afraid that wolves are going to be born with wings and fly around and attack people and fly from montana to new york. that's not realistic it doesn't work that way. i was one of those people early on explaining why hiv was never going to be a respiratory pathogen because we never understood which sells the virus was in and we understood that wasn't going to be an issue. that's different than this. number one, we have had examples of subhuman primates. we had one where the pigs transmitted to the subhuman primates and it was interesting to the people that counted a lot on this said that's not a problem because it's just from cleaning up the floor which is even worse if they fought through it it was deposited in the air slides that is worse. but the plaintiffs some people are concerned because we don't understand why that passed the

first time in the subhuman primates. today i've been given permission something i've known about for a few weeks when i wrote the piece is concerned me greatly. the colleagues made the national lab and actually took and put them in a little over a month and a half ago but they saw was remarkable. it was unlike the had ever seen. it was much more severe and as gary said it's very worrisome to me about what i saw. maybe this is a different virus. if you have that much maybe somebody might cough it up and you might get a cycle. i'm not saying that to scare people. plan b., what the hell are we going to do if we see the potential for the transition to quite be respiratory and nature?

do we have a plan? i don't know if it is a one in 1,000 but the point is if we can't talk about that because people say you're scaring people come up, then 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 true science. it was an attempt to have people think about this. what if we had another black swan events we had a reason to be concerned about airplanes i don't have that chance is that i want a plan and it isn't just based on idle speculation. let me just conclude by saying we all want certainty in this situation. i guarantee we will not get it great mother nature will not allow us to that. we have to stop providing certainty. we can still provide a very effective public health messages and we can still be in control of our own destiny as it relates to how we respond. but the virus is neutral to its

happening. we have to understand it. but i concluded the two final comments both very important people in my life in terms of being a kid from iowa. he once said if you don't know where you're going and i worry today do we really know what the road map is? it's almost already been thrown out. we need a global response that addresses this uncertainty that we have and does it in a very timely way. we cannot accept any more pledges. we cannot accept donations or numbers. we need action and that's different. finally, one of the wisest of all times said are these the shadows of things that will be. [applause]

we are going to morph into the panel discussion that will give us time to ask questions directly as well as to the panel participants. i would like to introduce right now josh who is the state of maryland secretary of health and mental hygiene has kindly agreed to be the moderator for the panel discussion session. thank you very much while we are waiting for everybody to take their seats i will just say i'm a little disappointed because i had been hoping he would have told us what he really thinks. [laughter] but i do hope to draw out on the

question and answer period. why don't we go down the line. i'm the secretary of the maryland department of health and mental hygiene. and i'm looking forward to this discussion. the main point of the period is to get questions and answers but in order to prepare people for that i think would be helpful for each of the panelists to get a brief introduction to what they do and their interest in ebola. >> i am an emergency physician at johns hopkins and also a professor and vice chair for research in the department of emergency medicine. department of emergency medicine. i've done work over the past 20 years i've been here at hopkins program development and emergency settings for rapid diagnosis of the various infectious diseases specifically hiv and influenza and involved

in the centers for excellence for the emerging infectious diseases where we've looked at developing diagnostics for various agents and now i'm the codirector of the influenza center for excellence. >> my name is nancy i'm a professor at the school of public health and also in the adversities bourbon institute of bioethics and i've become a little bit involved in thinking about the ethics issues in ebola. we have a long history of thinking about the issues and public health including infectious outbreaks, and we started to do a little orc particularly focused on liberia. >> i am the director of strategic communication programs at the center for communication programs here at the school. i oversee the teams that manage the fieldwork in about 30 countries and my name message is part of the panel today is going

to be that the medication man occasion and social mobilization are at the heart of our response today. it's important throughout the continuum of communication can help us care safely, treat safely and have safe burials and as was mentioned before, increased vigilance and decrease complacency. and to do that, we have to have better coordination and consistency of the messaging and if we do that we can build trust and reduce fear and address rumors. we can raise confidence, inspire communities to take action and provide ways to stay safe so that is my name message and just very briefly what we've been doing at the center. we've been involved in the response in liberia since the very first case through the staff that have been there under the u.s. aid funding but recently we've been asked to

ramp up the response in liberia and regional in liberia we are doing all kinds of communication activities including helping with the hot line that is overwhelmed these days and working on monitoring the evaluation systems where we've put things into the field recently and then soon we will be involved in the mass media community care. then the second part of the response response is in the regional preparedness where we are succumbing to staff to unicef and working with them locally developing preparedness tools and helping countries create their preparedness strategies in terms of communication. and just finally, i want to say that it's been a fabulous effort on behalf of the staff around the world to mobilize for this and kudos to the staff that have been there for quite some time in our traveling there and are traveling there as we speak. so hang us and i look forward to the conversation.

>> i'm an associate professor in the department of epidemiology here at the school and i've worked in multiple pathogens to characterize the transition dynamics of influenza and others. in ebola i have worked to characterize the transmission using national scale data and i'm currently working with doctor peters and others to design the surveillance systems to characterize the transmission clinical outcomes for the units that you heard about being deployed to liberia from the drc. a couple of points, the burden due to the other pathogens on ebola is something that we certainly need to be concerned about both now and into the future. but i also think that there's an opportunity to integrate them into the response of ebola. there are lots of causes of fever and sometimes and the

cases of ebola people might present the clinics and right now this might be the only sort of capacity to treat them so they impact the burden and the mortality in all three of the countries and reduce the burden of the cases that might show up later because of potentially distributing antimalarial broad response. i think taking up something said that in the international research agenda, some of the details of this response and where it is failing and where we are succeeding is the target of research. i think we have a problem in the scale that ebola makes it as it spreads it makes it harder to contain because you are taking

out all but the capacity and reducing the capacity to respond but i think working out the details of where we are failing in this response and then just sort of seeing the simple accounting, we just don't have the hospital beds to perform the isolation that we need to respond. and that just that is killing our response working of the details is something that needs to be done. >> my name is michael -- [laughter] i often get that wrong. i chaired the department of emergency medicine at the school of medicine and i have an appointment at the bloomberg school as well. there's a certain reality where the rubber hits the road related to ebola. although i am here today probably in my role as the director of the johns hopkins office of critical preparedness

and response and organization that was giving birth in 2003 to manage the overall response of the institution including the health system and the university >> i'm a reporter with the "washington post" and i have no expertise in this matter whatsoever. i spent a lot of my time calling folks on the panel sitting at the front couple of rows asking them to explain this but we solve virtually all of what the doctor spoke about in my assessment that is even worse than he described and i would be happy to get into that when you want to ask questions. >> this is a tremendously talented candle and it's been interesting so far.

we are going to be taking questions in a minute but i wanted to ask mr. bernstein to get more detail about his experience. >> i got there on september 12 and on the 13th early in the morning we started by going to the treatment centers. i went to two of the three treatment centers in the place in denver hospital which had been turned into the transfer. at any point in the next two weeks i could go to any of those places i would always find the same thing. there were people sitting to standing, lying on the ground outside of the gates. they generally do not get in if their symptoms are particularly dire like if they are being

taken out of the taxi cab on a stretcher they might jump the line. that is a chronic condition that shortage of beds. when i left, the "-open-double-quote treatment center of the sunday before i left it was called island clinic because it was on the island. it opened with 150 beds. it had 173 patients and that's just the way it is. they had begun a program in liberia before i left simply isolate the sick. maybe we can bend the reproductive curve by simply putting them in schools away from other people so at least not in affecting two people each infected person isn't affecting two people maybe we could get it down to 1.5 or something like that. most of liberia is not working.

i could never get a really good number on this with many people will tell you he beat 90% of the people are unemployed. schools are closed. there's a lot of people in the streets. they are just kind of moving about aimlessly. they don't have a sense of purpose. the monthly income in liberia was a $400 a month, the media and anti-have no idea what it is now going sure that it's much lower. people are beginning to have trouble feeding their families. in the two big slums in to show you the kind of thing the public health folks are up against most people have no water coming electricity, sanitation or refrigeration. for the city that has a 1.5 million residents there are probably 12 ambulances. you can call for an ambulance if you get ebola or something else

but the ambulance will not come. your chances of finding an ambulance or next to zero. if i had to break down the population into two very broad categories it would be the people who understand that ebola is real and are trying to take precautions that are ill equipped to do so and the people who don't get belief that ebola is real and they are either the the dying because of the stigma associated or denying it because the night was a coping strategy. for those who do understand it i thought people bringing sick and dying relatives to treatment centers would take those plastic bags that you get at the grocery store and they would try to put them on other parts of their body because they knew when they brought this person to the treatment center and the taxicab they were going to have to take that person out with their own hands and bring them to the gate and they would try to cover themselves in whatever way they could. i would call that the minority of the people.

most people pull up the taxicab and try to get some help for the relative because they have the money and they can't get in and they drive off to the next treatment center. a. a lot of people don't have the money for more than one trip and they would just leave the person there was a clear with them. i saw a lot of people very sick and dying in the outside treatment centers. >> crystallizes the tragedy that's going on. i wanted to ask having heard that too responded to the emergency department physician what do you see as the key priority for the healthcare infrastructure and are we on a trajectory to begin to meet those or what else should we do? much like the message is 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 the healthcare setting and it's scary to the point that we think there's a mechanism of transmission and if you take care of that in your fine. but i don't recall an infectious disease respiratory or otherwise a drop where the tiniest amount possible on your equipment as you're taking it off that might brush against some other part of your skin and then you touch your skin or your eyes and you're done or your done or you have a tiny scratch. we don't actually know, but to train everybody that might come into contact in a healthcare setting we have four, five, 6,000 people that might come into contact with patients that a pretty big deal.

on a front line, that's an even bigger deal because you have residence, you might have students, universities for an agency because somebody called in sick or whatnot and so to get everybody trained properly is a problem based on and reacting as you have suggested things change and reacting to some extent we did have a plan b. to take care of the potential patients so that we have a highly trained and highly drilled the staff who takes care of people rather than try to find ways to train four, 5,000 people who might come in contact with patients. >> i would echo those points. i think the improving and

ramping up the infrastructure for training across the country and hospitals and if you are speaking to the u.s. situation building that infrastructure i think the point about the effective screening approaches is important to make note of and to gather that information and create infrastructure for understanding the transmission and the most effective methods for screening. we worked at the various programs in the diagnostic tests that wasn't specifically mentioned about better bedside test that could be used to more quickly isolate patients at risk and more quickly make decisions about the need for isolation and treatment. >> i'm going to ask a couple more questions if that's okay.

one of the things that came out is the vulnerability of the very week acute care system typically you think of public health ascii dungeon, education, field vaccination, but the absence of the hospital infrastructure has really made it very difficult to come -- contain ebola. the question i have is to what extent are the interventions that are going to happen in west africa are how important is, how important is it that they build on the internal capacity that they leave behind in the meaningful capacity or is this a discrete problem that can be solved through a very focused effort on ebola? >> i think there are two goals.

i think if you have the capacity that you could put in place even temporarily, there would be the utility even less utility than capacity that would build upon the long-term resources of the country. but we are just behind the curve, and i want to address the projections. there've been questions about the projections and models. we don't really need a very complex model for what's going to happen in the short timescales. if this time scales. if this has been doubling the number of cases over roughly 28th eight to 50 days depending on the setting than it would be very odd for us to see the next 28 days something dramatic would dramatic would have to have been that we don't see the cases doubling the 28th to 50 days. so i do get is extremely optimistic and probably not

doable because in a month we are going to be doing things all that differently so i think the projections to your question because now every 28th to 50 days we've doubled with the have to do to respond to this. >> the model that you are working on to import and to translate over how does that relate to this end and is that something that you hope would happen? it's is important to provide the resources to get ahead of this. i think it does help long-term capacity because the outbreak is what every six months it's going to reduce all sorts of factors which will impact the long-term capacity in each of these affected countries.

>> that's a very important point. one of the observations that is striking is we are getting more and more intelligence on the ground that this is not like a fire line which is burning. this is little explosions. and we are seeing clusters of activity that tend to flame and cause a big problem and then they die down and come back again. and one of the big questions wouldn't it be nice if we had viruses to see what was happening how similar our day and what's really going on and how much of it is behavior related etc.. the other part you asked about, i know you had some really good neurosurgeon at this place but if you give a sledgehammer and that's all you had to work with they would have problems, to back. what we've done is given the equivalent of trying to deal with ebola on top of everything else that's going on. he very articulately laid out what's going on over there and trying to overlay comprehensive

medical care on top of that is just so difficult and that's why doctors without borders has come under criticism from one group they are not doing more in liberia in terms of the therapy etc. and i have to say i think they are right on the mark because they are doing the best they can with what they have under those conditions and to me they are doing what they are doing so i think that is the underlining issue we don't have a good assessment of how bad things are and the thing that worries me is if you look carefully across africa are not just there but anywhere in the developing world the same conditions are everywhere. they may not be as bad as liberia or sierra leone but if this got into my and into nairobi i don't know what would be any different and that is the message we all have to start to understand.

>> the last question i want to talk to and you mentioned it would be a critical part of this and we heard that the diagnostic test in order to test and scale the vaccine as a whole range of questions that come up two of which are what are the ethical issues in terms of getting it out there and getting it to the data that you need to base policy decisions as well as how do you communicate during the research in the middle of a crisis like this so i think i would like to ask a few comments >> n. e-echo thing so much of what you said from what they are trying to do in the messaging and i think we have all seen in the public health response at least to some media reports that come across as what's wrong with these people that the art running away doing these things to healthcare workers when

clearly people are responding from a place of fear and maybe the message is not having been locally crafted in a way that might make a big difference in the public health response we have that as a challenge with regards to research so there certainly are the challenges about and we are going to start rolling out vaccines. we tested with placebos? this is a place where the really sophisticated methodology and public health compassion and ethics can all be aligned but it takes a sophisticated thinking in the conversation i had with a methodologist yesterday specifically about this question made me convinced that the designs are going to be the way to go so that we feel confident that we are learning whether the treatments work while being able to maximize people who get access to something that seems to be effective. we know from the history including in africa where we and

other people worked the last 15 years on the challenges that there is so much suspicion of medical research particularly when it comes from the west we saw what happened with polio and with meningitis. you go in with the best of intentions thinking that you're going to help and whether the research is just taking blood for all of these studies, we should make a tremendous difference and again, we all know what happens when you take blood. then the rumors start into the messages have to do with helping people understand what a placebo is and why you were even getting something running from the united states giving the thing simply to learn. i think there's more and more people in africa trade that can help in health care healthcare but a lot of it is a challenge. >> i just want to take the

opportunity to talk about the kind of research that we are doing in liberia. as i said, people look to us in terms of behavior change communication as the experts in research and being able to attribute the effect of the programs to the interventions that we are designing. as for the kind of things that we are trying to look at the electronic media to see how the messages are trending and we are involved in the knowledge attitude and practice survey that is being mounted in the collaboration with the government and the multilateral agencies and we are also trying in an and innovative quick system that we are developing to look at a few indicators over the phone to get information from the key informants very quickly back to the comment that was made before about the virus time. we are having to adapt our apologies in order to get very quick information and all of this is trying to uncover the key factors in terms of the

norms and baviors that are affecting people's risk behaviors and confidence to act. .. we are talking about these three

countries as one analogous kind of place. it's not. you have very different populations with very different -- lie with those individuals killed? if you understand the background to that it's actually quite hard to understand how they could, these were not for the nationals that were attacked. these were natives and headed into a number of different issues. something that it will become located in this is where now a talk by rolling out the vaccine, talking about inviting and almost mandating that any program have that research and input component to it now and start understanding that. if we have a big outbreak in nigeria with this, you're right, we talked earlier about the polio vaccine issue in northern nigeria. why would we expect we would not have some kind of issue there? i don't think it's going to be just build it and they will come. but on the other hand, i think we have an opportunity to maybe

put our best foot forward ever if we start thinking about it now and don't handle it like a bunch of public health epidemiologist only but we handle it as a social, cultural event that really needs all of us on board. get to the vaccine to the. you can get in which make sure i get the vaccine. >> i think we'll go to some questions. start either way. go ahead. >> thank you very much. this is a very informative workshop seminar. i'm from liberia. i happen to be the president of the liberian association in maryland. and much of what you said is very, very true. i think information we can use with our community and with our people back home. my question has to do with one of the presentations, one of the

presenters, the series of -- develop test of vibrant on animals and approved to be not for the use of humankind. recently there was report of a doctor in liberia, western liberia, doctor logan, who was naming one of the treatment centers. he had 15 ebola patients in his care, and just studying people and trying to understand it for himself without medication and the right tools to work with. he discovered that ebola acts in destroying the internal organs the same way that hiv does. and so we decided to use what he

had, the medicatiomedicatio n all as 15 patients of the 15 patients, like two of them survived. there were two who died, and the two who died were patients that were taking five or six days after they had contracted the disease. those who were taking earlier than five day, they survive. my question is, have you given that they thought, or is there a possibility that we already have a vaccine that could possibly help fight the ebola crisis? would you be willing to consider -- [inaudible] as a possible -- against ebola pakistan? >> thank you for asking that. i think we heard from, maybe this is best addressed to you, that some of the hiv drugs have been tested without activity in

a bowl if i heard that correctly. but i do if there's anything further that you want to say or anyone on the panel would want to comment on that. did i get that right? yes, please. >> let me just say, we were unaware of those reports, and although we suspected the drugs would not work, it's the reason we did the testing. i showed the data, azt -- i forget what that is a trade name, but nevertheless those two drugs had zero evidence in one case had a virus activity. we got more virus replication. that's not to say of the drugs in widespread use shouldn't be tested and actually part of our reproducing program. but from our standpoint we were unable to confirm that those drugs might have worked. >> thank you. the question does remind me that

one of the critical function of state public health is not one to work with our health care institutions and thank the people who were in maryland also the community that is connected to west africa. the governor is, ask us to reach out and we're reaching out to leaders of the african community here in maryland and we'll be talking about ways to support them both in terms of giving them information that can be helpful and anything else that they need that we can provide. is there any comes by the speakers either on the question on thoughts about what either the school or the health department could be doing for people who are here and connected to people in africa? i would be interested. >> i can tell you one of the challenges we are seeing right now, and they come from twin cities, as you heard earlier, we are the largest liberian population outside of countries library residing here it's a community that has incredibly concerned and organized to try

to address this issue. they've got a great deal of pain. many of them living in minnesota. but knowing what's going on back home. and the big issues that we run into, frankly, and it's come up now both with the individuals but also the private sector jobs situation, someone wanted to go back home to help because their mother and father are now dead. they have two younger siblings and they want to do something to help and they want to go back into the issue and then come back to the united states. it's been a very heart-wrenching experience to so wait a minute, you're going to be a more risk. we don't have answers for that risk. we don't and this is one of the concerns that's come up. we've seen businesses now that are you looking at furloughing people for at least 21 days after they've returned from west africa. if you do that without the i guarantee you you'll not find that they're going to west africa, or at least likely you will not find out. if you pay them come is that a

situation where to start? so we are really, the policies are always a day late and a dollar short we got to look at these things anticipate it's going to happen more. if this spreads, we'l will havee same thing. this is a huge challenge. the people from the united states or other countries wanting to go back and help, and knowing that they will run into the fire, not away from it. >> that's true. i think also there's probably some significant levels of mental health support that we also need. >> they need health care workers more than they need treatment beds. it's hard to believe, because we are so short on the treatment beds, but it's actually only the second worst problem they face over there. the major problem is going to be once they are built, and they will be adequate -- inadequate, the number will be inadequate. they don't have the people to staff them. so any physician, nurse or other

kind of health care worker who feels like they can go over there and is willing to go there and do something, they i think she tried to find a way to do so because that's going to be the number one issue. the one thing you did see it provides a glimmer of hope is that when the resources and the training and the leadership were there, liberians are taking those jobs. a lot of that is a matter of the economy. they don't have jobs, their networking undertaking high risk jobs so they need money. but also they're stepping up and taking very dangerous jobs to try to combat this crisis. what they need or folks with expertise who can come over and run facilities and train people. i say that's probably their most serious need. >> that's very helpful. i would also emphasize that in west africa as well as here, the critical need of support of health care workers is obviously critical, yes.

>> iceland and one thing. i want to echo what lineages appear think about this, yesterday the liberian national health care workers all went on strike. they went on strike because up to 80% of them do not have masks, gloves and goggles. they're being asked to work in these cities. what the hell is wrong with that? why is that happening? you know, why can't we deliver -- we can deliver iphones from asia in 24 hours. why can we deliver masks, goggles and gloves to africa in one week? i don't get it. that's the part that frustrates me. because losing a group of liberians right now is huge. they are the backbone of what's been done as you saw over there. and yet i would, strike two, i know how much that hurts for them to strike. that's the part that is the disconnect that keeps coming back to about my recent time, bureaucracy time. we've got to get this together and they are not.

>> i just want to comment on it because, and like you might know this actually better, but it's not really getting the equipment even before the u.s. and that there is governments donated all sorts of institutions, for all types of ppe on boats and whatnot and getting it over there and there's been a tremendous amount all the way back, i think it was in august, ships worth of ppe because of the person who arranged that was the opposition leader and not the government, not the president of the government. the distribution model that exists, technically failed states, are covering this. and so we are left -- horrendous. we need health care workers. johns hopkins has a two team who has been trained to go into disasters, including these conditions. we are left with a gut wrenching

decision, which we really send our team into a dangerous a situation where ppe can't be a short, where one wiki of one type of ppe, the next week you have another type of ppe, where only now is the intensive training starting to ramp up, what are the security arrangements, can we get you out if you're there? there's a huge number of logistics and it everybody is looking for health care workers. and right now you are signing up to some extent if you can do with the frontier, msf, you might have a fighting chance but there's also other ngos and groups that are looking for health care workers. it's really not quite as simple as it seems on the surface. >> let me go to the next question. >> hi, thank you.

i'm a ph.d student here and global disease epidemiology and control. the discussion is not right into my question about the intended role the department of defense is going to put in all of this. we talked earlier about the financial pledges, but if i heard correctly i believe it was a gnome military medical personnel will be involved with direct contact with patients but i think we can understand that but i would love to hear the panels thought on that decision in light of you keep talking about the severe shortage and training health care workers, and why the dod is saying that its people will be involved in helping with that. >> first of all let me just say, i think one of the historic natures of this outbreak is the fact that msf has now urged the military involvement which after all those years of basically a detached position for all the

right reasons give you an idea just how far we've come in terms of just what the situation on the ground is. we need anything this is what he was getting it very courteous we need logistical support right now, supply chains are broken. we also need command and control. i wrote that "new york times" piece, i caught a lot of like because i kept saying the u.n. had to take a leadership role. everybody said the u.n. is broken. i agree with that but we need at least a nation so we can have a command and control structure where the u.s., the japanese, chinese, the cubans, the russians, the ugandans, the canadians, the eu and home countries could all have at least one hopefully kind of command and control structure. that is still a problem but i think the key thing the deity can bring right now is logistical support. if they can bring the personnel, they can stab them, that's great. that is a very, very key issue we're going to have. the other thing is so often we

get into public health crisis like this. they tend to be what i guess i would call short term. short term doesn't mean a week or two. this one could go on a long, long time. we will have to also realize we are not in a sprint. we are in a marathon. how we staff these will have to be looked at, how -- you can get one recruitment, maybe two recruited over there and how to get people to stay at had to support them emotionally, psychologically? i don't think we'll thought that far down the road get a. we need a much greater global commitment. i just want to acknowledge the fact i said earlier, th the u.s. under produce has done as much as they have both from the government standpoint and from the private sector, philanthropic standpoint. where is the rest of the world? why are we not seeing that? to president obama's credit his been saying that over and over get the last three weeks. where's the rest of the world? secretary kerry said at last week. where's the rest of the world? that's what i find just, if you

don't care about humanitarian side, shame on you. but by god, this is in your self interest. you've got to worry about terrorism, worried about the collapsed infrastructure. why are you not there? that i can't understand. >> i'll turn to you in one second but i will just pick up on that. i think it would be may be worthwhile i see professor peters here so they're eligible to answer any questions. and i think the question and your answer raises the issue of global leadership for the price of west africa, a lot of different things all try to move in the same direction or 101 in its role, and how does -- w.h.o. in israel, how does this, important point but we forget the answer i know you have something to say.

>> i have a completely different conversation. >> i will come back to them. i just wanted to see, particularly from the broader international health perspective, international relations. this is a huge challenge. isn't up for the challenge right now? feel free to come up and speak to that. >> sure. you've raised a question that can't be answered in 10 seconds, but i will say that by all evidence that the coordination that needs to be there, governments are pleading for and the people in the communities are pleading for really hasn't been there. one of the unprecedented things that has occurred is that the u.n. has created a mission for the ebola response, unmeer. this is the first time this has been done for public health event. and at the first among many. and that is meant to serve as the structure which brings all

of these different players together and working towards the same goal. that's not to say that the structure is completely set yet. really is not. but that's what it's meant to happen. so the u.n. is meant to serve that role. that's the leadership function that they are meant to play. the u.s. military doesn't want to and doesn't need to play that role. they can't charge in there and take control. in fact, they are in support of the usaid mission even within the u.s. government structure. but they do provide the critical logistical and other support that was mentioned. so i will just leave it there but i think there is a lot more to do in terms of generating the coordination necessary to get the resources where they need to be when they need to be there. >> i would agree with that. i think we're in the process of basically rebuilding the

coordination approaches as epidemic is ongoing. i think in the aftermath were certainly going to need to we look at how this is done. i think that the coordination center is being set up, this would be placed, in terms of command and control but we are a long ways from a coherent approach. when the time comes we will have to look at how we do that on the civilian fun. there is a lot of leadership that is emerging both within countries and again i think the example from congress a good one as well as the countries that are being attacked, or having undergoing the epidemic. but i think that there would be a role for looking at new ways in which we can have preparedness and response to these kind of epidemics. we're going to expect again in the coming years. >> last thought on this. >> i want to add one little piece of the risk of being controversial. i am absolutely convinced that this outbreak is w.h.o.'s 9/11.

and that i think that the future of w.h.o. is in question in terms of what comes out of luck in the future. i think it's going to be a lot of consideration about is the current w.h.o. outdated for it's time? both in terms of ability to respond to its authority, financial support, it's coordination, all of these things. everybody thought when the international health regulations came through this nonsense into the future this was an organization. i'm not saying that it's going to be gone but a dope with three or four years that the same w.h.o. we see will be there three to four years of my. i think this'll be a really very, very important time for reconsidering global health at how we respond to global health crises. [applause] >> i missed the discussion about global leadership and imports of giving in supplies and infrastructure but i just wanted to briefly comment on the kind

of issues david peters was talking about earlier in the day and the importance of local leadership. and local mobilization and the experience, just one hopeful sign, you know, the experience of local county in liberia with the cases their peak and every member right, at about 790 cases in august and have been going down ever since. when people did a debriefing last friday in monrovia about what worked and what didn't, they highlight all those issues that were being discussed earlier today. local leaders who were vocal in committed, mobilization through women groups and youth groups, and burial teams and monitoring teams to trace cases. so there are some hopeful signs when we focus on local level interventions, local leadership and social mobilization that can uncover those resources at the

community level. >> question. >> my name is bobby and i'm from liberia. ebola is -- tour -- mike allen members already dead because of ebola. it's important you have a conference like this. [inaudible] people from the three countries should be included in this group. so you don't get here, we don't hear your ideas about how to help the black man. there are people on the ground already. when the issues started, people from cuba when, approach the cover. they wanted to send the doctors. they don't send troops. they send doctors. the united states refuse for a

long time. just recently they released the. so we have far more cubans on the ground right now are helping people in the villages. so we think -- since 1822. talk a lot infrastructure. we gave you the first airline to fight world war ii. the relationship has not been beneficial in real terms. talk about how much you produce. that's good, but what about working with local -- knows something about it. that's all i want to say. [applause] >> thank you. first, i'd like to thank all the speakers because they give very clear image of the situation on

the science behind it and all that is needed. needed. >> could you speak into the michael? >> i'll try. currently 3000 people working in the three main country, 90% of them being national staff. we have 690 beds. we have admitted close to 404,000 patient so far i just looked at that, i received on friday, 4% of the only recover. so that means there is not enough staff, not enough beds, there is not enough of everything. there is not a good level of care. we know that the treatment centers, we have them, so there's a need -- [inaudible] they have to take into account a human way of treating patients, a human way of protecting the staff, start taking to the patient.

those have not been developed yet so we need to develop that as well. we need more people. those people need to be trained but that's not enough. supervision should be continued. supply should be continued. we cannot have staff without protection gear. so for the time being, we really need more people involved. it's not that much question of money, for one. it's a question of commitment. it is a question of using the science to improve what we are doing now. later and this is possible we need new diagnostics. the diagnostics should help. we need new treatments. we need new vaccines. that's really necessary because the outbreak is there to stay. we need, therefore, and a magic way of doing -- we need ways of doing those hires.

that is understandable for everybody. not just for the er members. so we really, really need much, much more but i would like to thank you for organizing this meeting one of asking for more. thank you. [applause] >> thank you. >> before you go, could i ask you a question? if people are watching on the webcast are following on twitter at johns hopkins, and they want to know how they can help innocent separate specifically, they can go to website and contribute. but what else could people in the public health world be doing? >> i think what needs to be done is people committing to put the state to individual with msf on with many other organizations but also people pushing politicians to make things move. there's been a lot of promises. we don't see that much yet on the ground. so i think that's the role of a

breakup pushing the politicians to get things moving. and for helping with the science to evaluate quickly models, really sick most of care come to evaluate quickly the way to make them available and affordable. these new tools cannot be minus 80 degrees. that's not going to reach the bush in africa. the axis asia and the afford the issue has to be taken into account as well. >> thank you. comments? >> let me plug something for britain would you think people who are listening can do that will help the entire response. this is a shameless plug. last wednesday we launched a website called health districts are, people looking occasion network.org, and the purpose of this portal, we checked last night, it has over 4000 hits and about 170 materials on it.

the whole purpose of the site is for people to share experiences, materials and media that they've been using. i just wanted to quickly since people are listening on the web, looking for very concrete things they can do, sharing their experiences is now quite easy eat you can go to that site. so thanks for the chance to shamelessly plug. plug. >> great. i also have a sneaky suspicion that at the mike clegg is tweeting right now. [laughter] >> i'm a bloomberg alum. question on vaccines and virus versus bureaucratic program time. what is the pathway to licensure for an ebola vaccine? how our regulatory agencies responded to kind of the overwhelming risk, given the pathway's? >> let me maybe do a little bit of the answer to that. people may know before his the

second of ago i worked at the food and administration, responsible for licensing. there are some very good and great people to work on vaccines will be working very close with the people developing the vaccines to think about the right kind of trials that were necessary to establish efficacy and safety. they may be able to -- a lot of access could happen during the trials based on the evidence along the way. i think that it may well be the case, under the people here would know this better, when you have different types of public health challenges, it may be you're going to need to get all the best people who understand the oversight of vaccines and room to figure out how to set the standards so that they can be done quickly and with created designs so the answer can be knowknow as quickly as possible. i think this is a challenge in a way to the regulatory system but i can say i think, knowing the people and a commitment to public health, i think it's one

they will be able to meet. i'm open to other comments on that. >> okay. >> i mentioned briefly but i'll say it again. nih is about to launch a comparison, actually three vaccines. in what is being rolled out as a phase to/three clinical trial bigotry synthetically powered, 30,000 people, and one would help that i'm not going to speak for the fda but one would hope once the results are analyze it would facilitate licensure of at least one of them. >> let me tell a quick story about h1n1 and the vaccine at that time. there's a push at the time to consider sort of experiment of vaccine and giving everyone asked the medal vaccine versus

pushing to get the data that could actually qualify for licensure. the agency felt very strongly that it would be a lot better if it could be licensed and you wouldn't be going out having to get informed consent from everybody and you would really feel like it was licensed. i think the framework of licensure and the fact that the anti-stand on the products is very important rather than just saying this might work, the risk is on you whether it will or whether the balance makes sense. and so i think the idea is to have a steady phase, to try with -- designed with an agent hopefully the agency can the couple enough so when you're willing to roll something out, we are standing behind the product that could make all the difference for people in west africa. >> a problem that would be great to have is how to use a vaccine that actually has evidence of

efficacy when you 15,000 doses. i think it's something we need to start thinking about and engaging country partners. because having 15,000 from having 100,000 doses of vaccine, it's not all that easy to think of how you actually use those. special targeting, health care workers would bid group that would be targeted as well, but it's going to be lots of issues of equity, of the perception about being used, and actual sort of trying to figure out how it is most effectively used. >> great. [inaudible] >> we may be winding down. this may be the last question. >> i am from the bloomberg school and i have two questions. the first is, as we have trauma center's and berries communities, is there any wisdom

in designating specific health care facilities as first institutions, at least until the point that, god forbid, they might be overwhelmed to respond to people who have suspected cases of ebola speak with you were speaking to the u.s.? >> yes, and other developed nations. >> as you know, initially the recommendation was to shelter and place in each any hospital in the u.s. who felt they should come up and take care of patients. people have already been questioning that regardless, and dallas having changed the whole spectrum but let me give you some insight as to what that really means. a real biocontainment unit is a concept that is completely

sealed off of all of the patient areas and is stand alone. we have 42 acute care, 4200 acute care hospitals in the u.s. half of them are under 100 beds. 180 some odd va hospital scum something like that. and we are likely to go in that direction. we made our recommendation last night any means that we should have a designated site at one of our hospitals. i won't get too into that because we haven't finalized exactly where, but even in the short term building that has to occur to meet certain specifications is enormous. and right now there's nebraska and the nih, and a marine that is creatively done this -- emory. we talk about a public health system but it has a boatload of private hospitals who are now faced with i want to play, i

want to contribute, i want to be a designated site because we think that's our responsibility. i've got figure out how to do it quickly and pay for it, and all, by the way, when i'm a designated site, what it all my other patients? suddenly come they going to go? if you want to go to the ebola hospital? we face the same issues with hiv. i think we can overcome them and we decided back in the early 80s to be a major hiv treatment center, research center and so forth. today, we see the benefits of that. but back then everyone had a center. if we are because they hiv hospital, all the patients run away and what happens to our business model? where's the public health system that might sure that that? it's a very complicated thing, but think we're going to go in that direction apart from the concept of designated centers is

probably the right way to go with the highly trained group of people who take care of these patients. >> anything you want to add to that? no. >> i think -- hello? hi. my name is kevin burns. i make family medical doctor. >> we've been given. >> we've been given a little extension so we'll go for a couple more questions. go ahead. >> is it on now? this way? okay. my name is kevin burns. on a family medical doctor and i'm currently a general preventive medicine resident here at the school of public health. on september 13, dr. buck became the fourth sierra leone and doctor to pass away from ebola, and it occurred when under a situation where there was a hospital in germany ready to receive her, and the w.h.o.

declined to fund her transportation. she's just one of a number of key, i would say almost irreplaceable assets in this epidemic of local doctors who were on the front line. and i wonder if analysts are in support of considering -- panelists are in support of transporting local doctors to outside the sulleys, particularly given that we are transporting a lot of foreign aid workers out of the area when they become sick. >> great question. nancy? >> it's a great question, and i want is a couple things about it. the. i want to separate the question of whether there's a duty to take them out for whether that's w.h.o.'s responsibility. first of all the fact that at least so far, employers have made commitments to their own employees international

employees, to airlift them out if they get sick. is not something that is unusual, and i would argue is something that is essential to its part of what gabe was talking about, if johns hopkins is going to send people over. my sense is johns hopkins has to get you to have enough equipment and if something happens they will be airlifted ou out in the same as i said analogously that if somebody from the "washington post" or abc news was covering ebola or the war in a afghanistan the lake gets blown off, use some abc news is going to airlift them out. so the fact that that hasn't happened so far with enmeshed people, if you think it's comfy when we see what happens to people in sierra leone but it seems to me that, i'm only making this up, but to be clear with the transparency. there are groups right now that

are willing to contribute extraordinary amount of money to ebola. there are some very wealthy foundations. trying to get what they can do that would be helpful. and i think a lot of us would have a lot of ideas and things they could do, particularly in the context of having interest in going but being willing to donate money. it seems to me that is the kind of thing that could be potentially set up. i think that w.h.o., this gets too much into what is the role of w.h.o. but i do know that's the role of w.h.o. and will be a very complicated slippery slope that would really have to be anticipated of the number of health care workers who were getting infected and with the budget would be. it's not really just one person who would be airlifted to germany to be a lot of people and that's an important thing to take on. i think it's an important conversation to raise and think of something to think about

addressing. but i want a separate role. >> i agree 100%. but let me give some context. at that time the airframe movement in and out of the area was dramatically impacted by refusal for landing rights. it was actually a problem occurring at the time of just tried to get certain aircraft in, plus you his contract through the usg for who could come in and out can we had a problem here in terms of going aircraft available, but you in a pneumatic tube basically for 12 hours and seal you off from every and that was the only contract that existed in addition up on the hill, one of the very first briefings i did, a very senior congressman with a great we brought us into the back to atlanta for treatment. said we're just contaminating our shores but what if the plane

blows up over atlanta? et cetera, et cetera. i realized i had a real hot livewire on that one because it was the first question in a briefing. i thought if i screw this one up on done. i might as a walk on right now. i painted a picture for him and saying, you have to understand, first of all think of this as a servicemen issue. if we send someone into harm's way are we as a country willing to bring them back if they give their life and they want to die back your? the biggest problem is getting people to go there because not just that they're afraid but they get sick, they wanted someone will bring them home. it was amazing. he turned 180 and said i never thought about like that. just a become one of the strong support to bring people in and out. we have some education to do here in terms of our policy makers, funders. as you said people who are willing to sure why that is important. it's really about a standard that says will bring our own home. whoever they may be, meaning not

just the u.s. but any country. that's one of the few fringe benefit you might get from giving a precious part of your life to do this. we should make that a hallmark of anything we do to we will bring you home. i think that's huge. >> one thing i've been surprised about, tremendous got health care workers just to the general population that if you talk to people over there, they know that health care is more a failed outside of liberia. because the only check is the infrared thermometer, you could take a few title if you thought you ebola or you come down with people, very easily clear the fever check. soberly to vigorously most give back is the money for the plane flight. a lot of them, most of them don't have a. i'm not talking about health care workers anymore. that will raise, if it ever were to happen, if people were to say i'm going to try to find care in

brussels or ivory coast or molly for something. that will be a hold of the situation. >> i think maybe -- >> so i am not at all an expert in the ethics of this, but i would go back a little bit to what i said is that there's very relatively simple things that we can bring into the field to really improve our medical response in the field. so while we conduct but many people out, i also think it's really important that we change the discussion about how much we should be offering people in the field. even with very simple interventions we potentially can improve the outcome of in areas of health care workers that are there. -- near you of health care workers. but think about it from a public

health you come partner messaging is we need to change the paradigm. we need to really think about how we can decrease mortality there. because we may not ever have the funds to bring everybody out of africa. >> before you go, can you maybe just follow up on that with, you know, what would you like to see it available to everybody? >> the data our strongest with iv hydration. this is even in the setting, some things are done with doctors without borders and other people but you just come you're getting people three, four, five, six liters. these people have a colorado >> diary and you have to aggressively hydrate them with electrolyte replacement. this has been done in the setting of not really having these portable point of care testing machines that allows to look at the electrolytes and

even do this rationally, or you know how we would do it in a more developed setting. that would be something. you can imagine there not see. you can manage their fevers. -- not see. there are things we're doing in developed countries that are not necessarily that expensive it can be part of this bundle of care. and then the other thing is just to think also on we can prove the affiliation of the people who are dying, and how can we incorporate some of that into a bundle of care. that's part of it. there are data out there suggesting that antibiotics, something very simple because there's translocation of the g.i. for me become an important component of this during the illness. and again, it's not terribly expensive. and then the other huge sort of

debate, discussion going on is when you're in this part of the world and the patient comes in, should we empirically be treating people for malaria while we're waiting for the diagnostic test? we are not talking about fancy, fancy stuff. we're not talking the extra machines are whatever. we are really talking about basically treating this as a diarrheal illness, and maintaining basic hydration with electrolyte replacement. >> i think we will go with one more question. >> hi. this question is for dr. osterholm. it's about what you said earlier in remarks which i thought was a big deal around cases where people are not presenting with fever. something that i've actually heard when i was in sierra leone back in july, not for any reason

reasons for ebola but for a malaria project. and i thought the comment was odd, and i've heard it a couple of times since then, the last time from you. and so if you look at the literature from the cdc, from the w.h.o., from other organizations, you don't see that coming out. you see fever and all these other symptoms. you must have fever, et cetera, et cetera. so can you shed some light on this and help me understand what's going on? >> thank you for that question. i can't shed light on it other than to say i think it's something we have to understand better. we can't be afraid to ask questions. the problem is the question right now that is tied so closely to a policy that is so rigid that people, i mean, i've actually heard people get to debate with others, which we all know is really so immaterial to the whole issue.

i didn't think we just have to keep an open mind. don't think most patients as we've seen in this outbreak reasoned with fever? athlete. absolute. i think there may be a subgroup that we don't know about we need to understand better? yes. which the application? they are real. whenever you about is we're ready for another black swan even if one patient presents in the u.s. hospital, it will have to happen, and doesn't have a fever, ends up having ebola and emergency room get gets exposed everyone a comeback as a public health didn't tell us the truth. we should prepare for that now. and then we need to study. i don't have an answer. i don't understand it but i've gotten to me just as the article i was not part of the "l.a. times" article but i can say i've gotten the same feedback from various groups of physicians reporting the same phenomenon, a real significant subset of the patients are not presented with fever right up through death. >> from the state health department perspective, we have

a pretty low threshold for people to call us. they have been called as from around the state with all sorts of cases, questions, and we want to be open to whatever could happen. we will be working with facilities with the to me preconception so that we can be prepared for anything that could, to maryland, as best we can. i want to thank the panelists for some terrific insight. i want to thank the professor for organizing this, terrific program on such short notice and the school of public health for really showing all of the different, incredible resources that can be brought to bear to talk about something that is really an incredible path right now. we've heard for the international health system. it's a test for all of the to scale up work to areas of the world are in dire need. it's a test for research, not just to understand this illness as well as we can but our

ability to develop therapeutics and diagnostics and ethically and quickly tested. it'it's a test for us to go to implement committee projects and communicate about them in ways that are effective at the local level. finally, i was it's an incredible test of our ability in the united states as in west africa to support front line health care workers. because we can't do that i don't think we've any chance of being successful. we are in the middle of this test. i think we certainly heard a lot of reasons for concerns right now but it is certainly a test that the world cannot afford to fail. and i think we've all learned a tremendous amount from the spam and from the rest of the day, and for the concluding comments on it i would like to ask you to come back up. >> thanks, josh. josh, i can only imagine how busy you are because i know how busy i am and i know you are busy or your so to take time to come from your duties as state

health officer should we really appreciate it. the panel discussion, the whole day was in many ways an incredible day. so my notes your say summarized the symbian points of today's discussion. which is we only have two minutes, so we have to stay another day to do that. i would point people to the twitter feeds from the school and from various others from your and for me and from others that have been summarizing many parts of this. our schools website we will archive the presentation so be available on the you and the powerpoint slides will be there as well. i heard so many insightful comments today. maybe the best metaphor was michael austro does many great metaphors, was if you give a great neurosurgeon a hammer and chisel, they will not do a good job. we've given public health workers frontline workers in

africa a hammer and chisel. the most poignant was a man from liberia got up and tells that he has lost 12 family members, and the cube is there, we are not to employ of this nobody from west africa on the podium. i apologize for that. we thought about that. we tried to get some people and it just didn't work out. but when i said, when we sent out the agenda yesterday, lisa cooper also pointed that out to me. we tried but we failed and we apologize for that. i think that to think that this happened is basically six days, was just incredible. i take some solace from what josh said. he called this a test. that's a great -- this is a test, but i think, and mike said that w.h.o. is going to change. there's no doubt about that but we are all going to change.

when you think about that we now have vaccines which been sitting on the shelf about to go into clinical trials in such an ago the short period of time it shows we are moving, maybe not in virus time yet but we are not we were two or three years ago. we saw that with sars, how sars changed things and in many ways mirror system better. my hope is that this current test is going to make all this better what we do. i want to thank andy peck goes who also has a day job who has worked nonstop and getting this together, so thank you. [applause] >> and their office of external affairs did an incredible job. i was watching the live feed. we have some around 2500 people watching us live, and the sound quality and if you were actually. that's important i think to get this information out. interest that people showed

about today's show, shows how hungry are for information and for insight. we couldn't have had that insights from our speakers. many of our speakers were in house but there were several who traveled. peter, it was a tour de force. that would've tweeted about your talk, is a tour de force of vaccines and drugs. mike came all the way from minnesota. and then, of course, josh came from several blocks but a world away. [laughter] and linney. >> from liberia and is here with us, and brought insights that were really remarkable. i did want to mention that our magazine to which i don't have a copy of, despite what over there, we'll have some outside has an article on some of the work that's going on, on behalf of the school on ebola. so take a look at it.

it's also at our website. pass it up. it's out there. we have on the school so please pick up a copy. in fact, we are having a life you this afternoon from 3:30 to five. alive kickoff for the magazine. we'll have some refreshment and we will talk about the articles in there, including the ebola wonder i hope to see you there. again, my thanks to everybody who did such a phenomenal job. i think we'll look back on this day as the day with our school we dedicate itself to addressing this topic of ebola. end to emerging diseases and support front line health workers around the world, so thanks very much. [applause] [inaudible conversations] >> will good morning. i'm honored to be participating in this prestigious symposium.

i will say at the outset that is the director of the research facility we are in the business of developing medical countermeasure for the organist which require high levels of biocontainment. what keeps me up at night is what happens if one of my lab workers catches his experiment? we do have medical treatment facilities, special content studies unit in bethesda will handle cases of occupational exposures, cdc of course as emory and about two years ago i convened a symposium with two colleagues, rickety and lisa hensley, bringing the medical directors of those berries facilities together to review medical countermeasures that could be possibly pre-position in those facilities so they would be available on short notice. and it was somewhat disturbing at that time that there were no medical countermeasures that

could be pre-position. the best way to 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 was the most promising things. this later groundwork actually for what's been happening. recently where there was a meeting several weeks ago at the world health organization where might refute the state of the art and i'm trying very heavily from mike's slides here. i thank him for providing them to me. this makes it ago. there we go. this is the famous disclaimer, you know, i am you know, i am and nih and play but i'm not recommend anything but a just reviewing the literature and these are my opinions and those of my colleagues, and the caveat also that the assessment of efficacy is based almost solely on animal testing david. up until recent there was no experience of any of these countermeasures. recently there has been some experience and i will get to

that in time. when you look at animal models, the are animal models for ebola using mice and guinea pigs and nonhuman primates for obvious reasons none of the primates are regarded as the best disease models but, of course, one has to be careful in interpreting these data. has there's usually insufficient data to assess cover billy between humans and nonhuman primates. we know more about pathogenesis and nonhuman primates than we do in humans. interventions targeting host of functions may be impacted by species differences among the viruses. metabolism may complicate dosing. so the more promising drugs have more in monkeys. all target effects may differ between humans and nonhuman primates. i won't go into this other than to say a bullet is a very simple virus that has a fairly

complicated lifecycle. there are a number of points for intervention to end its replication strategy and in the interaction with the innate immune system. so the way of going to go through this is i'm going to go to the available vaccine followed by therapeutics, and within each category tell you what's known about nonhuman primate efficacy data and with what we know about human dosing. the way we like to present this is was a virtual product label. you can see who makes it, descriptive of the park, where iis it in the phone, how does it act, efficacy data and nonhuman primates is available. human safety data if it's available, and viable product quantities if it's known. manufacturing and capacity. ..

and is the dose the same for that strategy or is it going to be hired in general use? so the vaccines which are getting some attraction right now is one developed at the vaccine research center and in conjunction with the virus with

the ebola gene inserted and into nonhuman primates, immunized anticipation that's 100% protected and it is now in phase one testing in this country. the vector if south has been in over 200 subjects and the ebola protein vaccine has now been in about 80 subjects in the phase one study which is being conducted will eventually have to hundred people. the company predicts 1300 cases of the vaccine to could be available december, and its current surge is minus 80 degrees and is known to be stable for a protracted period of time at minus 20. the other vaccine that is getting a lot of attention as one based on the virus and the

same idea that proteins is traded out. it was actually developed about ten years ago in the public health agency and its now licensed in the bio protection which is in the process of wrapping it up. it is effective as a single dose and general use of vaccine. it's known to be protected at 100% within 21 days and there is some data that suggests it is effective when given almost immediately less than an hour after exposure into nonhuman primates. it was actually this light is out of date. it was used several years ago for the accident in germany and its now it's now been subsequently used in some of the patients evacuated to the united states. there are about 1400 are available now and as i said it is being ramped up.

other vaccines that there is lots of them out there but they are further back in the pipeline. we have the platform that developed the vaccine that probably isn't going to be useful in africa and it also has the combined modified vaccine. the army is developing the lp and thomas johnson -- thomas jefferson university has both live and reactivated vaccines which actually look very good and that one is coming up fast. so the timelines have already started phase number one testing and you can see other tests are scheduled to occur. 15,000 doses in phase number two

would be available in december and this is actually a late breaker that i understand there is now a clinical trial developing in liberia involving 30,000 people, 10,000 people on each one arm gets an unrelated vaccine probably hepatitis. okay. there is bad. for the target populations are obviously front-line health-care workers and untapped cases in the vaccination. other high-risk exposures and potential media postexposure with the clearcase definition. so now we are going to turn to the therapeutic considerations with antiviral activity that target the virus directly and a host of the function required for the lifecycle or something that augments and then other

host directed therapies will be discussed as well. with all the products that are still under development, the treatment doses and regimes are uncertain at the present time and the mechanism may dictate the usage and they may be effective early and impact of the efficacy that must also be considered. so we have all heard about zemap. in and the medical directors meeting the predecessors were selected as the one the medical directors felt most comfortable using because they are comfortable with the idea of passing the immunization that's been used effectively in many other diseases and the data up to very good. this is actually produced in tobacco plants at least two of the three helped canada. it's been used now in seven

cases and has neutralized antibodies in the cocktail. zmapp is effective in the protocol in experimental effective monkeys once it is still 100% effective. there are no controlled unit safety data and there is none of that has been used. but they are ramping up production and expects to have 12 to 20 doses by december and as i mentioned it's been used several times in the patients evacuated to europe and although all but one of the patients survived it is not clear whether the zmapp had any beneficial effect because nobody uses the measure before and after the infusion, so we just don't know.

it has been of course used many times in the past and it was used with seven of eight patients in the days of the outbreak that survived but it was really into possible to impossible to assess if that had anything to do with the survival. i can tell you where we have the survivors and we use it in the path of the innovation scheme it rarely if ever works and the way it works is when you comes in trade and make it highly concentrated the networks but, you know so again collecting the plasma in the field and using it in that environment is fraught with some dangers and i'm thinking that if the zmapp were something like it can be ramped up, that's probably the treatment of choice. that's not a recommendation, that's just my opinion. i don't want to get fired. [laughter]

we are developing a critical for plasma collection in west africa and again as i say it has been used in patients evacuated with the indeterminate results. other passive immunization schemes the russians actually produced the igg years ago and it was shown to be pretty effective in the primates in the laying of the time to get the primates developed. so that didn't really go anywhere. there was an outfit in france that has been interested. this technique has been used commercially for the rabies and tetanus so we are meeting with them later this week to see the immunizing perhaps with the rabies vaccine as a source of that antibody and then another

interesting wrinkle on the passive immunization is the cattle producing antibodies. this is being done in conjunction with the stanford applied biologics and those animals now will be available in four to six months to read we tend to test all of these things into nonhuman primates. this is in the nano particles in the 35 and silences the genes and it has been shown to be 83% effective with 67% at 72. there is a phase one dose that has been completed and the fda put on a partial hold because there was an incident of hypertension and the thought now

is they would release the clinical hold and provide the doses lower somewhat and it appears that within three or four months it will be available as well. other antivirals looking further back in the pipeline, the products block the production 60 to 80% effective in the monkeys tested in the infection phase number one has been completed and potentially 24 treatment courses could be made available right about now. there's been a lot of interest. the japanese government has the same great quantity and has suggested using it and it is a license for influenza in japan. currently in phase number three for the complicated influenza.

at the bottom line up front it doesn't work. the studies that were done in which higher doses were tested in monkeys and once again that he laid time eventually is still 100%. a small molecule by the inhibitor again has shown good efficacy. 100%, somewhat lower efficacy against ebola with the submission is anticipated in november and potentially 2000 treatment increases for next year. this is actually in the stockpile now for smallpox and it is a small inhibitor and has activity against the fuel by races and it has been in phase number three the same drug for

the virus is a good safety record and is potentially 3500 treatment courses available and it was used in the dallas case although unsuccessfully. with the caviar for the intervention caveat that the intervention was initiated quite late in the disease course. we intend to test this one in the guinea pig model. it is not into primate model. there are a number of strategies related to the inhibition of cascade to have been shown they are somewhat effective on primates. it's now discontinued and was also shown to be somewhat effective but again its availability is unknown. so those could conceivably be used in the intensive care unit and it is unlikely that these but have any utilities in west africa.

another thing is repurposing the approved drugs. if you already have an approved drug and you can use it off label, so much the better. i'm going to put up some data that came up over the weekend where we look at the three tc since those were being suggested for use against terror -- you can see that they had no effect. we tested it in the human liver cells and the same thing again, so i think they are off the table. here it shows they have some efficacy in this test. finally there are many products available. the blockade of the receptors and the models actually accelerate the disease. basically they interfere on the altitude, human interference have the latest time but have

never been uniformly effective. the virus expresses the window of the antibody therapy. and it's interesting that some receptor modulators including the classic effects without requiring the functional er impacts the latent viral entry and 90% survival in a mouse model and it's not even the primates indicate ocular disturbances in males but we may go back and test this again. finally, just another of other drugs that have been identified can see them listed there all of which we will be testing to see if by some chance they actually work. i think i'm running out of time, i am. so to say that you have to in any of these things continue to

provide care for the patients of course and act all of the reports that suggest the clinical care can improve the survival rates as rate as we have heard from some of the other speakers. in summary there are no approved products but they are in the development. they are in limited availability. some will be available sooner rather than others. there are products for other indications that they have a benefit. there are multiple vaccines under development that have the potential to have significant impact in the future if this trial gets off in liberia and december i think you're going to see a change in that epidemic curve that we've been looking at. but of course it is unknown how these will perform in people with ebola. with that i think i will stop and think you for your attention. [applause]

>> thank you very much peter. now for the last talk and the first session here i would like to introduce joshua epstein the professor at johns hopkins school of medicine and director of johns hopkins university center for advanced modeling and social behavioral health sciences. >> thank you very much. thank you president daniels and especially today i want to talk about the fact i use the phrase long-term that betrays a certain sobriety about this topic and i will come back to that. the things i want to cover in the talk are reasons to doubt

the the worst-case estimates that has come out of the cdc. i want to also talk about why i don't ebola but they don't completely. i expect endemic cycles are plausible and i would like to talk about why the outburst now why did we see this spike in incidences and i want to talk about an idea that i think is worth pursuing called the mobilization of the recovered. i know that this fixes some stick my problems but i want to come back to those and then talk about the global modeling that we have done with a little bit on the global side of things and then talk about the overall implications of the strategy. but first of all, i know that others typically skepticism about models so i want to just run a quick survey. how many in the room or modelers

wrong answer. i think everyone in the room is a modeler and when you close your eyes and imagine a process of any sort, and epidemic spread of democracy, migration from economic future, what have you coming you are running some model. it's just an implicit mental model that you haven't written down. so, the choice in life is not whether the model or not. you are a model. the only choice is to do so explicitly or not an explicit models have the advantage that they force your assumptions into the parody to yourself and to others. they permit you to explore the sensitivity of the results to those assumptions. they are replicable by others and they are comparable to the data and can even tell you what data is worth collecting. so, the modeling has many names and is conducted at many scales and i will show you both between models suggesting the model avenues and more -- -- high

fidelity large-scale models. it's been this easy model that is commendably explicit and it was done under a lot of pressure in the eye respects the people that built a model. it is for those reasons a very rudimentary model. the user has to supply 30 numbers or so per run so it has more of a flavor of an accounting tool fan and actual dynamics model and the assumptions implicit is that the populations are well mixed, but there is no space, there is no behavioral and a petition and a larger family in the model produces a classical type of projector he with a high peak and fade out and it heats up too fast and cool down too fast in my view as this general class of

models does. here's how it heats up. this is how the famous 1.4 million worst-case scenario unfolds. we have run this epicenter is it easy enough to run. if a corrected word means that for every reported case there are 2.5 unreported cases which is a very high ratio that we would like to bring down. david and others are working hard to do that. but the standard model heats up and then falls down. that's how these models were qualitatively. i am suggesting that this type of care is more likely. we can avoid this huge peak with various measures and behavioral adaptation to contribute a lot to the avoidance of that data will not die down to zero. there will be an endemic level and in endemic cycle of the

disease for a variety of reasons so there is a long-term prospect of persistence and management question that i think needs to be faced squarely. why will this be less grave than the worst-case? because lens of the disease will increase vigilance in complying with the containment measures like personal hygiene, use of personal protective equipment, home decontamination for safe transportation to the ebola care units and improved burial practices and i think that as david mentioned, we are seeing this sort of change in liberia and we have colleagues from virginia tech and brian lewis who i think document to do that quite well with the data available. there is a containment challenge of course one of them is simply in the healthcare workforce.

it's hard to staff and operation of the scale with trusted well-trained individuals and trust is a huge factor. remember a healthcare workers were killed in guinea and they were chased away in sierra leone because they were feared to be spreading the disseminating virus instead of decontaminating it so there is a lot of poor information and distrust to overcome and i think that will be important if and when we have a vaccine. you know, the polio vaccine is refused in nigeria. polio is resurgent in nigeria because of that distrust. so here's an idea of how to get a larger healthcare workforce. i've called this the mobilization of recovered but i first heard the idea in the department and now we've modeled it out a little bit at the

center for advanced modeling. the basic review is as long as we know the people that survived the disease are permanently immune. so let's train them and use them as a workforce and controlling the epidemic. it's pretty compelling if you assume and i'm not as doing so but we have a case fatality rate of something like 70% i hope we can reduce that. then you have 300,000 survivors with that confirmed in unity. so mobilize them as health-care workers. they are immune to the disease at least a current very end and they are aware of the culture and speak the language and they are trusted by others in their community. so let's convert them into a healthcare workforce. what potential impact could that

have? here is a simple set where we recycled, recovered into people who can reduce the transmission rate by improving these practices, training people with waste removal and all these things. i know this looks a little daunting but the basic idea is if you just take a classical standard model where the susceptible fall because they become infected than the infected pool halls and they are otherwise removed from circulation with no mobilization if you mobilize and run the very same on the very same simple one, you get a much higher, 20% improvement in the number of people that are healthy and the corresponding reduction to the number of people who die and the peak is a tiny bit later. the blue curve under the

strategy is 20% higher with 100% more mobilization of recovered and these are very conservative models. this random mix is not that these people are targeted as were targeted as they should be. but they target the models just throwing them back into the pool. so, it's a simple idea what are the incentives? there could be humanitarian incentives for people to do this and as my always practical colleague reminded me in a phone call you can also pay people to do things. here is a methodological lesson is here is a 20 model that suggests a fruitful policy. it's simple and transparent and i'm not predicting anything or making claims about the model, but i think there are lots of reasons other than the

prediction to build models and if you're interested in that topic, for 68 reasons other than the prediction you might enjoy my little piece published recently in the taking on the newspapers here at hopkins and i would encourage you to enroll and i would say doctor henderson would agree that we have the success in building the models and focus attention on the different avenues. and it disciplines the dialogue. if it's the structure on the discussion and that's important in the settings. okay. i don't think that ebola will vanish one is for the evolution and another is the persistence of animal reservoirs like that

and then there will be behavioral cycles of the children's and complacency even given the vaccine. on the first factor there's ongoing evolution of the virus. we have in fact seen it's been around for a long time. this is the 76 strain starting in 1976 it's been around a long time into and these are different outbreaks by year so it's not new. i think that is an interesting question and it's possible that it is implicated implicated but i'm very interested to work with doctor jonathan at the steam who focused on the deforestation and if you think about it, this increases the vector density and it does so in a nonlinear way if

you reduce the land cover from the ten by ten to 99 you cut the areas i almost 20% so if it is the same number to the same area the probability of the contact grows accordingly. so deforestation forces the reservoir and increases the probability we be forced in the first place as ways to transport these people into urban settings and the animals for sale and so forth. you can see the whole area has been taken out and you can't quite see the colors very well but the whole point of deforestation is to build the roads back in the cities.

the mechanism is that you be forced into the roads to transport to the urban settings i think lawrence for drawing my attention to the roads. deforestation in africa is of course a huge issue. it's going on everywhere and i think it's implicated. so, recall my alternative curb and this is what i was saying. we had this reduction but we also get cycles for those reasons. but we also get cycles for the behavioral reasons. and this is documented in the work that i publish with derek and john parker and others and also the recent book of mine but the idea is simply if you take the vaccine for example this didn't come out and that should

be disproportionate to that if you take a very simple picture and say the rate of the vaccine acceptance is proportionate to the level of the infection and the growth rate in the vaccine acceptance is proportional to the level the rate of the infection decreases with the level of the vaccine then you get oscillations so it's like the yellow yellow diet -- yo-yo diet. i lose a lot of weight and get sloppy about my diet. but when i get heavy enough i get serious and my vigilance increases and you get the vigilance and complacency. a huge number but one of them is in the vaccine