there are many. this is a virus coming from the french word [inaudible] and there are two viruses in this particular family, both ebola and of marburg. the ebola name actually came from the ebola river, which is in the republic of congo that was first discovered in 1970. there are five species of this virus and all of them reside in africa except for the one that is found in the philippines. that is the one that does not infect humans as far as we know. the strain is certainly one of the most feared with very high mortality. the outbreak primarily began in

central africa and this includes the outbreaks that have been reported worldwide and have been garnered. it is actually relatively recently that this has emerged in west. and in fact this actually started around the area and this includes where siberia and liberia intersect. in an embossed the case of a 2-year-old boy and this includes moving into sierra leone and liberia. and so nice chain of events, if you will, with transmission moving from very remote areas

into urban areas. and that is one of the most notable features of this particular outbreak. and they are found to be over 8000 suspect cases and half are little but more than confirmed. the country that has been most affected by this has been liberia and also significant cases in sierra leone and guinea as you all know. what is most important is that most of these cases have occurred in last three to four weeks and the burden of this particular outbreak is increasing. so in the democratic republic of congo, the outbreak is actually a separate outbreak and begin in

the province were some of the original optics occurred with a pregnant woman that budget is animal that was killed and given to her by her husband. since then they have had 71 cases and it appears that the outbreak is slowing down and they have had 43 deaths. what i would like to talk about now is the clinical presentation of this because the disease presents very acutely, usually six to 10 days after exposure but up to 21 days and very nonspecific symptoms with fever and weakness and diarrhea and vomiting, severe headache. it sounds like influenza and that is one of the big challenges. it sounds not only like influenza but larry at and typhoid fever and a lot of things that you see on this part of the world.

and it's really not as dramatic as in the movie outbreak. what you see is even a rash that looks like this, hemorrhaging is actually pretty rare. even in many situations of less than 15% of the cases. so it's not really this that is bleeding to death in these patients. this is a cartoon of how the disease progresses with the non-specifics and the symptoms that occur early on and then you move to the more hemorrhagic phase to reemphasize it can be minimal. between six and 16 days is when people declare them elves and they can progress into a bigger

form of the disease or they can move into a phase where they have clinical improvement, which is actually thought to be partly associated with an immune response. so i'd like to argue that we need to move away from isolating patients and i would like to show you some data about basic medical care and make the argument that this is like hiv where we argued that we can take an hiv drug into africa and improve the outcomes. so i think that we can take the bold medical care and improve outcomes. so this is data and there is an outbreak of this hemorrhagic fever with extremely high cases of fatalities of around 87 or 88% in africa. ..

the use of electrolytes without being able to measure electrolytes so we are just giving people electrolyte supplements and therapy that the case fidelity rate where they

have tried this or the etu via bullet treatment centers has dramatically decreased. they are investigational therapies that the talk about in the western world, i'm not going to dwell on these because someone later in the symposium will be giving a much more area dight discussion than i can give. but just to note that these have not been used in africa. they have been primarily used here. now the second component of this is hardly against transmission and i fully believe, you will never get anybody who works in infection control telling you we must not do infection control and i believe isolation welcome need to do is use to break infection. through breaks of the skin mucus membrane exposure and exposure with needles. initially as i mentioned you can get infection from me eating

bush made or infected animal but the transmission from human-to-human is really the contact in the direct contact with the secretions whether it's sweat or blood etc.. there is no evidence really of airborne transmission with this particular virus. it can be aerosolized by some of our medical treatments but at this point we don't think at least the zaire strain is. so the risk of transmission, what do we know about this? as i said there have are been 26 prior outbreaks. all of these have actually been terminated with pretty simple barrier precautions. a lot of what you are currently seeing has not been needed to determine these outbreaks. it requires a very assiduous attention to making sure your

tpp is appropriate but it doesn't need to be super complicated. now what do we know about these? one of the outbreaks were we have the best data, 16% of household contact developed a bola. 29% who had direct contact with cases their fluids became infected but no household members who had no direct contact became infected. so i think that's one of the messages we can dispel is that if you don't have contact you are not going to become infected. interacting in this outbreak 80 of this outbreak 80 of the cases so 80 out of the 315 were health care workers and the epidemic was arrested by the institution a simple barrier precaution in intensive training. this is an active -- epidemic curve from pickwick pickwick and here's where the implemented barrier precautions.

you can see that there were cases for about a week after the implementation that would fit with the fact that these people were incubating. there was one isolated case and by the way the black bars are health care workers. whether there was transmission and this particular health care worker admitted to rubbing her eyes. in terms of uganda what have we learned? 26 laboratory confirmed cases and the specimens were tested using rg tcr. they actually found a confined virus in many of the bodily secretions. you can see blood in the stool. seaman can continue for up to 90 days after you get better from the infection. what i found most interesting about the study and the reason i present it is among the environmental isolate none of

the isolates were positive for nonbloody specimens. this is truly the bloody specimen where you can isolate this in the environment. and then finally there is the very similar case from a johannesburg hospital, an unrecognized ebola case became an recovered recovered. the patient had upper and lower endoscopies during their care and in anesthesia assistant put in a central line. he had many procedures they would see commonly in the hospital. hemodialysis and wasn't debated and ultimately died. despite this they had no secondary transmission. so what about spain and alice? people say trish what happened there are? what i can tell you is there is

a very dangerous moment when you undress and this is not a health care worker issue. this is really a systems issue. when you get out of these isolation units you are tired. you take off your protective gear. you are sweating and remember it's about 115 degrees in these foods especially if you are in africa. you take off your glasses or you just touch her face like that. it can be something as simple as that there can be almost devastating and it's very unforgiving to see. so what do we do? we want to identify cases as david peters mentioned. we want to triage these cases. we certainly want to put in place infection control and we want to train people about doing it. i'm not going to dwell much on these. i think david covered this well but just really wanted to point out that this outbreak has been complicated by a lot of human

factored distrust not only at the government but of medical care providers. by improving outcomes i think we can improve that distress. the other human factor in terms of medical infrastructure, these are rudimentary overcrowded hospitals. i don't know how many of you heard the piece on npr this morning about the initial case in liberia and the challenges with isolation. there's a lack of personal protective equipment. sometimes it is reused and not appropriately cleaned. sometimes it's even makeshift. just to give you a sense of this, here is from a mmwr last week where they talked about challenges with supplies of nonsterile gloves, obstetrical gloves that were depleted are absent.

there are not many handwashing statements. the handwashing station consists of water jugs and even sometimes those are scarce. their supplies of soap legion alcohol or depleted and you have as i mentioned rudimentary isolation facilities. david really dealt with some of the challenges with the cultural habits that have complicated this. let me just summarize by saying this is an acute viral illness that from our perspective what is remarkable about this this mers cokie h. seven and nine is one that is impacted health care providers who are just doing their jobs. i think that all of these are examples of failure of infection control. this is something that is not. it's just about doing it right.

it's about learning how to drive. we have to really start thinking about paying attention to how can we drive down this road a little bit better? to read garner the kind of respect, not respect but the kind of trust we need and the medical care i think we have to change the paradigm of care look at the data about hydration and integrate those into the public health response and start talking about not only decreasing transmission by isolation and prevention but also by increasing mortality so thank you. [applause] >> we are going to move on to her next speakers. josh michaud associate director of global health policy at the

kaiser family foundation and professorial lecturer at the international development department at john hopkins schools for international studies. his talk is entitled financing and governing the global response to ebola. are we where we need to be? >> i think we are ready to go. it's a pleasure to be here and thank you to the organizers for putting this wonderful program together. some honor for me to join the rest of the speakers to talk about this very pressing issue. my talk today is going to be

focused on three main things. i wanted to cover the economic, social and some of the political impacts of ebola in west africa. i wanted to talk about the response the u.s. government response date and the international community responds as well as the financing that's been provided to support the ebola response in west africa. then i would like to take a step back and look at the broader implications of this outbreak for the governance of responses to public health events of international concern. so i think the cases have been mentioned already. we are up to over 4000 deaths in west africa from this virus across, five countries that have had cases that the three most effective countries and what i wanted to focus on the first was the broader economic and social

impacts. the world bank put out a study initially in september and they updated it last week discussing what they saw as the economic impact of the opal epidemic in the three most affected west african countries. this is just one of the charge from it. there are many different ways that they have slice and dice the data but they have looked at several scenarios going forward one were ebola is well-controlled which they call low if poland one where the epidemic is not controlled and by the end of 2015 you have on the order of 200,000 cases which is a very high estimate. but should that occur the economic implications are very dire. in 2013 both sierra leone and liberia were among the countries that experienced the highest rates of growth in the world.

sierra leone was second and liberia was sixth actually but the ebola outbreak has already caused the economies in these countries to shrink and that trend will only continue. wrapped up in this economic data is what's going on, the major sectors that are drivers of the economy in these countries, the agriculture sector which makes up 50% of the economy in my area, the mining sector which makes up a great portion of the economies in the country are severely impacted by the controls on movement and the decisions made by individuals and firms and businesses to not engage in productive economic behavior. the fiscal implications and the tax revenues for these governments at the time they need to be spending more on responding to the epidemic have

been shrinking. tax and tariff revenues are down and will continue to do so. but most of the cost from the economic contraction is due to this aversion behavior with the economists are causing -- calling the version behavior basically the fear and distrust demonstrated by the virus. while we don't have good data on the impact of that particular behavior in west africa right now the world bank did a study on the sars epidemic and found a big billions of dollars lost during that epidemic in 2002 and 2003, 80 to 90% of the economic losses could be explained by this aversion behavior not the direct cost of patient care but not the indirect cost of lost productivity. so this is obviously a very important for the government and the liberian government itself has said this raises the specter

of this becoming a failed state. as the government representatives themselves. they were meant to have a national election today but were unable to hold it and had to postpone it due to the emergency from ebola. turning now to the u.s. government response there are multiple u.s. government agencies that have responded to the outbreak in west africa. i want to talk about all of these. some of these agencies are focused on vaccine development and we have other speakers to cover that topic but i will talk about usaid, cdc and the department of defense. usaid is the lead government agency in charge of coordinating all the different u.s. government agencies involved in responding with africa. they have a disaster assistance response team which has been on the ground since early august. 20 to 30 people and they

coordinate all of the resources provided by the others. that includes the cdc which has on the order of 120 or 130 station across west africa right now the largest deployment of their staff for an international health response. it's the first time the u.s. government through the office of foreign disaster assistance has declared a disaster that is a public health disaster so there are a lot of first involved in the response to this. as you likely have heard the military is becoming involved in the ebola response. president obama made a statement about a month ago now saying that the department of defense would become increasingly involved. at the time he stated that would mean 3000 troops would be sent over to assist in response. that has now been bumped up to 4000 troops. not all of those are in the

process of scaling that up somewhere in the order of 200 to 300 troops are there right now but their responsibilities is to help build the ebola ebola treatment unit and liberia. 17 hundred units is going to set up a training program for up to 500 health care workers a week to help staff those ebola treatment units. they also support logistics and transportation by a created an air bridge for moving personnel and equipment and also are involved in laboratory testin t. there has been a bright line that has been drawn by the leaders in the department of defense and no military medical personnel will be involved in direct patient care. at least that's the thinking right now. so the funding piece of this, this chart shows you on the line as the cases have increased over time the commitments by the u.s.

government have also increased. there was an early response back when the first cases were reported out of any cdc involved in the early response but that led up a little bit in august is the first teams were sent out and then of course last month we dramatically scaled up. the pledge for the us government for september was $750 million would be provided to support ebola response. this has now increased in october to 1.25 billion dollars, 1 billion of which is made up of the department of defense budget to be reprogrammed for the funds meant for supplemental funding for the war effort in iraq and afghanistan now provided for for this he did -- humanitarian effort. clearly the largest expenditure in the humanitarian effort into

your t's history. but that money is not ready to go. the congress asked the administration the leaders of the department of defense to provide a detailed plan about how that money will be spent and in which ways they plan on doing that. by the end of this week is a matter of fact. turning to the international response what has been the international donors support for the ebola response. this data comes from the u.n., the office of the coordinators for humanitarian affairs. they have a financial transit tracking service which tries to keep tabs on all of the money being provided by all the different players not just donor governments by private actors as well that are being funneled towards the support for the west africa response. i just pulled out some of this information. you can see at the top there are

two categories of financing. there are contributions and commitments which are considered to be firm either money in the bank or commitments made on a legal basis as pledges of support. it's important to keep in mind what is a commitment to what is the pledge and you can see together they total $818 million. i pulled out from that data the commitment in the bar chart by various donors and actors. you can see the united states has provided the most in terms of financing to date but there are other very important supporters such as the world bank and the african development bank. even the gates foundation pledged $50 million and have provided 14 of that as far as

the data showed yesterday. other governments have provided much less of course and there has been some pressure on other wealthy countries to provide more support. this is what is then provided and what is the estimate of what is needed. the u.n. has done an estimate of that and released a report in the middle of september. basically outlining what they see as all of the financing needs that would be required to mount a full and complete response to ebola in west africa. i won't go through all of these categories here but you can see there are fairly comprehensive in that they not only consider the cost for treatment of individuals and in ebola treatment units and tracing from a public-health standpoint but also food security and providing nutrition making sure that there are transport and fuel for cars

and vehicles and also community engagement. if you add up their assessment of all the things that are needed to get to basically a billion dollars for the next six months for the ebola response. we think back to the previous slide in terms of firm commitments we have half a billion dollars or 50% of this need estimated by the u.n.. if you add in the pledged amount we are about 83% of this total. so that's the financing piece but of course if you are going to build 17 ebola treatment -- you will need to staff them. one of the most striking figures at least to me from a recent world health organization situation report from last week was this chart showing the bed capacity and requirements for patient for a bowl in the three countries most affected. you can see in the case of

liberia and sierra leone that only 20 to 26% of the cases that need to be isolated in beds are currently in demand so it's much higher than the current capacity as far as estimated by the w.h.o.. these data come from the ministries of health of the relevant countries. so another bottleneck here is not just financing but where will all of the health care workers put all of these beds and clinics come from? there is work being done to train us health care workers but that remains a lot more to be done. the president of sierra leone said he believes up to 3000 people will be required in this country alone. so just to close i would like to step back a bit and talk about the governance and the financing

response to emerging infectious diseases in general. the theme that have been emerging over the past several months in relation to ebola have been the international community has done too little too late and has been poorly coordinated as it has approached this. it might seem ironic that it's less than 10 years ago that the international community came together to basically reinvents the framework by which they come together and mobilize against emerging infectious diseases. that framework is the international health regulations which which were a vice in 2005 and came it into an effect 2007. now that framework when it was revised expanded w.h.o.'s mandate in the context of these public health offense of international concern and a set minimum requirements for countries to build the capacity

to prepare for it to detect and respond to emerging events of international concern within their borders. and so in theory that the framework was there but clearly in reality the investments have not been made over the seven or eight years since that document was signed. the weakness had been all along that these countries that are very poor are unable to invest in their core capacity. there is no mechanism or no requirement for international assistance to help in this regard to build up the health capacities. everyone was on their own. even though it wasn't in the best interest of all to make sure that the capacities did exist. so right now and even earlier this year there have been an effort to bolster that effort.

the u.s.-led effort to make the international health regulations vision a reality is called the global health security agenda and this was launched in february. you may not have heard about them but you may have heard about it now. it was announced on the day that the u.s. government was closed due to a snowstorm. they didn't gather the kind of attention that it is now because the ebola crisis represents the exact thing that this agenda is trying to address. recently a few weeks ago they had a meeting to bring together leaders of the u.s. government and there was very high-level representation. including president obama as well as the organizations and 30 other partner countries which made pledges toward building capacity in their own countries with assistance from united states. as of now there's no additional money associated with this

agenda. it's really meant to be a mobilizing force to get the different actors to work towards a common goal of building public health capacity. another idea has been quoted last week by the president of the world bank jim kim saying he thinks there needs to be a global pandemic emergency facility basically pre-positioned money and access including personnel who are experts in responding to emerging diseases. that can be rapidly mobilize in the case of an epidemic. this is an idea at this point and it's unclear how it would work out but it's clear from these efforts that the framework encapsulated by the international health regulations hasn't done the job it was intended to. either by working on all string those or going around world health organization's and another sensitive as global

pandemic emergency facility. there are attempts to try and tweak the system and make it work better for the next time. in closing i would just say the lessons that i can see from this epidemic so far in the broader landscape of governance and health emergencies are that there is no substitute for making sure that every country has the basic capacity to detect and respond to emerging infectious diseases because they can and do arrive and spread without warning. therefore any country without that capacity becomes a weak link for its neighbors and perhaps for the entire globe. finally under funding global institutions needs to underwhelming results in a time of need. thank you. [applause] >> thank you for that. we have incorporated time for

questions at this symposium because we feel it's important to have people not to speak to the audience that set up a conversation between the audience and the people have gathered here here. there are two microphones on the side here. right now this is a natural breaking point and i would encourage anyone who has a question to walk right up and we will call on you. if i can ask the three speakers from this morning symposium to come up and field some of these questions. this is a natural breakpoint in her presentation. we have heard about the ebola outbreak in some of the responses. please use the microphone. we will field some questions about this part of the presentation before we move onto the second second part of our symposium. >> if the mics are active we can start.

[inaudible] >> some of them are older in 2015 and some of them are couple hundred thousand. i saw one projecting 15,000. what assumptions go into those numbers and how many cases will we have by 2015 and which one do you see as closer to reality? >> i am happy to answer that. josh epstein will be talking a bit more about this because it's part of his talk. i don't think any of the numbers can be believed in terms of what the projections are. some of the high-end projections are over 4 million but the problem is the assumptions that go into it are very unclear and the types of models we have are rather outdated. so for example the model we see from cbc assumes there is 2.5 times as many people that are identified.

they have assumptions about full mixing of the population and assumptions that basically look at what happens at the hospital and the community and burial and they have these contained areas where different transmission rates but they don't account for changes in behavior and changes in implementation. they are really kind of rigid in terms of what they can do. i would look at the model not so much in terms of the exact numbers are of what protection because none of them have a way of changing the exponential curve until it saturated and that is clearly not the case in reality. you can use the model is an indicator of relative impact of different strategies at this time. i think that this is an area of importance of developing a different class of models that can be more responsive and put

in place in the future. i think josh will talk more about this specifically. >> good morning and thank you. i am from library and i have been here for three months. i was at cdc attending the training course. my concern here is we figured out at that time most of the international organizations the ngos and nongovernmental organizations are now going to cdc to get trained. it's an intense course for three days. before they can go to any of the west african countries. a simple calculation, some of them were researchers and people who would not be working in the clinical aspect. if the cdc is -- is johns

hopkins thinking of also developing a site for training volunteers or others who want to go to these countries? we asked the question at cdc because there are many nurses and health care workers in minnesota. we asked them is their problem they don't have enough instructions so i was wondering if would be better these training -- are set up in different institutions? >> i don't know. >> i think it's a good question terms of what we can do in the hospital. i think it's one of the reasons why we got involved in, because it was being able to do the training they are. partly it's also a question of being able to adapt to their resources that you have so that

kind of protective equipment we have here in the hospital is going to be different from what we are going to be able to get in liberia and sierra leone and guinea. it's a good point whether that can be more in the u.s.. i think it's important. we found an opportunity to do something practical and get health workers in these coherent units together and hopefully we can build from that experience. >> we have dave kelen who can also comment. >> w.h.o. is doing training so there are multiple groups that are doing training with one of the challenges is the efforts have not been well-integrated or catalogued. so it's hard for a lot of people to really get their hands around all of the activities that are ongoing. i think your point is absolutely valid and that we do need to

make sure that we provide these resources and this is something that we are good at. but really to do this effectively they probably are going to have to really encourage a lot more international leadership than we have seen today. >> thank you for that comment. i think it really helps concentrate the will of the institution to step forward into this type type of training. it's a fairly major effort of foot involves in the institute for mr. armstrong himself is one of the board of trustees to put a major program together related to the training, training the trainers and training individuals and this is actually going to get started in a major way tonight and already has senior level institutional support.

the real question is how quickly can we act because your question is we need these people now. there are people who want to be trained and everybody going to the cdc is just a little bit of a trickle. it helps us to concentrate the urgency to put these programs together. >> do you have a question? >> good morning. the ebola has created a lot of -- and sierra leone. in sierra leone there are over 50,000. [inaudible] are there any plans in place to take care of orphans who have

lost family members to ebola? 's. >> i don't of any large plans but it's certainly something that was highlighted in, by the, team and unicef so it is part of what they have asked us to do as well as the community mobilization team to look at what you do with orphans and also actually there's a lot of stigmatization around survivors as well as well as a lot of psychosocial trauma among caregivers. there is a need to have that kind of program to address those kinds of concerns for orphans as well as for survivors and caregivers. i think that's something that is going to emerge and something we are working on. again i think we are a small part of what has to be a larger effort.

>> i know the save the children is working on this very topic and is try to bring awareness. those are two organizations. save the children would be a good place to look for those efforts and where they are. >> let's take one last question. >> my name is catherine bertram and my question is in relation to a slide from trish pearl map showing the three stages -- trish pearl and it looked like the slide that was in the latter stage where your immune system is going to kick and are not. my question is what do we know about cases where maybe the immune system kicks enduring the earlier stages or if there are cases where there are mild

symptoms that present where the regular immune system kicks in? >> i think there's going to be a little bit of discussion in the next session about some of this if you care about the people are given serum early on in the illness and it's an attempt to neutralize anybody early on. i think that there's a sense that this act acts like a lot of ordinary viruses and that you can modulate the immune system in a way to impact not only the severity but even perhaps the development of infection. the other types of interventions that are going on is they are vaccinated people early on after exposure to see if they can prevent also the severity of illness.

i would say there is not a lot known about the pathophysiology and one of the things a lot of the research community is trying to do better understand the mechanisms of illness given this is the first time the developed world in a large way is involved in the care and having access. i think there's a lot to come but i know dr. jahrling will be speaking about some of these issues in the next session. >> thank you very much. [applause]

>> good morning. i'm honored to be participating in this prestigious symposium. i will say at the outset that is the director the research facility we are in the business of developing countermeasures for those organisms which require high levels of biocontainment and what keeps me up at night is what happens if one of my lab workers catches this experiment. we do have medical treatment facilities and special containment studies unit in bethesda. we will handle cases of occupational exposure from the four teacher campus. cdc has memory and two years ago i convened a symposium with two

colleagues rick davey and lisa hensley bringing the medical directors of those various facilities together to review medical countermeasures that could be possibly pre-positioned in those facilities so they would be available on short notice. it was somewhat disturbing at that time that there were no countermeasures. the best we could do was to review the literature and see where things were in the pipeline and to try to get an assessment of what we felt for the most promising things. this lay the groundwork actually for what's been happening recently where there was a meeting several weeks ago that the world health organization where mike carella reviewed the state-of-the-art and i'm going heavily from mike's slides and i thank him for providing them to me. this makes it go. there we go. this is the famous disclaimer. i am in an nih employee and i'm

not recommend anything. i'm just reviewing the literature and these are my opinions and those of my colleagues in the caveat that the assessment of efficacy is based on animal testing data. up until recently there was no experience with countermeasures and the horse recently there has been some experience and i will get to that in time. when you look at animal models there are animal models for using mice and nonhuman primates. one has to be careful in interpreting these data. there is usually insufficient data to assess comparability between humans and nonhuman primates. we know more about primates than we do in humans. interventions targeting functions may be impacted by species differences among the viruses.

metabolism a continent that complicates dosing. off target effects differ between humans and nonhuman primates. we will go into this other than to say a bullet is a simple virus but still has a fairly complicated lifecycle. there are number of points for intervention in this replication strategy and its interaction with the innate -- innate immune system. i'm going to go through the available vaccines followed by therapeutics and within each category till you what's known about efficacy data and what we know about human dosing. the way we like to present this is to have a virtual product labeling you can see who makes it, the description of the project how does it act efficacy data and nonhuman primates available. human safety data is available.

available product quantities manufacturing capacity. can be ramped up and if so how quickly and other considerations use has prophylaxis or treatment or combination. let's talk about vaccines. first talking about vaccines generally used for preexposure and at risk populations and the like. considerations are in the number of doses and can you get away with a single dose or is a prime boost strategy required? how long does it take to provide protective immunogenicity and the duration of the immunity and the possibility that the vaccines will reduce disease. the question is there a window of opportunity for postexposure prophylaxis and is the does the same for that strategy or is it going to be higher than for

general use? the vaccines which are getting some traction right now is one developed at the research center at niac in conjunction with smithkline based on the chimp adenovirus with the ebola protein gene inserted along with the sudan gene. in nonhuman primates immunized in anticipation of infection 100% effective and it is now in phase one testin testing in this country. they vector itself has been in over 200 subjects in the ebola like protein vaccine has now been in 80 subjects in the phase one study which is being conducted and will eventually have 200 people. the company projects 15,000

doses of the monovalent vaccine to be available in december and minus 80 degrees and known to be stable for a time at minus 20. the other vaccine which is getting a lot of attention is one based on a virus. the same idea the glycoprotein is traded for the glycoprotein of ebola. it was actually developed 10 years ago at the public health agency of canada and now is licensed for breyer put -- bioprotection. it is effective as a single do dose. it's a general use vaccine meant to be protected by 100% within 21 days and there is some data that suggest when given almost immediately less than an hour after exposure. in nonhuman primates.

the slide is now out of date. it was used several years ago in germany. it has now been subsequently used in patients evacuated to the united states. there are about 1400 doses available now as i said and being ramped up. other vaccines, there are lots of them out there but they are further back in the pipeline. a trivalent and bavarian nordic has developed a vaccine based on nba. caruso has a combined modified vaccine in the adenovirus vaccine. the arm is developing a b.o.p. and thomas johnson jefferson university has live and inactive rabies vector vaccines and that

one is coming up fast. so the timelines brc has already started phase one testing. you can see other tests are scheduled to occur. 15,000 doses for phase two would be available in december and this is actually a late breaker that i understand that there is now a three arm clinical trial developing library involving 30,000 people. 10,000 people on each arm. one arm gives bse in the third arm gets an unrelated vaccine probably hepatitis. so the target populations for vaccines are front-line health care workers and a ring vaccination. other high-risk exposures and potential immediate postexposure

use with a the clearcase definition. now we are going to turn to therapeutic considerations with anti-viral activity which may target the virus directly required for its lifecycle or something that augments those defenses. and other hose directed their peace will be discussed as well. all the products are under development. the actual treatment dosage and regiments are uncertain at the present time. the mechanism of action may dictate usage. they may be effective early and host factors may impact efficacy and must also be considered. we have all heard about zmapp. zmapp is the monoclonal cockta cocktail. in our directors meeting a predecessor zmapp was selected because they are comfortable with the idea of passive immunization being used in many

other diseases and animal efficacy data looks very good. this is actually british in tobacco plants. the third is produced at health canada. the pie and he has been used in seven cases. it has two mutualize in antibodies and the cocktail and one adc seed. zmapp is 100% effective when initiated in a trigger to trade protocol in experimental effective monkeys. it is still 100% effective. this is pretty turned good. there are no controlled human safety data. none of that has been used. but they are ramping up production and they expect to have 12 to 20 doses, drop in a bucket by december you said

several times in patients evacuated to europe. and although all the patients ultimately survived it's unclear whether the zmapp had any beneficial effect because nobody has been measuring before-and-after infusion so we just don't know. human, less and serum been used many times in the past. it was really impossible to assess whether that had anything to do with their survival. i can tell you experimentally infected monkeys when we had survivors and take their plasma and use it in a passive immunization scheme that rarely if ever works. the only time it works is when you concentrated and make it ig concentrated and then it works. ..

>> >> to delay the time of death so that did not go anywhere.

and this technique has been used commercially for tetanus and also with some horses. and perhaps as a source for the antibody. another interesting wrinkle is from cattle producing antibodies this is done in conjunction of applied biologics and is available so now turning to the next one with those liquid

particles with the preliminaries and has spent shown to me 83 percent effective at 72. the dozes completed with the fda put it on a partial old because there was questions on the thai release then they would release the clinical whole. of third into barrels in the pipeline with of protein production six year 80 percent effective on monkeys when tested. phase one single dose has been completed and also to

be made available about now. the japanese government has this in great quantity and this is licensed in japan currently complicated were for influenza but the bottom-line with the studies that we have done those were tested in monkeys and again delayed is still 100 percent fatal - - fatal. with the inhibitor is head showed 100 percent efficacy but lower efficacy against ebola and as notes dash anticipated in november but

then actually this is in the stockpile for smallpox it is an inhibitor with activity against viruses and is in phase three is a good safety record and it was used in the dallas case with the intervention was initiated. we intend to test this one. there are a number of strategies related to cascade to have shown a coagulation similarly

effective than primates but was also shown to be similar so they conceivably could be used in the intensive care unit if they would have any utility in west africa. another thing is to repurchase the fury have approved drug so much the better. over the weekend with a debt days as was being suggested for use in west africa. but basically it had no effect. and tested in other cells same thing and again the same thing so i think these are off the table.

this just shows the appeal most to have some efficacy finally the interferon products basically to have the delay time of death but not uniformly effective and then expands the window for their paper co and they have the effect is that requiring that e.r. anderson survival in the mouse model. early studies show the ocular disturbances in males

but we may go back to test this again. and then another of drugs identified all of which we will be testing to see if they actually work. then i think they're running out of time. i am. so in any of these things have to provide care for the severely il patients in that critical care can improve the survival rate as they have heard from other speakers. the novel products are in development some will be available sooner than others and their other indications that have therapeutic benefit. and vaccines to have significant impact in the future and i thank you will

see a change in that curve we have spent looking at. but so with that i will stop and thank you for your patience. [applause] >> of late to introduce the professor from johns hopkins and director of the university's center for advanced mulling with behavioral health sciences for immediate and long term. >> thank you very much.

for organizing this. i want to talk about the ebola modeling for immediate and long-term that it p.j.'s us certain sobriety about this topic and i will come back to that. the things that i want to cover our the worst-case estimates coming out of the cdc and also why i doubt ebola will fade out completely and related the why the outburst now and you talk about the idea from there are some stigma problems and the global model and that side of

things then overall the strategy. but first of all, i know there is skepticism about models suggest for a quick survey how many people have the model? wrong. [laughter] wrong answer. everyone is the room is a modeler when you close your eyes to mention the process an epidemic, and migration come economic future you have some model. it is when you have not written down. the choices is not a few model or not. you are. and has the advantage to clarity to yourself and others to explore the

sensitivity and to tell you what it is worth selecting. and to show a toy models but this entire discussion is the cdc will a model. and for those reasons that the user has to supply a certain number because of the recounting tool. and the populations are well

mixed no adaptation in shows a trajectory. if it heats up too fast and cools down too fast. here's how it heats up and then the worst case scenario. that means every reported case and we try to bring it down there working hard to do that. but the standard model heats up then falls down.

and with serious matters to into view a lot but then at the intimate level so there is a long-term process long-term measures question that needs to be faced. i think the prevalence would increase to comply with containment measures like personal hygiene and personal protective equipment. to the ebola care units and treatment centers and the practices.

so we see this sort of change from liberia. but there is the containment challenge but one of them is the health care work force with trusted and well-trained individuals and that is a huge factor. and any efforts were chased away from zero leone and spreading the disseminating virus so there is a lot of for information and that is important and from what was

used in nigeria ampulla resurged in nigeria because of distrust for cozier is an idea how to get a larger health care work force by first heard about and now we have modeled the dow at the centers for advanced modeling but as far as we know people can survive the disease. so trained as a work force to control the epidemic. i am not assuming but with the fatality rate of 70% but if you take those numbers you have 300,000 survivors

with unit what -- with immunity's immobilize them as health care workers so they are immune to the various they are aware of the culture and they speak the language and they are trusted by the others in their community, so convert that into a health care work force. the potential impact? here is of a simple set of fronts where we recycle into those that to have the transmission rate i know this looks a little daunting but if you just take the classical standard model because they become infected

but with no mobilization and to recover if you mobilize the recovery it is 20 percent of those who are healthy and a corresponding reduction of the people do die. and this strategy is 20% higher 100 percent more mobilization. these are conservative models it is not that they are targeted so is a simple idea. where the incentives? humanitarian for people to do this hearing is an

exercise here is a model that's just this simple and transparent i am not predicting anything and there are reasons other than production and if you're interested for 16 reasons other than prediction you may enjoy my the topees that i published recently and to take on the supreme court here at hopkins i encourage you to enroll. and focus potential on those approaches and to put

structure on the discussion especially with those settings. so i don't think ebola will vanish the other is the persistence. and then vigilance and complacency with the first factor the ongoing evolution of the virus has been around a long time with the first micrograph of the virus 1976. has been around a long time. it is not new. why the fight now?

that is an interesting question. it is possible the variation is simply can -- implicated but dr. epstein no relation is focused on deforestation but this increase is of vector density. if you reduce land cover from 10 by 10 down at nine by nine cut the area by 20 percent the same number of bats retreating into a smaller area so the contact rose accordingly so deforestation forces a retreat which increases the probability of contact with humans and that is a way to

transport these people into urban settings. and here's liberia. this whole area has been taken out. but the whole point of deforestation. so that mechanism if you deforest and build roads that transport. and thanks for joining a -- drawing my attention to the roads. it is a huge issue. it is implicated in that. but we also give cycles for

those reasons. this is documented and also and a recent book of mine. if you take the vaccine it is disproportionate if you take a simple picture the acceptance is proportionate to level of infection, but the rate of infection but decreases with the level of vaccines, very simple mechanism. it is the same idea.

so i get sloppy about my diet. so i gain more weight but if i get heavy enough i get serious and then you get cycles of vigilance than complacency. one of them is maximum uptake. >> with that adherence to medications if you can imagine vigilance and compliance with the same behavior that is just from 1980 with cycles of vigilance and complacency.

even with the advent of vaccine. you can expect the cycles of this sort. and practically out of the woods italy takes a few have those susceptible. so let's talk about this than i wrap up. is the unfortunate with those wa chose to sticks the average incubation period is 10 days. that is bad news and when joe is infected to go to the airport tuesday he has no fever and then to develop

symptoms one week later. it is not entirely contain it is is that period but using screening. to have the of global scale of the planetary scale of the infectious disease model with 6.5 billion individuals with rising your soft writer engineer but it has them published in also featured in nature. with this model there is randomness in the way things are around the world it is

the model because of what happened. so you start with the same configuration with exactly the same with the global transformations of how things spread but now generates oddly enough but again just one realization with the introduction in new york than in stempel and introductions in lots of different places.

but those introductions in developed countries are likely nobody runs global models that that it would appear or it would appear in germany or the united states. the numbers are huge the number of people that travel is fusion that anchor be -- incubation period is porous it is not shocking few cases in the developed world and in the united states what can i do? you can get a flu shot. because that will cut the background noise of symptoms to help the conditions to be more efficient in the ebola

cases cannot watch everyone with the sniffles to think they have the ebola. intermediate countries of high urban population density high standards of public health with high-risk with the developed countries the simple model suggests has the promising intervention but ebola is unlikely to disappear with endemic cycles will continue as they have for 40 years driven by ongoing evolution and behavior in the cycles

of complacency and vigilance i think those will persist even when we have a vaccine. i think it is boris. but sustained transmission is unlikely but to have worldwide vigilance is the central so everyone is at risk. everyone is a risk. all these countries should be vigilant. with the multi school hopkins group immediately funded but also with the ministries of health david tudor's is day.

= doctor of health. and colleagues from all over the school and university not all from my center and colleagues from the university redo work closely and other people inside the university. so i should be the flagship for the global infectious diseases but they are informed wonderfully with the international ngos so

that allows us to have that will take school infrastructure like what we try to deal with i thank you very much. [applause]

to implement the strategy is for the current outbreak. i will introduce a colleague of mine and professor of microbiology and immunology

at john hopkins bloomberg school of health. [applause] good morning. for leading spokesman for ebola prepared this is my pleasure to introduce the chair of public health center for infectious diseases at the university of minnesota. the mayor of iowa he attended college in santa clara to the university of minnesota this studying public health and had the distinguished career in public health. the activities following 2001 attack might step up to the international arena. special adviser to secretary of health and human services with public health awareness

to the economic forum on pandemic is. and with the microbial threats and the antibiotic resistance. it requires eight - - bravery on the one hand they don't like to be criticized but has done an eloquent job with the public and in 2000 published a book that made "the new york times" best-seller list and

response to the current epidemic has a series of articles articulating what is happening and what we need to know in what we need to fight ebola. africa has changed with the population shift than september 11'' we are afraid to say about ebola in which she raises the possibility to call for leadership of the united nations. one feature was titled the epidemic is about to get worse. much worse also such as the cdc in terms of the prediction and also this past weekend issued the

blacks won unprecedented and how regret how we proceed. so that prospective on that epidemic with one step back please join me to welcome dr. michael. [applause] >> first of all, things for that kind introduction. he is a dear friend and colleague and i appreciate the invitation. in addition i have to say it is humbling because two of the mentors in my career have been both the preceding deans although today one is in london and cannot be here but i take full responsibility for all the things i say wrong and what i say right to.

it is all seriousness and honored to be here today to share this. but i want to thank president daniels for being here to take some time to come to an event like this says a lot about this institution and mindset with this issue and i thank you. and i never forgets every time i give one of these talks with those tragedy i had a conversation yesterday that was very painful where one of my colleagues actually went down the street and saw two children struggling by themselves and nobody was there to help and it was heart wrenching to hear a man who's spent all this time in the treatment center watching these people

die then watched these young children. you never forget at the heart of all of this is that. so let me start by saying i have no disclosures to make from a financial standpoint. but i know a helluva lot less of ebola to date than i did six months ago so whenever i have to say in that light as they made an effort to my understand ebola right now we're doing a major piece with the transmission of the virus we have 700 in great detail and the more i learn the lesson i know. say using that to set the town about my comments today. it was not ignorance but the illusion of knowledge. we will talk about that today.

and the nobel prize laureate of civic said reality must take precedence over public reality but i would say of a successful health response a mistake priority for nature cannot be fooled. that sets the tone for my comments i want to share with you i've written a series of articles overtime from where was back in july when i wrote the first piece. i don't consider having been wrong but willing to understand as we learn more remittal ultimately have the change what is happening to the world around us. using the concept of the blacks one event an

economist describes nicely this swan that thought was not to not exist was a well-publicized book in 2007 to suggest the black swan event comes at a great surprise catastrophic events and they happen quickly which could be a the first slight alteration but we should have known about it. double-a-2 challenge that notion we are about to see a rolling blackouts associate with this event. hope we can anticipate as opposed to waiting until they happen and what we could have done about it. imagine this story line of the last 10 days in

individual coming from west africa to dallas county texas to be rapidly identified to have the effective incomprehensive response to the context of the community and the health care worker is one where we didn't write. you could've kept an extra 10 days and figure all the things that might have gone right to but today i hope to share the to change tomorrow to do something today but to take a step back by asking ourselves where we're at is a critical issue. so today let me say i am of the notion we have a lot of unexpected deaths topped - - ahead of us. do not expect anything

cardoon stone today is not blown up by a piece of dynamite. this is a very different statement that we are afraid we cannot respond but also sustained credibility as a public health world. one of the things i find very concerning is the amount of hubris from the standpoint of the history of the virus. 24 outbreaks in humans i use that loosely most were community outbreaks but five had water to cases in a laboratory situation. there was roughly 2400 cases of illness in 40 years.

if you look specifically the long beset of generations is where we had five generations. that is hardly played the human species and tell now. we know about what it does to people then maybe we find out something is different today. and in the title of my op-ed piece the virus has not changed, africa has changed. said it was just a gas can waiting for a match. but maybe not just that. i will come back to that. sold off isn't the same virus in a different

setting? it could be. but i will share more about that. to a knowledge one thing we make this up as rico. we have done that in the past we just have to be mindful make up as rigo and we have to become more comfortable with uncertainty you cannot people they don't know there is a complete literature it is something very scary though literature shows over and over two things one is if you tell them with certainty then eight and b don't happen. then they wonder about your

credibility. the second thing is if you have dueling banjos you will scare people don't say that the literature supports that is when people are concerned one of the worst enemies is dogma that should be at the first instance that is very different from the science of what we know and what we articulate but do not fall into the trap of dogma. about eight or b or c.? that is a dangerous thing. i actually laid out that was three plants. i set up to say we are feeling miserable with a plan a to stop it dead in its tracks to the three

countries using the techniques that we had used effectively used for so many years. there were reasons for that. first of all, we did have one miraculously ederle was remarkable with the one individual and minnesota resident that traveled to liberia and was infected but if you looked at the intensity of that effort over 1,000 people followed up and largely within the health care setting where exposure occurred they extinguished that was remarkable and a real testament to the nigerians and the cdc but if he went undetected for a couple of generations that is not the same situation at all. we do know that these can work but with my simple mind the way i look at this hour

after hour you put them in the upper river you say swim upstream then to have such a situation with no infrastructure so first we have that unpredictability epidemic we just have to a acknowledged that because we day be honest and say we're trying hour best? i still say we ought to try everything we can even hold infection control kits are anything you can do but

don't make promises we can answer. because then we just contribute to the problem. i want 2.0 the presentations were outstanding it was very good. one area we have a lot of criticism is the cdc says 1.4 million cases by the middle of january the then 20,000 by november 43 countries? how can maybe so far off? this is another area where hubris' king give us in trouble. my answer is there will be lots of cases in recent know what that number will be and we have to except that. nobody is right or wrong their precision around these estimates have the entire

convoy we also understand progress is painfully slow. to talk about is on virus time we're all operating on bureaucracy time and the virus is winning hands down and still is. i commend the u.s. government's response no other country has put for that response has been inadequate. when the president tells us five weeks ago he will send 3,000 troops then last weekend their own a 200 troops now there are 300 troops that is not 3,000. of people all over the nation are not there it is not happening. everybody is to blame because the world was not prepared to respond. is an ironic and with the

only country in the world the has the facility in a country of cuba. it is important for this sysop thing operating in a different situation imagined and minneapolis having called the fire department for backup with the trucks going down i 80 is wonderful but in the meantime minneapolis would burn down that is a new world order with infectious diseases by that calculation many more deaths than those affected countries today from

pregnant women with the most terrible conditions it is a tragedy not even reported on right now. and to meet that talks about what happens with these situations the health system collapses incredible so don't talk about to build up the bet spent the entire health care system it will be very important. and ganic come back to the fact with no lack of clarity we can try that approach to

quarantine ready to a acknowledge i a swimming 4 miles an hour but the current is 6 miles an hour and that will not be enough. it is now time to reconsider our response. you heard yesterday federal agencies wonder how they consider their response. but we stood up. i have to tell you we're not willing to get the message out that uncertainty is reality. i am not afraid to say i don't know. or what might have been but i always come back to what are the data? we need to do more of that. what are the data? this is apart from my article rice said wake up

world. we don't get a. but i commend you all for that but west africa is their. and we have to understand what is the next black swan waiting to occur? and in the political peace of very well-known part a number of young men and boys come home will establish a

site the migrant workers. early october they leave to go back east to charcoal plantations in some media sources question about that. that this was happening that get at of places that nobody knows was no checkpoints. no identification cards. this is where i got that information. talking to the anthropologist and sociologists that try to understand but it has been a crash course in very valuable.

but what does that mean? if you're worried about this infectious diseases forest fire in africa and the sparks flying from dallas to imagine from the east right now. i know how it won't. i can show you the routes and then try to get out of the affected -- infected countries. what about all the slums of the three countries' combined? west africa was a can of gas waiting for a match effort is a tanker truck and we don't get that yet. there is no plan me but how

did we fight this what do we do? we cannot find it on one front little loan to. all i am asking for somebody bear thinking about a plan be. it is not just about ebola. i have had some briefings on the hill for leadership and beyond the immediate help group is the intelligence committees. and already concerned about the breeding ground for terrorist. it is the self-interest effort also. and we do not want to give

the world to another place where the states are so failed you can do without impunity in terms of issues around terrorism, etc.. and with that transmission but what is planned c? the only one that really have is time convinced of that. this will be an endemic disease. and has seen themselves to shut down the clinic to bring it back then is a huge

piece so what we really have to understand but the vaccine will be answered i have great concerns about the vaccine situation and some may say i was brain-dead i was in deep trouble in the '80s when making comments of an aids vaccine and i was quoted in "the new york times" that i didn't understand how that could have been like did not get my arms around now that a virus would work.

i was welcoming the chance to be wrong benes asia mediates vaccine but i do believe we can have the effective ebola vaccine. but there is a big disconnect what to get this there and africa. what we're doing right now we're not getting this all the way through talk about $57 million investment i think united states for that so the rnc with the efficacy how will we make it and where will me make it?

i want to know that now. that means now. and with my organization to bring together the world's efforts cities of those efforts -- a reference to come up with a document within 60 days business says usual but you don't wait so to me that is very important