>> 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

e 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

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 that we have nine. i am understand but we don't know. it is the travesty with the single step was one location in zero leone they know what the hell they're talking about we need that agenda

right now. to understand those transmissions is it just of population? our other things going on? but we have an obligation not to have another blacks one event. but we don't have a clue we need data in clinical outcomes. but looking at what makes a difference what can we do about that? can we? with those dire conditions

with those intensive care of kids. and also i just have to say right now we have to do a better job. but we have a problem that we always couched things with certainty but that does not exist. that is different from being scary. seeing the "l.a. times" on sunday with a piece on fever. but there is the problem with that with that definition so there was a

certain sense of selection maybe it was minimal but it was their. i personally heard clinicians' with the ignition of the treatment center 101 fever but he never did. but what happens when the media gets allover there'd be a fever but those patients didn't even know what you're talking about. tell them what you might have happened and then when it happens you don't tell

them the complete truth. i just want to say to comments please understand the different issues there is a series of things written about this recently. . .

>> this is more of a classic example of what we shouldn't do. i have been talking to a number of virologists that are very concerned about it. and they make me concerned about it. and in the media we were recently talking about it. and it is not this great evolutionary mutation that will happen. let me just tell you how someone will take it. most people would say he is a very noted science writer. he said the chances are tiny. but ebola itself is very unlikely to change to be

airborne. and that is like saying that you're worried about wolves and you're afraid they're going to be like wolves and grow wings. and until we understood which sells the virus has been and in we understood it wouldn't be an issue. that's different than this. number one, we had talked about what had been transmitted and it was interesting because one of the people that common and a lot on its axis but that's not a problem because they think they were cleaning up the litter on the floor that did this and that is even worse. the point being that some people

are concerned because we don't understand why that virus past the first time. and today i had been given permission something that i had known about for a few weeks. gary actually took one of the strains from guinea and put it in their little over a month and a half ago and what they saw was remarkable. it was unlike any of the viruses they have ever seen. it was much more severe and if gary said it was one of the most prominent biologist in the world said maybe this is a different virus. maybe there is that possibility. and maybe someone might cough it up. i'm not saying that scare people. plan be. what the heck are we going to do if we suddenly see the potential

for transmission? we have a plan? i don't know if it's a one in a million chance, but the point is if we can't talk about that because people say you're scaring people, the blowback has been substantial. i guess i'm getting old and it doesn't bother me so much anymore because it was all based on what i believe to be the true science. it was an attempt to help people think about this. so now we really have a reason to be concerned and i don't know what the chances. and this is not just based on idle speculation. slummy just conclude by saying that we all want certain things in this situation and i guarantee you that we will not get it and mother nature will not allow us to have it. we can still provide various public health messages and we can still be in control of our own destiny as to how it relates to we respond.

but we have to understand this. so to final comments were very important, in terms of being a kid from iowa, a one said if you don't know where you're going from any road will get you there. and i worry, and we know what the roadmap road map is here? has who given us one? but that one has ari been thrown out. we need a global response that addresses this uncertainty that we have and does it in a timely way. we can't accept donations, we can't accept numbers, we need action. and finally one of the wisest people of all time says that are these the shadows of things that will be where the shadows that may be only remapped ebenezer scrooge. thank you.

[applause] [applause] >> so actually we are going to go on into our panel discussion so we can ask questions of mike as well as our panelists here. i would like to introduce right now josh who has kindly agreed to be the moderator for our panel discussion questions. >> hello. [inaudible] [inaudible] thank you, everyone, for letting us speak. i'm a little of this and it because i would've hoped that

doctor michael osterholm would've told us what he really thought. [laughter] and i do hope that we have a chance to draw him out a little bit as the questions end. okay, going on down the line, i am part of the department of health and mental hygiene and i am looking forward to this discussion. the main point of this is to get questions and answers. but in order to prepare, i think it would be helpful to each of the panelists just to give us introductions and what they do and their interest in ebola. >> good morning, i am an emergency physician here at johns hopkins and i'm also a professor and vice chair for research at the department of emergency medicine. i have done work for the past 20 years i have been here and i have been in program development and emergency settings for rapid diagnosis of infectious diseases

specifically hiv and influence. and we have looked at developing diagnostics for various infectious agents and now i am a codirector of the center for excellence here at johns hopkins. >> my name is nancy kass, i am here in the institute of bioethics and i think that i am involved in thinking about the ethics issue going on in ebola. we have a long history thinking about this in public health including infectious outbreaks and we are starting to do a little bit of work here in liberia. >> hello, i am bill glass, director of strategic communications at our program here at the school. and i oversee the teams that manage our field work here in 30

countries. my main message is part of this panel today that communication is at the heart of our response today. and it's important throughout the care continuum that communication can help us present and care safely and treat safely and have faith aerials. as was mentioned before, have increased vigilance and increased complacency. so to do that, we have to have better coordination and consistency of our message and if we can do that, we can build trust and reduce fear and address rumors and we can raise confidence and inspire people to take action and provide households ways to stay safe. until we have been involved in the response since the very first cases throughout our staff that have been there under usaid funding. recently we have been asked

wrapup our response in liberia and regionally in liberia we are doing all kinds of communication activities, including helping with the hotline that is overwhelmed there these days. as well as working on monitoring the evaluation systems where we have put them into the field recently. soon we will be involved in mass media community care. the second part of our response is regional preparedness and working with everyone locally, at developing tools in helping countries create their preparedness strategy in terms of communication. and finally i would like to say that it has been a fabulous effort on behalf of the staff around the world to mobilize for this and kudos to the staff that has been there for some time and are traveling there as we speak. so i thank you and i look

forward to the conversation. >> good morning. i'm an associate professor here at the school and i've worked in multiple emerging pathogens to characterize influenza and others and ebola, i have worked to characterize it transmissions on massive scale data and i'm working with doctor peters and others to design and characterize critical outcomes for the units that you heard about being deployed. so couple points i would like to make. i think that the burden due to other pathogens, it's something that we need to be concerned about both now and in the future. but i also think that there is an opportunity to integrate them into the response and there's lots of fevers and symptoms that will be potentially might be

presented to clinics and this might be the only sort of capacity to treat them. so there might be an opportunity with the impact associated with malaria, and in all three of these countries and also reducing the burden that might show up later because of potentially distributing anti-malaria in broad response. so picking up something that the doctor said, international research agenda, some of the details of this response and where it is failing and where does exceeding the target of research. we have tools that have contained ebola epidemics in the past and i think we have a problem in scale that it really makes it -- as it spreads, it's

harder to contain it because you're taking up all of the capacity and responding in ways to control these small epidemics and other locations. but i think that working out the details of where we are failing in this response, we just don't have the hospital beds to perform the situation that we need to respond. so we are hampered as well. >> thank you. >> my name is michael osterholm. [laughter] and i often do that. i'm here at the school of medicine and i have a appointment at the bloomberg school as well. we are both practicing emergency physicians and so there's a certain reality where the rubber hits the road for us in regards to ebola. i'm here and probably my role is

the office of ctical event preparedness and an organization that has been given birth in 2003, managing the overall response of the institution including the health system and the university. >> hello, i'm a reporter here at "the washington post" and i have no expertise in this matter whatsoever. [laughter] i spent a lot of my time calling folks on this channel and asking them to explain this. i did go to monroeville for two weeks in september and saw virtually all of what the doctor spoke about and my assessment is that it's probably even worse than he described and i would be happy to get into that when you all want to ask questions. >> great. this is a tremendously talented panel with an unbelievably

interesting bunch of individuals so far. had a couple of questions and i'm hoping that maybe we could give a little bit more detail about the experiences. >> sure. >> cut me off whenever you want here. i got there on september 12 and on september 13 in the morning we started by going to the treatment centers. i've been to two of the three centers in a place called redemption hospital which is a hospital that has been turned into a transfer point. at any point in the next two weeks that i wanted to i could go to those places, i would always find the same thing. the treatment centers were full and there were people sitting, standing, lying on the ground outside the gates of all of those facilities trying to get in, generally they could not get in.

they could not give an end if their symptoms were particularly dire, they might jump the line. and that is a chronic condition there is a shortage of beds. they opened another treatment center the sunday before i left called island clinic because it was on the island and the open on a sunday with 150 beds and on wednesday it had 173 patients senate. and that is just the way it is. they have begun a program in liberia before i left to isolate the sick. they had said we will never be able to treat everyone with fluids and electrolytes until maybe we can bend the reproductive curve by simply taking the sick and putting them in schools away from other people. so we start affecting two people, each infected person, maybe we can get down 1.5 or something like that.

most of liberia is not working. i could never get a really good number on this, but many people would say 80 or 90% of the people are unemployed. schools are closed. there are a lot of people in the streets just kind of milling about aimlessly. and you don't have a sense of purpose. before ebola the monthly income was about $400 per month median income and i have no idea what it is now but i'm sure it's much lower. and so in the two big bombs in monrovia just to show you the kind of thing that public health folks are up against, most people have no water or electricity or sanitation or refrigeration. for the city that has 1.5 million residents, there are probably 12 ambulances. you can call for an interview and see if you get ebola or

something else and it won't come. and so the chances of finding this or next to zero. breaking this down into two broad categories are the people that understand the situation is real and are ill-equipped to do so, and the people that don't you leave that it is real and are either denying it because of stigma associated with denying it because denial is a coping strategy. for those who do understand it, i saw people bringing sick and dying relatives to treatment centers and it would take those little plastic bags that you get at the grocery store and they would wrap their hands and sometimes try to put them on other parts of their body because they knew when they brought this person here to the treatment center they were going to have to take that person out with their own hands and bring them to the date and they would try to cover themselves in whatever way they could.

i would call that a minority of the people. most people just pull up in a taxicab and try to get some help for their relatives, they have the money and they drive off to the next treatment center and a lot of people don't have the money for more than one trip and they were just leaving the person they are and a lot of people were very sick and dying outside of treatment centers. >> asking about having her that respond to the emergency department, what do you see as the key priority in this? are we on a trajectory to begin to meet that? >> i very much like the message and i'm not trying to say more

than you actually know. the main priority as you are hearing in the news is to try to prevent even the remotest likelihood of transmission in a health care setting. and it is scary to the point that we think that there is a mechanism of transmission and if you take care of that then you are fine. but i don't recall an infectious disease respiratory or otherwise where the tiniest amount that it might be a part of this, we don't actually know but to train everyone that might come into contact in a health care setting. we have many that might come

into contact with patients and that's a pretty big deal. and so that is an even bigger deal because you have residents and students and nurses and those who are coming in from an agency and so to get everybody trained properly is a problem. and so based upon us, as you have suggested, things change and reacting to some extent these onerous, we did have a plan and we are forming teams to take your potential patients so that we have a highly trained highly drilled staff who takes care of people rather than trying to figure out a way to train for 5000 people that might come in contact. >> i would like to echo those

points. i think that the improving and ramping up the infrastructure across the country in hospitals and as he speak to the u.s. situation, building that infrastructure, i think the point about screening approaches , to gather that information and create infrastructure for that condition than most effective methods for screening, one of the things we have worked on over the years with various programs is developing what was not specifically mentioned but it could be used more quickly isolate patients at risk and more quickly make decisions about the isolation and treatment.

>> asking a couple more questions and then we will go to the other questions if that is okay. one of the things is the vulnerability of the week system in this country, and ebola has really played on that. typically you think about prevention, education, but the absence of this data structure has made it very difficult to contain ebola. so the question i have is to what extent are the interventions going to happen and how important is the that they build on the internal capacity that they leave behind a meaningful capacity or ability to take care of patients or is this sort of a problem that can be followed through a focused effort on ebola. >> well, i think that there are

two very laudable goal is. and this is less utility that would build upon the long-term resources of the country. but we are just behind the curve and i want to talk about the projections in the models. we don't even need a very complex model because we have a pretty good forecaster will happen and this has been doubling the number of cases over roughly 20 to 50 days depending on the setting and it will be very odd for a tuesday in the next 28 days, something dramatic would have to happen that we don't see cases double. so these cases estimates, i think it's extremely optimistic

and probably not doable. we are ready had 8000 in a month. so are we going to be doing things all that differently? >> the model that you are working on to translate over, how does that relate to this? is that something that would happen in this capacity? >> it's very much sort of a caveat to provide resources ahead of it. i think it does help long-term capacity because with every six months goes on and it's going to reduce all sorts of factors that will impact the long-term capacity. >> well, first of all, does the

lid on what was said, i think that that's a very important point. one of the observations is striking that we are getting one more from the ground that this is not like little explosions. we are seeing clusters of activity flaming and causing a big problem and then they kind of died down and come back together. and so one of the big questions is when it be nice for us to see what is happening in house lawyer are they and what is really going on. the other part you asked about was the infrastructure and i know you have some really good now surgeons at this place and if you had a sledge hammer and chisel and that's all you have to work with, they'd have problems as well. but what we have done is basically given him an equivalent of that on top of trying to deal with everything else that is going on and lenny really articularly laid out in trying to overlay the

comprehensive medical care on top of that is just so difficult. and that is why the doctor says come out of criticism of one group that they are not doing more for liberia and i have a day that i think that they are right on the market to do the best they can with what they have under those conditions of doing what they're doing. so that is the underlying issue and i don't think we have a good idea of how bad things are. the thing that worries me is that if you look carefully across africa, anywhere in the developing world, those same conditions are everywhere. this got into mum buy. some worker got it there and it's got into nairobi in a slum and they are. so i don't know what would be any different. and that is the message we all have to understand.

>> okay, so the last question you mentioned would be a critical part of diagnostic tests and so in order to test this there are a whole range of different questions above,, of view of what are the ethical issues in terms of getting it out there and making good policy decisions including how do you communicate without doing research in the middle of a crisis like this. so i think that i would like to ask for comments on that. >> in echoing so much of what you said in regards to the messaging, and we have lost in this in regards to the public health response. at least some media reports come across as what is wrong with these people that they are running away when the health

care workers -- clearly people are responding from a place of fear and maybe messages not having been crafted in a way that may make a difference in the public health response. we have that on steroids is a challenge with regards to research. they are certainly the research ethics challenges about when we will start rolling out vaccines, who gets them first, do we test, this is a place where sophisticated methodology and public health compassion can all be aligned but it takes sophisticated thinking and i had a conversation yesterday that really made me convinced that adaptive designs are the way to go so we feel confident that we are learning whether or not the treatments work while to maximize it