistair maybe one for you. I know you guys have talked about bringing the leverage ratio down to 3 and 3.5 by year end, it's how should we think about capital deployment and M&A this year given -- given the balance there.

Alistair Macdonald -- Chief Executive Officer

Yeah, I mean we want to remain opportunistic is as we go forward. The prime priority for us is to continue to pay down debt. And we've been bringing leverage down over the last 2 or 3 years on that basis, but if there are deals to be done that help us drive toward strategic goals like we did with Synteract and Illingworth, we're going to -- we're going to be interested in taking a look at those kind of took in level of deals that can take us into the high-growth market or can open up channels for us like Illingworth does, so priority is going to be paying down the debt obviously, but we still be open to more deals like that or if there was something geographically we wanted to do we look at that as well.

Patrick Donnelly -- Citi -- Analyst

All right, thanks guys.

Alistair Macdonald -- Chief Executive Officer

Thanks Patrick.

Jason Meggs -- Chief Financial Officer

Thanks Patrick.

Operator

Our next question coming from the line of Erin Wright with Credit Suisse. Your line is now open.

Erin Wright -- Credit Suisse -- Analyst

Great, thanks. Can you talk about the sustainability of the strength that we've seen in real world evidence and with the growth was in the quarter and what your expectations are for the durability of that strength in 2021 that's been a theme across the [Phonetic] real world lately.

Alistair Macdonald -- Chief Executive Officer

Yeah, good morning, Erin. Yeah, we got some of the questions that JPM around real world evidence and it is a very interesting space. We have grown a very good capability there from a smaller base and we saw great growth last year I think it was our fastest growing organic group. So we're interested to keep hiring in that space if we've had a lot of success bringing into that group from over CROs, as well as pharma and I think it's really, it's a really important space to hire people in from a large pharma, who are typically the biggest customer of that kind of service. I do think it's going to be a growth area for the next several years not just 2021 and I think COVID will fuel that as well as a lot of patients that are going to need longer term followup. However, those that were in the vaccine trials, those that are in some kind of deficit from a long -- what we call long COVID or who have been in a trial to look at some of the treatment impacts because we need to see a lot more data on these patients because a lot of it wasn't collected as they went through Phase III because of the speed. So I think that will fuel demand in the long-term follow-up real world space as well as people looking at data using data to answer questions that come back from regulators. So you see organizations who have got the capability to produce regulatory grade submission packages we work with [Phonetic] constant ARI on that kind of thing in the oncology space. So you know that the ability to pull that data together and then look at the gaps that you still have to answer your question from the regulator is going to be a big part of that real world growth as well.

Erin Wright -- Credit Suisse -- Analyst

Okay, great, that's helpful. And then can you speak a little bit about the acquisition of Illingworth and how much that adds to topline growth, presumably that was all embedded in guidance and margin profile as well as the customer base profile and you sort of overlap there and do you anticipate meaningful near term stepped up investment associated with your positioning around decentralized trials.

Alistair Macdonald -- Chief Executive Officer

I'm going to try to remember all of that question that. So I think I'll start with customer profile. So even with a pretty small organization in comparison to the largest right. But one of the things that we immediately attracted to customer base. They work with all the big pharmas globally so you access to new contacts, new channels through that as well. So that's a good element of that. Yeah. We will continue to investing in obviously will be bringing them on to some of our systems, but we're going to use them as an independent business unit, they obviously have some of the CROs as customers to. So we've had conversations with those, and it's a quite a rare asset. So we have to, we'll obviously be delivering for all of the CROs, as well as direct pharma customers, but also being able to introduce that to our SMID customers, we were dealing with outsource work -- dealing with and had a good relationship and they do great work, which is a big driver of the acquisition itself. We will continue to invest in it. Yes. The numbers have been incorporated into the overall guidance and it's a fast-growing area I think fueled by COVID, but it was a fast-growing area before COVID as well. So we want to make sure that we ride that as we implemented as part of our decentralized trial approach. It is so great and while having the right technologies to do decentralized trials, but you still got to go and check on those patients that are being dosed at home and Illingworth gives us the capacity and the reach to do that on a lot of trials and a lot of locations. So we're very excited to be able to bring that to customers as an option. As you know people are a little bit more reluctant to go to a trial site or go to a hospital for treatment if it can be delivered at home, we can now do that. So we're excited about that. I think that covered it all, but did I miss anything.

Erin Wright -- Credit Suisse -- Analyst

No. That was great. Thank you so much.

Operator

Our next question coming from the line of Elizabeth Anderson with Evercore ISI. Your line is open.

Elizabeth Anderson -- Evercore ISI -- Analyst

Hi, good morning, guys. Maybe just sort of a follow on to Erin's question. How are sponsors sort of thinking about some of the more remote patient monitoring and remote trials as we move out of COVID, would you say that it was sort of a stop gap measure, are they more willing to engage in the trial. I just wanted to see how that pacing had changes sort of moving toward a post COVID world.

Alistair Macdonald -- Chief Executive Officer

Yeah. Hi Elizabeth. Great, great question. Obviously, it was used as a big stop gap at the high of COVID not for sure. But now, and it's been something we've been pushing as Syneos but also, as I think as the CRO industry for a while. The customers that we can do remote monitoring, etc. We still have been very active on ACRO on these discussions and talking directly with the FDA on it. The reluctance has always been customers are worried about what the regulator will think of data that's been monitored more remotely. But I think a lot of those concerns are now put to bed because this has been a big test, there's been no real I've seen anyway, no real big quality issues associated with the remote monitoring. So it can be a strategy. I don't think it takes over, I think it becomes an adjunct to a well monitored trial. So maybe you have several visits within an overall program that can now be done remotely or through telemedicine rather than having to have a patient come all the way into a site, etc., particularly if there are a lot of visits, maybe some of those visits can be done remotely. I think you will end up with a hybrid where you still have a lot of in-person trial work at the site supplemented by remote monitoring or alternatively or down from home in the home health channel that if we can our services Illingworth so I think it becomes, it's here to stay. I think if you look to trials. I think it's in 2019, 3% of them had a high level of digital implementation and I expect that will go up to 15%, 20% over the next 4 or 5 years, you have to design these things into new trials as it comes through. So yes, we'll see it more and more, but I think we and of those like they are all very prepared to be able to deliver that.

Elizabeth Anderson -- Evercore ISI -- Analyst

It makes sense. Thank you.

Alistair Macdonald -- Chief Executive Officer

Thanks, Elizabeth.

Operator

Our next question coming from the line of Sandy Draper with Truist Securities. Your line is open.

Sandy Draper -- Truist Securities -- Analyst

Thanks. This is a stand on for Sandy. Maybe we can keep the distributed trials going here, I'm just thinking about obviously distribution of trials of kind of puts the script on the quantity of sites that you're working with. How do you think about maybe the capacity to handle a more of a distributor trial type of environment, is there a theoretical ceiling to how many trials you can handle, that have a distributed component to them.

Alistair Macdonald -- Chief Executive Officer

Good question. I don't think so. I mean obviously down the home health channel Illingworth is a smaller organization but we tapped into big home health networks -- big home health nurse network so the capacity for that pretty good and can expand and scale very rapidly. So in that sense, no and remote monitoring actually takes some of the bird and down on the site. So I think it's a site designed -- as trial designs mature and maybe incorporate a little bit more remote and a little bit more home health, it probably takes a little bit more pressure off of the in-person monitoring, with those resources have been pretty thin over the years and is always a bit of a [Phonetic]silent war in there so, I think probably helps rather than hinders in a way and helps us to service more down because you've got 2 or 3 channels, potentially within any one trial rather than one single channel.

Sandy Draper -- Truist Securities -- Analyst

Got it. That's helpful. Maybe one more from me on Synteract. I'm just curious about your integration plans, is the plan here to fully roll up Synteract into your core operations or is it going to operate separately and maybe how it does the go-to-market strategy really in the same way as it is separate or is it going to be integrated with the core of Syneos operations.

Alistair Macdonald -- Chief Executive Officer

Yeah, we are holding it as a separate business unit, which services are emerging biotech group. And I think the Synteract team has been phenomenal since they joined us in working and how they plug in. What we saw in due diligence with them was a very different customer base. And their customer base wants that agility, they don't need to be kind of institutional hammer that Syneos Health can be some time but they won that nimbleness in the project team on that direct contact high touch kind of engagement and we do a lot of that with our SMID clients but our SMID clients are quite big now where they need that structure, the Synteract group have that more agile boutique kind of CRO field. So we're trying to maintain that, obviously the back end the G&A is going to be integrated now and where we can support from a functional perspective, biometrics etc. that's coming together, but also one of the -- one of the big elements of working with Synteract, they had a limited geographic footprint really to Western Europe and the US or North America, I should say. So when they were not work that was truly global which they do win quite a lot of that they weren't able to service all of that work in Japan and Asia and Latin America and what we do now for them is we all the network, so if they want to study that we got a couple of million bucks at the monitoring out in Japan or China Argentina wherever it may be, we now do that work for them. So it's good revenue synergy there between the organizations as we built. So we'll keep it as a separate business unit targeting that high-paced, high-growth emerging biotech sector and is integrating well so far.

Sandy Draper -- Truist Securities -- Analyst

Got it. Thank you.

Alistair Macdonald -- Chief Executive Officer

Thank you.

Operator

Our next question coming from the line of Dan Brennan with UBS. Your line is now open.

Dan Brennan -- UBS -- Analyst

Great, Thanks for taking the questions. I may have missed it, Jason and Alistair. So just in terms of the outlook for '21, did you discuss kind of Clinical versus Commercial, what to expect there and then you know the burn came up a few times. Jason, but just what would the clinical outlook imply the burn rate to go through the year.

Jason Meggs -- Chief Financial Officer

Yeah. Hey, Dan. We haven't talked specifically about Clinical versus Commercial but when you look at obviously Synteract and Illingworth and the contributions we talk about there on the M&A side, that's clinical and then if you look organically without all the divestiture activity that has happened, because we've had a divestitures of contingent staffing in clinical and then the medication adherence in commercial. Think about commercial being above the sort of organic growth rates that we've talked about in the business and clinical as well. So that's kind of a steer of how we're looking at. It's a strong years as Alistair said for both segments. On the burn rate on the clinical side, we've talked about how we bottomed in quarter 2, the COVID, at 8.7 and has come up to that 9.2, 9.3 range, typical seasonality in quarter 1, that we see every year where the burn rate can step down plus we've had strong awards just mathematically can cause it to step down. So it will step down some in quarter 1 as we've outlined and then start to recover again through Q2 and through the back half but not getting back up to that 11%, 11.5% given we've seen our average study period extend from low 50 [Phonetic] mots to 60 mots given all the oncology and Phase III work that we're winning. So that's how we're looking at it thinking about it on the burn rate side.

Dan Brennan -- UBS -- Analyst

Great, thank you and thanks, Jason. And then maybe within Commercial could you just give us a little bit more color on deployment and communications how we're thinking about the outlook in '21 there these talked about some pharma sales, head count reductions that they are anticipating in ' 21. Are you seeing anything on that front or is that factored in the guidance. Thank you.

Jason Meggs -- Chief Financial Officer

Yeah, Consulting has been growing, continue to grow just really strong business. The Communications business has been performing really well, winning a lot of new work and really starting to hit their stride there and Deployment Solutions I think Michelle has talked about. Alistair talked about how we launched a record number of teams in 2020 and we'll continue to see that this year. And that's before we start seeing the Syneos One team come in that we've talked about the COVID opportunities that if they are approved. So really all business is doing well and we expect to grow and then Michelle, I'll let you talk a little bit about the reps and the VEBA discussion.

Michelle Keefe -- President, Commercial Solutions

Sure. So, no, it's a great question. So one thing I always say is that there is more than one CRM company, so they have to how that managing market share between companies and CRMs, I can't speak to that that but the the jump that that means that there is a reduction in overall sales representatives. I don't know if you can make that leap. I think what we're seeing is a diversity in the types of people that pharma needs to launch their brands right So you hear us talk about nurse educators, clinical trial, liaisons, reimbursement specialists, etc. With the way the FDA's approving new products that again was 57 in 2020. They tend to be more specialty products and they are more complex so the types of people calling on customers is a much more diverse group of background. And then when you layer on the fact that we have been very successful in enabling them to be fully digitally enabled and virtually enabled an orchestrators and managing their HCP interaction. We're finding that it it's just a different type of commercial model launch so overall, we have seen a lot of interest in the business and we see folks starting new teams with us that I think as Jason said, we had a record number of team start in 2020 and we also because of our full-service commercial, which is another piece of information we have good line of sight between Syneos One and full-service commercial, 2 brands that we're currently doing clinical -- I'm sorry consulting and communications work on that have not launched teams yet. And it's not in our backlog and it's not in our and it's not in our goals of of work target yet, right, because it is 12 months out. And so we have good line of sight to that as well, so we feel very strongly that our business, that's not the case.

Dan Brennan -- UBS -- Analyst

And then if I could sneak one more in, with the variance that have come up there is slightly a longer tail to a lot of the COVID work that is being done. Would you care to give us a view, and I think COVID bookings are less than 7% of total in '21. less than 10% of bookings in 2020, what do you think that ticked up of this year given the pipeline, the demand that you're likely seeing now for additional COVID work.

Alistair Macdonald -- Chief Executive Officer

Yeah, that's a good question. I think with the variance that we're seeing and work moving into a long-term follow-up real world, I could see it being, I could see the pipeline staying roughly where it is for a quarter or 2 more and then it depends what happens with the virus right. In all previous pandemic like this, you see 2 peaks and then it goes away. We've had a second peak largely seeing lots of buyers numbers dropping in around -- around the globe, either through locked downs or a little bit more naturally so there is a lot -- there's a lot of environmental factors to kind of pick a number around that, but I think we'll see a continued kind of RFP flow in and around COVID for several quarters yet probably -- possibly through the end of the year and maybe even 2020. It's just hard to call at the moment where that goes. Because if everybody get a handle on it, vaccine rollouts successful does that demand drop away. I don't know, but well we see more demand for ongoing longer COVID long-long COVID trials. Again, I think probably yes but I just don't know to what level. So it's a really hard question to answer, I think.

Dan Brennan -- UBS -- Analyst

Great. And that was really helpful. Thanks again.

Alistair Macdonald -- Chief Executive Officer

Thanks, Dan.

Jason Meggs -- Chief Financial Officer

Thanks.

Operator

Our next question coming from the line of Jack Meehan with Nephron Research. Your line is open.

Jack Meehan -- Nephron Research -- Analyst

Thank you. Good morning. I wanted to continue on on the vaccine work, it sounds like you've won some more business since the last time we spoke, just to clarify, is any of this OWS related and then just thoughts around given we have the approved vaccines and there is some variance out there just the level of visibility into this work progressing, as it's built into the ramp and any risk around cancellations, just your thoughts around that.

Alistair Macdonald -- Chief Executive Officer

Yeah. Thanks, Jack, say so. I think the answer to the OWS is no, we've worked on through the OWS things in terms of functional support, data management analysis, etc. and the new work that we are working on is, tends to be not that, smaller companies. non-US entities so kind of more global work and yeah, with the profile. I mean the majority of our work is the treatment -- is on the treatment side, so there's obviously a lot of that going on good access to patients, we're seeing good enrollment in those trials. On the vaccine side, I think the vaccine trials that we've got going are enrolling well. There's still a lot of -- even though the numbers are trending down in several Western market you still got a lot of COVID in other locations, So these are global trials, where we're seeing a lot of enrollment in around the globe. Latin America, Asia, etc. So yeah, I mean if it's the vaccines well and there is vaccine equity so all countries are getting good vaccine program going distributed then yeah there will be, it will be harder to find patients as we go out, which is great right. That's kind of what we want almost as a society. Well, that's what we do want as a society but we'll deal with that as we go. You got to stay flexible and be able to move to different sites where there is low collaborate. So it's countries without a high level.

Jack Meehan -- Nephron Research -- Analyst

Appreciate it. And Jason one clarification. For the first quarter guide for the 2 segments. I appreciate all the qualitative commentary you gave, there is obviously a lot of moving parts with M&A divestitures, FX, reimbursed expenses. I was wondering if you can just help us with maybe some revenue ranges for clinical and commercial for the first quarter.

Jason Meggs -- Chief Financial Officer

So I guess we're not officially guiding Jack by segments, just given the integrated nature of all we're doing these days and how Syneos One and the different full service product development capability we are dropping in, but I think the way to to think about it is with reimbursables performing the way they are these teams standing up on the commercial side. Think of that sort of flattish to down a little bit sequentially. Just given seasonality and then clinical is obviously going to be when you think about core Syneos plus the plus the acquisitions.

Jack Meehan -- Nephron Research -- Analyst

Yeah. That's helpful.

Jason Meggs -- Chief Financial Officer

Jack. Okay. I mean I think that will help you in getting to the range there.

Operator

That's all the time we have for questions today. I will now turn the call back over to Mr, Alistair Macdonald for closing remarks.

Alistair Macdonald -- Chief Executive Officer

Okay, thank you. So our sincere thanks to the entire Syneos team for all they've done in the face of these unprecedented conditions that we faced over 2020. We remain very confident in our market positioning and look forward to strong growth and profitability in 2021 as the recovery from COVID-19 continues. So thanks for your attendance today everybody and for your continued interest and investment in our organization. Please be safe. Have a great day and be good, see you soon. Thank you.

Operator

[Operator Closing Remarks]

Duration: 76 minutes

Call participants:

Ronnie Speight -- Senior Vice President, Investor Relations

Alistair Macdonald -- Chief Executive Officer

Jason Meggs -- Chief Financial Officer

Michelle Keefe -- President, Commercial Solutions

Paul Colvin -- President, Clinical Solutions

Eric Coldwell -- Baird -- Analyst

Robert Jones -- Goldman Sachs -- Analyst

Tycho Peterson -- JPMorgan -- Analyst

David Windley -- Jefferies -- Analyst

John Kreger -- William Blair -- Analyst

Patrick Donnelly -- Citi -- Analyst

Erin Wright -- Credit Suisse -- Analyst

Elizabeth Anderson -- Evercore ISI -- Analyst

Sandy Draper -- Truist Securities -- Analyst

Dan Brennan -- UBS -- Analyst

Jack Meehan -- Nephron Research -- Analyst

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