together we account for that roughly, it's about 45% and climbing, unfortunately. ..

it will erase the good work done everywhere else. never before has there been a greater urgency to countries around the world coming together to meet what is not just in a higher mental threat -- environmental threats and security threats because we all see refugees in certain parts of the country replaced by a vast changes and the ability to grow food and seawater and the ability to survive. and that will change the nature of the security of the conflict in the world and that is the reality that we are up against and why it is so imperative the united states and china lead the world with genuine reductions that put us on a path to real progress. our shared responsibility to address climate change brings

with it one of the greatest economic opportunities in history with shared responsibility can come prosperity. the solution to climate change is as clear as the problem itself and it's not somewhere else there in the sky over the horizon in possible to grab of. it's staring us in the face. the solution is energy policy. it's as simple as that. it solves the problem of climate change. you also having to kick the economies into gear and produced jobs can't have economic opportunity unlike any that we have ever known because the economic future is pleased to be the largest market for growth has ever known. between now and 2035, investments in the sector is expected to reach nearly

$17 trillion. the market that made everybody wealthy in america and that they saw their income go up in the '90s and the greatest wealth in the nation is created in the 1990s. a 1 trillion-dollar market with 1 billion users be energy market is a 6 trillion-dollar market with four to 5 billion users today yet it's growing to go to maybe 5 billion over the next 40 or 50 years. $17 trillion is more than the entire gdp of china and india combined. with a few smart choices together we can and sure that clean energy is the most attractive investment in the global energy sector and that entrepreneurs around the world can prosper as they help us innovate our way out of this mess and towards a healthy planet. none of this will happen if we don't make it happen.

how the two countries believed, china and the united states, or don't lead on climate energy will make the difference whether we are able to take advantage of this unprecedented economic opportunity and whether the world is able to effect if we address climate change and the threat that it poses to the disparity in health. our cooperation also makes a difference when it comes to nuclear proliferation we are encouraged on the negotiations as a full partner in the p5 plus one and we are hopeful that working more closely together the united states and china will ultimately bring the realization that the current approach is leading to a dead-end and the only path that will bring security and prosperity is to

make progress towards denuclearize the korean peninsula. our cooperation can also make a difference. it can also make a difference in countering violent extremist groups like isis seek to harm people at every corner of the globe and bring stability to places like afghanistan where today we are partnering to support political cohesiveness and prevent afghanistan from again becoming a safe haven for terrorists. we welcome china's role as a critical player in the afghan region and church asked last week in fact the special representative asked afghanistan and pakistan if the council are all traveled to beijing to participate in a conference focused on supporting afghan peace and reconstruction. and as we have seen with the epidemic china has also shown

that it's prepared to take on a bigger role in addressing the international crisis including those that emerge far from asia even those on the opposite side of the globe. we are grateful china committed more than $130 million to date to help address the crisis and last week china announced its plans to dispatch the unit for the people's liberation army to liberia to help manage the crisis. that's global leadership and that cooperation is more than welcome. we all need to do more and fast. but with the kind of support from china that we've seen is critical and it speaks to china's understanding of global interest in the responsibilities the fact is among the major threats into crisis to face the world today they are really there really isn't one that

couldn't be addressed more effectively with a standard u.s. china cooperation in the state counselor and i discussed earlier this month in boston with china engaged more on the stage, our cooperation can also be seized for opportunities for change and for growth i could be opportunities for development in africa, central america and other parts of asia. we talked about that. but the possibility of the united states and china operating on specific development targets. there are countries across the regions where both china and the united states are deeply invested. if we doubled down on coordinating our assistance and make sure that we are coordinated with and bring more into the 21st century faster and help millions of families left themselves out of poverty and give more people across the

world the tools and data to shape their own future and has the help of more countries make the transition from foreign aid to foreign trade will benefit in terms of economic growth, expanded markets, job creation and ultimately the stability and prosperity in the dignity that comes from that. eons that as these regions become more prosperous the leave me, they are going to become more stable and in the end, that means we can all be more secure. the bottom line is this: how the united states and china comprise one quarter of the global population. the make up one third of the global economy. we generate one fifth of the trade and when we are pulling in this interaction on any issue we can send curve in a way that no other nation on earth can

accomplish. between governments, we are doing more than ever to ensure that is the case. jack lew the secretary of treasury and i meet regularly with our counterparts in the strategic and economic dialogue. today although he has more than 100 different bilateral dialogues on trade and transportation we are in fact focused at the highest level on a regular basis but i will tell you if this relationship is going to live up to its full potential government to government, cooperation and enough is not enough. a recent poll indicated americans view china less favorably than they did just a few years ago and vice versa. so we need to do more to connect our people and make sure that we are communicating effectively between each other so that we

are communicating to our people effectively. we need to build on the sense of common purpose and camaraderie that can be essential for decades to come and that is on the exchange i cochaired with china's vice premier. one of the best ways for us to improve our connection is by expanding the student exchanges. i just stopped and went with a bunch of students who've been part of the exchange and i hope you are all aware of resident obama's 100,000 strong initiative. today more students from china study the united states than any other foreign country and we are actively investing in ways to expand study abroad opportunities for american students in china because we recognize nothing brings about a valid common understanding of the effectively getting the

chance to live in another country, see the world through another lan and for which friendships that can last for decades. the number of foreign ministers i interact with in the middle east and elsewhere probably sit in front of me and talk about their graduate school were under the graduate school experiences. it has lasted forever and it helps to be able to work through difficult moments. let me take this opportunity to note that this is not an earth shattering principle i've just articulated. it's something that has long understood. you've had an international campus for nearly 30 years and focuses on at everything from facilitating the student exchanges to all the prospects of business relationships in the

future and as a result if students are better prepared than most for the globalized world that we live in. but believe it or not there are places that don't take it for granted that way that you do for whom this would be a new enterprise even though now in 2014. so i want to thank david and theaters for their leadership on this effort and ultimately the united states and china need to find more ways to interact at more levels of government across more sectors and among more people who live in all of the corners of the nation's. these connections will help us understand each other better and forge a better relationship going forward. they will help us work through the different is and they will ultimately erase the misperceptions and stereotypes that fuel mistrust and these connections will help us pull in the same direction to take

advantage of the unique opportunities our countries have to help each other and ultimately to help the world. we don't underestimate, i certainly don't cover the complexity of the world we are living in today and the sensitivity of the challenge that we face. the path to a productive relationship between the united states and china has seen its bumps that may seem like more. but the fact is it's never been more important than to continue down the path that we are on. our nations face a genuine test of leadership. we have to make the right choices for both washington and aging. in many ways the world we are living in today is much more like 19th century and 18th century global diplomacy.

that's a power that is a power and different interests than it is a bifurcated world he lived in and the cold war and much of the 20th century. this is a new posting bursting on the scene of new powers. but guess what they are doing the things we wanted them to do. at least 15 of today's countries giving aid to other countries where only ten to 15 years ago they avoid themselves and we welcome the growth of the nations for their global responsibilities and for the assumption of increased global ability to make a difference. but it's more complicated. when other countries have stronger economies and there's more competition for goods and services and for market share is a more complicated world. and with the release of sectarianism and radical

religious extremism and other things that have come from this, we all face more difficult complex diplomatic paths. but it is clear that coming from the different places we come from, china and the united states, we do have the opportunity as the two leading powers to find solutions to major challenges facing the world today and if we can cooperate together and help show the way, that would help bring other nations along and establish the norms. we had an opportunity to demonstrate how the major power and the emerging power can cooperate to serve the interest of both and in doing so improves the prospects for stability, prosperity and peace around by a cleaner from pole to pole for what this world we live in.

maybe that is a lofty objective. i don't think it is too lofty. i think it is easy to say in the speech, yes, but a lot harder to produce it. but it will be in the doing of it, and the quality of our dialogue and persistent search for solutions to the issues large and small in and the determination to manage the differences come in to find the big places to cooperate and in order to seize the opportunities when they arise that will provide the measure of the failure or success. when he was in the twilight of his life come at you was asked about the contributions he has made as the marshall plan commits the u.s. soviet relations. he didn't brag or boast he just said i've been extremely lucky and i've been around at the time when important things needed to

be done. there's never been a demand more than there is today for important things to be done. i hope the united states and china were blessed with ample resources can do important things now and i hope as we come together in the days ahead and work together in the months and years to come that we are going to need that charge and up to the standards conscious when he founded the school that left his life. thank you all very much. [applause] >> thank you mr. secretary for

sharing your views on this important relationship. we wish you and president obama your trip to china. thank you. [applause] [inaudible conversations]

and audible conversations and audible conversations is a [inaudible conversations] [inaudible conversations]

[inaudible conversations] [inaudible conversations]

secretary john kerry and asia soon attending talks in beijing during the asia-pacific economic cooperation meeting next week. issues include clean energy, cybersecurity end of the economic empowerment of women. we will have updates on his trip on the c-span networks. tonight election night on c-span2.

i'm calling to comment on a debate that i saw between bruce fine and john yoo regarding the declaration of war and the war powers act. it's quite interesting to watch the legal debate and also demonstrated some of the attitude of the neocon

proposition of any of the hearsay in the country's ability to go to war. >> i would like to commend c-span2 for airing the information from the writers on greece and the military. it was excellent information that gave the level of the nuance is and for instance the posttraumatic stress disorders can climb up and be resolved if you continue to try the various interventions.

>> c-span is one of the best programs. i wish that we could join more than once. >> at 202, e-mail comments at c-span.org comment that c-span.org or send a message of c-span comments doctors and health professionals studying ebola share information on treatment and management of the virus. in areas where more data is needed. the briefing was held at the national academy of sciences hosted by the institute of medicine. this run for two hours and 40 minutes.

[inaudible conversations] it is my great pleasure to welcome all of you to this very important meeting. i understand that as of yesterday we had over 700 people yesterday who limited the size to 250 in order to be manageable for that a lot of people can be on the webcast. so we are seeing the devastating effect of the ebola virus outside of the united states because we have seen it entered the united states as well. fortunately, the public health

and how it responds to a virus in the u.s. has been robust and of the small handful of people only one has died. of course in west africa that picture is very different. there we have seen over thousands of cases and an alarming high fatality rate. fortunately we have just heard that the epidemic in liberia may be slowing down but we are still far from where we need to be. the cdc has projected that in the worst-case scenario over a million people could be affected by january in liberia and sierra leone. what went wrong in west africa there are many lessons to be learned and so that we can be better prepared in the future. they need to we need to step up to infrastructure globally.

in fact they recently released a report on investing in the global health systems which make the case strengthening the future of the global health. they wrote a powerful op-ed that eliminated this particular issue as a key factor in this crisis. countries with weak public health need to manage and contain this disease. but even in the u.s. we need to pay considerable attention to how we are identified to treat individuals with a virus and prevent its dissemination. the emergence of ebola is a wake-up call and the importance of having a robust preparedness public hospital system. in addition, it is important to ensure guidance and actions are based on up-to-date scientific

evidence. only then can we stress that we are doing our best for our patients and for the providers and for our society. we are in the scientific nones of ebola and we must put enormous the enormous effort into the research that address them. for example, we need to learn more of the transmission and methods of activation and disinfection of contaminated services. we also need to understand how the personal protective equipment can be the best used by anyone who may be exposed to a virus and not just professionals. so there's a lot of lessons learned and there will be lots of opportunities for all of us to have that conversation, discussion and move forward based on what we've learned. so, the authors are or the

assistant secretary of care -- response to together the nih and cdc asked that we can convene this workshop to provide rapid information that the scientific spirit he is standing from the virus disease. the ipo is suited for this because as a trusted independent and a space that people can grapple and debate many of the topics openly. the team has asked us to develop this workshop to inform them that the medical and health communities are the priority research that needs to be performed immediately to ensure that the current guidelines are based on the most current scientific evidence to inform public health officials, health care providers and the public with the most current information about transmission, health risk and measures that

should be taken to prevent the spread of ebola. what must perform now before we lose access to form the important specimens upon the information and the data? ultimately we should aim for for having a research system that allows us to collect and analyze data and provide advice in real-time. we will be addressing these objectives enabled more detail next. so, we are here to listen to the various points of view. we are looking to identify research needs and gaps. we are not here to provide a protocol advice at this time as that was not the intention of this workshop. we've opened the workshop to the world through the webcast so no matter where you are in west africa or the u.s. you can learn along side with the

participants. we have over 700 people registered to watch the webcast today, and the videos will be posted on the website for future reference. i want to put up a slide to acknowledge the committee. the chair lynn goldman and all of the other people that reflected on the slide that i won't have time to read all the names. this is a workshop that is academy's plight and therefore many parts of the research council have come together to bring the expertise to this issue. i would like to acknowledge the policy, global health, population public health practice in the life sciences division. i also think so many of you that come from far and wide in the

expert advice to inform the direction of the ebola research in this country. some are not able to make it because they are literally battling the epidemic even as we speak and of course our thoughts are with them today. we have a full day ahead of us. we are diving into the ebola transmission routes, survival and behaviors, waste management, the disinfection methods and at the end of the day we discussed the urgency of researching each topic. but this this workshop is timely, important and exciting moment. we are advising the direction where it's not a conversation to be taken likely and i would invite all of you to bring your energy and brainpower to this discussion. i would like to turn the meeting

over to doctor goldman who is the chair of the meeting and she will make some remarks. thank you. >> thanks so much and my thanks go as well to the workshop planning committee. we've done a lot of work in a short. of time and i appreciate the volunteerism especially the speakers that are with us today, the facilitators that have volunteered to help us and then of course also to all of you for being in attendance in person at the academy is and also online. you will contribute in many important ways to this discussion and i appreciate that. the workshop format is to bring forth ideas about research priorities but not to provide a recommendation. we do believe that it is

possible to help to foster the research during the response to inform the practice and also to ensure that guidance in the future is based on the most current science. but we are not here to review those are participate in developing them. as well as understanding the potential gaps that exist. then we will split into the breakout areas one on the transmission routes of entry and exit for the virus and the virus in the environment and a third

on the personal protective equipment and personal protective behaviors to prevent the transmission and reduce exposure to the virus and forth about the handling of the potential contaminated materials, waste and disinfection. we know from a lot of the data that they are at risk and this would show the epidemic transmission diagram from the cases that occurred earlier in nigeria. the responders of all kinds whether health health-care workers or family care providers have been particularly at risk for acquiring this disease so we know that the workforce is at risk. we think about this in the context of protecting workers we are thinking about exposure and the concept of exposure has to

do with the contact between the outer boundary of the human body and a mixture of public and string this case a virus such as ebola and that requires the presence of the pollutant and actual contact with it and a quantification of the amount of the pollutant. so the whole paradigm has to do with looking at the agence such as the ebola virus as either biological fluids or animal reservoirs for the virus, exposure routes and in the case of needles, sticks or respiratory and biological responses such as infection disease or just an even responses to that infection.

we are going to learn more about this agent on the virus. it's a very interesting and obviously very dangerous agents. it's certainly important to understand and this is from the epidemic in sierra sierra leone come at a recent, the recent paper in the new journal of medicine that simply documents a fair proportion of the cases of diarrhea and vomiting in a smaller proportion coughing so these are three ways bodily fluids are certainly going to potentially be involved.

we don't know if there are risks with companion animals and there's has been a question about what to do with companion animals and this is a picture of one of the nurses who miss trees treated at the nurse and her dog friendly both were sent home friday one after being treated and the other after being guaranteed for 21 days. and reducing or preventing or modifying the lease of the hazard all the way to some of the things that could be done in the future like increasing the resistance and improving

emergency response and improving the care and rehabilitation. and and some writing with a physical barrier and modifying the services and basic structures finding ways to separate people who might be at risk from the hazard. and they are most concerned about the responders, care providers of all kinds whether occupationally involved in providing the care or family members. when we think about occupational exposures and potential interventions that we can use to eliminate or reduce the exposures, we think about that these as occurring on a hierarchy where we know that it is far more efficacious if we can treat the environment or change the process to prevent

the possibility of exposure in the first place. to take the problematic behavioral approaches where we try to change the way that people work together, the behaviors around the cases, and the least efficacious actual become of the use of personal protective equipment. and so, the personal protective equipment is considered to be a last resort, but something that is very, very necessary if there is no way to protect people through engineering or administrative approaches. and indeed we have a lot of information about ppe. we are not here to review the spec to remind you we are not starting from ground zero, these are the protocols at emory and diversity primary health currently has on their website which are legal drafts into

which i think is even experienced with treating these kinds of illnesses that are in the process of learning and we currently also have the waste management protocols. osha has blood-borne pathogen and they have many regulations and there is an enormous patchwork of state and local regulations about the management and handling of bayou hazardous waste. so come at the same time we know the few cases that we have had in the united states have played the challenges just in terms of the quantities of the waste that have been generated and, for example in new york with one case of an entire truck that pulled up at the apartment to haul off waste that in dallas with one patient was

140 barrels, 55-gallon their roles were generated from the single apartment and that in fact the controversies about how the ashes from incinerating that waste will be handled. we will produce a workshop report that will be prepared by the institute of medicine and this will be publicly available and will reflect what has transpired at the workshop. there will be further deliberations by the planning committee. what will emerge as with the speakers at the workshop bring forward the also the breakout groups bring forward. it will be published by the national academies press. the ideas will be at the workshop disciplines and not the national academy of sciences or the planning committee. and there will be no former consensus findings and recommendations coming from this

activity. so, with that and to conclude once again by thinking evil for being here i would now like to turn to doctor nicole she is the assistant secretary for preparedness and emergency response at the department of health and human services and she will give you a perspective from the standpoint of her agency for this workshop. thank you for being here. >> thanks to all of you for coming in for tuning in on the web and other ways and thanks very much to the planning kennedy for rapidly pulling this together. i will take a quick step back and give you a little bit of perspective. i came into this position in 2009 just as h1n1 was wrapping up. the second week on the job i ended up on a phone call with ten intensive care unit from

around the country each talking about the eight or ten patients who were in the icu and a few of us listened to them and thought over the next couple of weeks ago to be possible to put together some information about how it is that people provide this disease. we went out to the nih for the research that agreed to modify the protocol for sending bp identified data and we felt that we were on our way. the committees of the respective universities are to approve the changes to the protocol and we completely missed the window to know potentially how best to treat the people of h1n1. 18 months later we learned from this work at about 40% of the children that died died from

staff and not from h1n1. and it was with that. we were not as equipped as we needed to be across the government to do science, to the kind of research that needs to be done in any emergency or to affect the course and trajectory or to be sure that we are never in the same situation twice. it's a mess. we are holding the workshop together. my office has launched a comprehensive science response initiative which is now across the hhs. one immediate outcome of that is that there is now a public health emergency that could be used in any emergency. another in a decent outcome of that work has been a process that's important to get groups

of experts together not only inside government but outside government to identify with the research priorities are. in that spirit we now have a standing arrangement with the institute of medicine so that in the event of emergency or disaster or another public health crisis and other interested parties and help identify what the research priorities are that will help manage this event and help us not be in the same situation next time. there is a lot of science already going on and i don't want you to think there isn't. for example vaccine candidates that have been developed are promising and finishing safety studies at walter reed and hopefully will go into clinical trials in west africa in

december. similarly a number of theater piece or into various phases of testing and will be subject. we expect the rigorous clinical trials so those are not the focus. similarly, the group has put together the finishing of the guidelines for the youth in west africa for the same set of reasons we have to do a media things to manage this epidemic. so that is the kind of science that is going on and it doesn't need to be the focus here but it needs to be on impacting the public health and medical response for this and for the future. during the deepwater arrives in we put together all the the together all the different federal agencies that were involved in research during the event. we learned that there were 17

different federal agencies all of whom were involved in research, science and one way or another they largely didn't know about one another and because of the way that they collected a lot of their data it became very difficult to leverage all of the tremendous work that has been done. in this event under the auspices of the office of science and technology policy at the white house all the different agencies ranging from. they've come together to identify what it is they can bring to the fight and what it is that they are doing and identify both priorities come opportunities and collaboration, however we need to hear from people out of the federal government. when we planned this workshop we are in a very different situation in this epidemic that we are now. we have not had a case or cases in the united states. so we are going to be flexible

today in terms of how we think about this agenda and how we identify together with the science priorities are. so the public and healthcare workers had many concerns have many concerns about how to protect themselves both in west africa and here. environmental issues as doctors had earlier come up in situations like this both to guide the public health response and to address public concerns. i don't know how many of you saw for example the peace in the news this weekend about some of the challenges not only with the risk from the patient's apartment in dallas but the fact that right now the ashes from his cremation remain in limbo because there is not any place that will accept them. so again it speaks to the need between the science and dealing with public policy and dealing with public concern.

this is not an exercise in the could have, should have, would have. i am hoping that today we can focus on actionable work that will help us move forward to protect the public health both here and potentially in west africa and work better should be prioritized now. i want to stress i'm looking at this from a sense of the priority and not just good issues and ideas. some of the process will have a time element. what needs to be done now or to be posed to answer the questions in the future and that involves also the collection of data and the specimens or whatever and finally as both of the speakers have said let's please keep in mind that this is a workshop and not a consensus process or a process to develop formal recommendations.

look forward to the deliberations of the day. [applause] >> it's now my pleasure to bring forward our first speaker. doctor james is a professor of medicine and director of the galveston national galveston -- a laboratory at the university of texas medical branch. and he's going to talk to us today that the characteristics of the ebola virus in the u.s. environment, what do we know. in either some assumptions being made based on the science. thank you for being with us today.

>> first let me thank the organizers for inviting me and figure out how to drive everything. okay so first let me say the disclaimers, number one this is not a comprehensive overview, it is just some of the key questions you will hear a lot of duplication because there are so many examples and we are all going to be talking about it so i apologize for that and advance. second, but i'm going to talk about is the only influenced. and we worked through the key issues we are going to be discussing today discussing today's webpages to start with a quick overview. i check the numbers at the who on friday and at that time we had nearly 14,000 cases that are

a mortality rate of about 70%. so this outbreak in africa is clearly out of control and is going in a very wrong direction. i think this is important to realize. significantly, the number of health-care workers is astonishing. the healthcare infrastructure has been decimated, and as a result, the international community's responsibility now is to provide the resources that this feedback into our national strategy on how we manage the returning volunteers and i think that this is an important key to keep in mind. if you volunteer for a month overseas and then have to have pre- weeks in quarantine a lot of people are going to be thinking twice about volunteering and this is a real issue.

on the rare flights from africa we got a whole lot of places including significantly to asia as well as europe, south africa and the united states so there's lots of opportunity for dissemination as we go forward in this. what are we worrying about is maybe three groups or individuals that we might consider the international mr. duncan is a good example of that category but have been infected but have ended up on our shores completely asymptomatic but have subsequently become infected. international travelers there are business people that can come along and another way of this example yet but i do know what that during sars we saw it on more than one occasion. these are the folks in the move today and an important part of

me for the response but for the national discussion as we go forward. the experience in dallas is exactly what would have happened at 99% if 99% of the other hospitals around the country. so the hospitals in general are not ready to manage this kind of case. as a result of couple of nurses became infected and virtually they've now survived and are treated well at emory and nih. they have the ability to treat these patients. the returners are from africa.

they are aware of the case is coming to do a very good job about it i think now have a most hospitals have been the experience in dallas i'm virtually certain they are a lot better prepared now than they were a month or two ago. but the last example is a health-care worker who self identified, followed the rules as we have articulated them and desist that he became clinical admitted to the hospital. it expands into context doesn't appear to be as great as we somehow have seemed to the best of my knowledge we found no secondary cases from either the nurses are mr. duncan's family

and he recalled that he was quite ill so there appears to be a standard for transmission that is significant. we have gone in and decontaminated the residence that i'm aware of, three of them, but i don't know the details on the list. but the two that i do know about really did a cleanup. in the case of mr. duncan they even took the toilet. so you heard those 55 gallons that were taken. we really don't know how to manage this quite well. similarly, the race from the hospitals we had nearly 155-gallon drums of the waste associated with mr. duncan's treatment and how to manage it was a significant problem. we work through it but it was really quite challenging.

and then we already heard a little bit about the pets and how to manage pests and bentley. so, with the ebola virus, we haven't seen anything that is out of the ordinary. it seems to be following the same rules that we have seen all along. we've noticed the importance and we've seen the importance of the appropriate to avoid contamination and we've seen some challenges associated with the cleanup of medical waste. we are all well aware of that and we are screening the people in the country. in west africa we are using traditional interventions trying to separate those infection to those that are not infected.

the who has aggressively set out from the cbc exit monitoring so that prior to leaving and trying to exclude sick patients and now into the entry to the united states we are doing the same thing. in our discussion about how to quarantine is continuing on. so this is fine for the outbreak from west africa to become transmissible in say asia or another place how would we manage that. i think this is a challenge but hopefully we will not have to face. so, the hospitals are well prepared to manage the ebola patients and approve the words and clearly we can do this if we know in advance. we know the risk that they are coming in and being handled like every other patient and then my gosh we have a problem down the

road. ..

in my mind is, incineration doesn't necessarily kill ebola, 1500 degrees centigrade is not sufficient. just a footnote, we had a briefing for texas board of regents and they asked me to give an update, i specifically said incineration specifically kills ebola so there is no questions the other one, i'm sure you all have your examples, school systems closed because somebody who flew on an airplane with somebody who they knew had ebola so anyway, lots of issues. ing of the whole discussion that continues today about how do we manage trammers and what is the -- travelers and what is the science behind this and lots of discussions and lots of observations and i'm not going to read all these to you but you've all seen the headlines i'm sure.

the most recent nurse, said, enough already, there is no scientific basis for this. this is continuing to be discussed but nonetheless, in my opinion, at least, personal observation, a welcome pushback on, on this ongoing discussion. so, we've got lots of newsworthy issues here. official comments from idsa. idsa does not support mandatory or voluntary quarantine. a very thoughtful editorial. this is from thursday kaplan at nbc news. again, showing why this is a bad idea. so lots of discussion on this and it's not resolved. so, let me just touch on a couple of signing tisk papers i -- scientific papers i come across and many of authors are

here today so i will defer to epthem for the details. you saw this most recent edition of the "new england journal of medicine." this is the 16th of october. this is an overview of the situation in west africa. let me draw your attention down here to frequency. incubation period and context of onset and. 21 days is our cutoff. there are a few cases that appear to occur after that. you will recall that w.h.o.'s criteria for calling a country free is 42 days. that is exactly the reason for it. everybody has always known this is biological and that there are some occasion outlyers. the numbers here you probably can't see closely but this is 9.4 days average for incubation period. so that's's pretty, data on potential viral shedding, viral

load. let me start with a paper by tom kisek from the outbreak in 1995. this is igm. goes up very quickly and again this is anti-again or -- antigen or days post-on set. very nice data there. then looking at the antigen if you will, you can see, again a nice curve. that was followed by john tanner's paper from the outbreak of ebola in sudan in 2004. this is based on pcr. a little refinement of data. the curve starting low and going up as the disease progresses. importantly here the dark bars represent the fatal outcome and open bars are those that survived. you can see there's a strong correlation between viral load and the outcome of disease.

the assetment of risk of ebola virus transmission from bodily fluids. this is dan bush's work. only paper i can find. dan can explain a little bit more. i want to highlight a couple of things. number one, this column here is pcr positive. you probably can't read it but the bottom line you have 14 positive samples. and there's a whole bunch of different categories, is a life, skin, urine, vomit, sputum, breast milk and stool and so on. the center column here is virus culture positive. there were a total of four positive. importantly of those four, two of the specimens were convalescent, one in semen and one in breast milk. we haven't talked much at all about possibility of transmission after recovery. i think this is something that needs a little further

discussion. he also did a very nice study on one of the wards sampling a whole bunch of different sites and then attempting both virus culture and pcr. you can see a lot of negatives there. either they were very clean or i will let him explain what that really means. there was some positive results here both in blood stain samples from doctors gloves and all that so. many of you have seen these papers on the persistence ever the virus on various surfaces. highlighted here is ebola. this is work by segraponte. this is work looking at survival of virus over time and this is in hours. whoops, i'm sorry. this is 144 hours and this is two logs of virus. so you can see that the virus survives for some length of

time, perhaps longer than one might assume. this is a similar study based on storage of material. this scale here is in days. the important point, all of the results are at 40 key grease centigrade. appears perhaps the virus can survive a little bit longer than one might normally assume. this is clearly an area that additional information is needed. the 40 degrees centigrade is significant when we were dealing with all the medical waste in dallas, that was stored in a refrigerated truck at 40 de-- 4 degrees or a trailer. we were preserving the material waiting to, we've seen the slides already about the dog. fortunately bentley is doing just fine. only paper that i could find dealt with pets was emerging infectious diseases that was published in 2005.

this is from the group in gabon. this is only antibody but this is prevalence here. this is based on controls from france. and so, i'm not sure exactly how to interpret this but nonetheless, in ebola endemic villages there was fairly significant number of animals positive. so what that means, i don't know. whether or not they shed virus, if it is really antibody, who knows. but it is an area for further investigation. we talked a lot about aerosol transmission. this is the only date that that you're going to see. this is from our laboratory. coincidentally we completed a aerosol transmission to non-human primates. you see very low doses, about 100 to 200, to 500, easily infected and killed non-human primates. there is a lot of data from the

military about aerosol transmissibility of ebola virus. this, you're all, i'm sure have seen mike's article. this raised a lot of discussion. is it airborne, blah, blah, all of this. nonetheless, i think it is important to remember that this virus is now been through an enormous number of human-to-human transmissions that, we really don't know what, how the virus has adapted if at all. i don't for a minute think it has become airborne but there are some characteristics that it would be nice to know more about. unfortunately, we don't really have that, that information. we talked a lot about ppe and the importance of it. this is photographs from 1995. you can see what was born at that time. this is another photograph from

there, i'm sorry. and many of you will have seen that the "jama" article calling for a review of ppe and new ppe equipment. so i think this again is an area where we may well benefit from the review of what is being done and are there improvements to be made. okay. so what do we know? well, we've confirmed previous observations on the lack of transmissibility before cases are symptommic. we confirmed the value of personal monitoring, potentially exposed persons as an early warning system. there is no question in my mind that this is very important. we know risk of transmission can be mitigated by ppe and we need to do it right and that is an area of continued investigation and some simulation studies that

vomit can go a whole long way. what don't we know? impact of unprecedented number of human-to-human transmissions. i mentioned that already. this is reflect as another problem that we had, don't have access, the global scientific community doesn't have access to the virus. our research efforts are somewhat hampered. how to clean apartments. we can clean them and how clean is clean? how much should we do? this is ongoing. the duration of infect tivity in bodily fluids. we talked about that, the risk associated with domestic pets and clearly opportunities there. we don't have any diagnostics that can be used presymptommicly. last but not least, we don't have a good strategy how to communicate with the public risk, especially with the ebola.

i think with that i'm done. thank you very much. [applause] >> what we're going to do, we're going to actually proceed with a presentation from our panel about the existing research landscape. we have one other talk. then we're going to bring the speakers and the panelists book up to the stage for some time for questions and interactions. and so it's my pleasure to invite cj peters from the center for bio defense and infectious diseases as university of texas medical branch to come forward to, to talk about landscape on ebola and on going initiatives.

>> thank you very much. unfortunately our information technology people seem to feel like part of their mission statement is to be sure nobody on the faculty can use the internet. so i don't have any slides but let me tell you what i'm going to tell you, what i wanted to tell you anyway. i think our mission is to tell basically the truth, the whole truth and nothing but the truth and the truth has to inconclude, i don't know. -- to include, i don't know. if you don't work in that context, you will find some of your truth will be found to be wanting and your credibility will go down the tubes. the first truth i think is, the

incubation period. the incubation period is advertised as 21.0 days but as many of you who have worked in this area before will know, incubation periods are distribution and usually it is a lodgetudenal distribution. if you look on internet, you will find a number of papers using the log normal but the "jama" function and so on and you find that the institution period varies according to who calculates it by what formula so. so 21 days is basically the longest interval that was found between cases in the 1976 outbreak. so it is almost a sure bet, given the way the other calculations work out that we'll have someone who surpasses that

incubation period. i would guess from looking at the calculations i would guess that there is about a 5% of the people will be found to exceed that incubation period. what that is glowing to do for the media and population i don't know but it is going to be going to come back what dr. leduc described as communication strategy and somebody is going to have to be thinking about that. another thing that i think we need to be thinking is, very soon, there is going to be a need to compare therapeutic

modalities and that will include drugs, convalescent plasma, monoclones and then it is going to go into something no one has really talked about in general terms and that is, patient care. about you look at a ebola patient postmortem they're full of antigen. generally the fatal cases don't have much immunoresponse so you are left with a difficult situation and my thoughts would have been that, management of fluid and electrolytes would probably not make a great deal of difference. if you look at cases in this country it apparently has. we have very locations compared to west africa. so i think that should be formally looked at. another thing that is on the

menu for treatment modalities is, question of dissemination of coagulation. evidence of this is present in every patient that has been tested and in all of the models. we figure that is one of the problems. how important it is we don't know. burton and darling did some studies with a drug actually been in people that didn't look for thrombo embolism. it isn't used widely now but in the monkeys it was very he efficacious and preventing coagulation and improves survival and many times the death of monkeys that didn't survive the nematode accessory

protein known family as napsi. and that is, study had very interesting outcome. the p.j. remias were lower in the control monkeys, significant lower. how dic plays in with, with virus production is not clear to me but perhaps it, destroys sites of replication. it may act in a spleen to allow more effective immune response, preventing clotting in the spleen but forewhatever reason that is something that really recommends itself for a disease for which we really have no established therapy.

speaking of established therapy, i'm worried about two things. one is enthusiasm for potentially worthless products that have been given to somebody who will survive anyway and that may well be convalescent plasma because there is no experimental system where that really works suppression of viremia and monkeys getting up off a cage floor and walking. it just hasn't worked that well. only report where it seemed to work a report in 1999 when we were there and one of the things that was most striking about that, a, there were no controls and b, when you looked at deaths that occurred in rest of the

cohort of patients you saw that these people were destined to survive anyway. they were in a high survival group. that is, young women. they were late in the epidemic where deaths were somewhat less. and, they received their, their convalescent blood at a time when most patients had already declared whether they were going to live or die. so, it was, sort of like dessert after you finished the meal. they got a unit of convalescent blood and that has given rise to at love thoughts that i think could lead to a lot of wasted effort and wasted patient time. i believe that the, we could be better said by testing some of the things that just mentioned

but if we do use convalescent plasma it should be subjected to a rigorous test like anything else. one of the, i'm thinking back to the pulmonary syndrome here in the u.s. where things are actually a little easier. but, in a situation like this, people don't want to do a controlled trial. they don't realize without a controlled trial, you will never be able to bring the full force of what you have been working with to bear on the disease. you won't be able to get the money. you won't be able to get general acceptance when people look back at it. i think it is very important that we support drugs and therapeutic procedures where we controlled trial, a controlled

random trial. there are certain other obstacles to this. that is, this is not a common practice in africa and and the general attitude they find when you go to ministry of health in say kenya, sierra leone, the response is, well, if it works let's give it to everybody. if it doesn't work, let's don't give it to anybody. i think that's a good philosophy but you don't know whether it works until you've done the trial. so i think we have to resist the impulse and the pressures to just pull something out of the freezer and use it. i guess one of the things that was on my list which unfortunately didn't make, the electrons didn't make it across

the wires was the issue of staffing. who is going to do all of this stuff? well, i don't think you want to pull volunteer x into a trial like this. i think we've got terrible problems with staffing and dan and tom will talk about that later but we ought to be able to recruit staffing. and to be able to release people involved in patient care and so on, who are capable of doing these kind of trials. also reminds me, one of the things we absolutely must fix, we have to do the clinical virology of ebola. we have to understand viremia day by today, antibody production day by day an

excretion of the virus outside. i don't know if you seen anything in the literature about the vomit but i very much like to know but if you look through the literature, vomit is often described as one of the ways to get infected. so i need we fled that kind of clinical virology. we have to fix export of samples of system. you can do rcpr on the site but that is not the same as ineffectivety. another issue is quarantine. if you knew about what happened to somebody, you should think about quarantine and how effective it should be and how soon it should be.

well many years ago i went to bolivia to work up an outbreak of bolivian hemorraghic fever with air personal transmission. i can tell you several things rung a bell with me. recently, one is, that, i was living in panama and my wife works in the clinical lab and everybody in the clinical lab said, oh, we're so sorry to see cj peters go. we liked him. he is not coming back. i think that is one of the messages that we don't want to send and i think there have been some attempts at this. i. 569after the outbreak i was communicating with my boss which ham radio and no internet at

that time and no telephone lines to cochamba. i noticed when he was coming back he was strangely silent. i finally found an airplane that would break the strike which had come to pass. while i was there and i plowback to la paz, and there got on the military net and discovered that i wasn't wanted. panama didn't want me. the u.s. didn't want me. the canal zone didn't want me. so i, i just didn't know whether to do a back stroke out to sea or what to do. carl, who is very, very persuasive guy who persuaded me to come back if i undergo three-week quarantine. does this sound familiar? the laboratory had some rooms in the top floors. so i was to, when i came back, i

was ushered out of the, out of the airport, fastest clearing customs i ever had in panama and ensconced in the, in the at tick at at our lab -- attic at our lab. i can tell you it is not pleasant after you had a tense situation and you're coming back and you're wife and kids are kind of brought by in the hall and you wave at them. it was not good. we should think about that when we look at these guys who are returning and if they have a significant exposure, like a needle stick, then i think you know, they have to go for the quarantine. but these people who don't have highly dangerous exposures don't deserve to be locked up, given what we know or think we know about ebola.

and inevitably there will be some assumption that we've made that will turn out not to be true but right now the dogma is you're not infectious until you're sick and the sicker you get, the more infectious you get. as far as i can tell, that is based on two things. one, or three things. one is fate. two is the old diagram which has been partly verified for ebola in monkeys. that the initial growth is in the him much node -- him of node, -- lymph. and subsequent viremia reaches target organs and this is the point where people become infectious. i don't think this is proven and

where is the epidemiological study to back this up. the only thing that i can find that several of us did on families and looking at transmission to family groups, in those patients and that showed that there was very little transmission, if any, at the, in the early periods and late another period at home when they were sick. there was some transmission and later as they became sicker there was even more transmission but still only about 25% of the contacts were infected. so i don't know how we'll devise a information strategy which will impact the public that believes if you go to dallas and you come back you should be

quarantined because they had a case there. but we need to do that and we need to look for a scientific basis for many of the things that we're using. thanks. [applause] >> next member of panel is dr. john howard. he is director of the national institute for occupational safety and health at the centers for disease control prevention and actually dr. peters, dr. peters, if you don't mind, you can stay up here. we're going to move, we'll bring up the other name tags. >> okay. have a seat. >> thank you very much. i want to thank dr. luri and iom and national research council getting us all together. what i'm going to do today a deep dive into five personal protective equipment knowledge generation priorities along with

three biological behavior priorities. the thing i want to emphasize at the start, while doctor we're talking about ebola virus, i think it is important to note that all of the issues that i'm going to raise really have broader applications for pathogens. and certainly if we see in this internationalization of the world in terms of an infectious diseases, if we see more of these events, all of these issues i think are going to be extremely important for us. so the five that that ppe issues, one, how do we quantify worker exposure to match appropriate ppe with the required level of exposure protection? what research is needed to appropriate test methods to demonstrate a given type of ppe will protect the worker? what are effective donning and offing procedures to protect against self-contamination. are there novel ppe designs to

be used in patient settings. lastly, not just fedex interested in logistics how we best understand ppe utilization in the health care system to better inform supply chain issues. the first question, matching ppe with required level of exposure protection, here the issue is proportional protection. i think it is important one. it is a important research topic. the point i want to emphasize, the observation is important. we've done years of data in assigning the level of protection in industrial settings but similar assessments are very complex in the health care setting and i don't think we've done a lot of research in that area. we need to do certainly more in that area. what research is needed to determine the appropriate test methods to demonstrate that ppe will protect workers? here we're talking about the scientific basis for ppe. for identifying, validating, determining the test methods.

a lot of ppe recommendations are really not associated with a national standard, an international standard, a consensus standard and there is a lot of concern regarding whether appropriate test method is being used to evaluate, for instance, permanent me ages. there is -- per me ages. there is at niosh we're doing a lot of studies. we have a sweating mannequin. to determine appropriation duration for wearing ppe. permeability studies for looking at ppe according to society of material standards. glove degradation and effect bleach and alcohol saturation on gloves. fluid penetration studies of niosh certified respirators and fda surgical and 59 and other things like surgical masks. three, what is the most

important effective donning and doving. emphasis not so much on donning. these are clean items, in use, during use and especially during do f-ing. several speakers. this is ex-dreamingly important to protect against self-contamination. fourth, are there novel ppe designs effective for health care workers to using in patient care settings. these are very unique settings and they're very stressful settings both for provider as well as patients involved. president obama announced a grand challenge to design and improve ppe when he visited cdc a while back in terms of health care workers not being able to wear the traditional ppe because of the significant amount of stress associated with heat. at the white house usaid

ideation session participants discussed the ppe limitations, brainstormed a number of improvements. these ideas will be evaluated by a team of experts. promising ideas will be funded. niosh will evaluate the prototypes. five, this supply chain issue. we don't often think about that as a research question. but i want to put it out today because it is a complex question. we need to determine what metrics we're going to use in the supply chain management for this issue. we're starting to see shortages now in certain items. we don't want that to happen. how can we prevent it from happening? so what we're trying to do is pilot surveillance system, developed and implemented for the four hospitals in terms of just respiratory protective devices, evaluating performance devices between knew and aged. we're looking to develop more ppe recommendations for

additional ebola referral centers as they're added to the system. the three biological behavior knowledge generation priorities i wanted to put on the table today, how long does the ebola virus remain viable on surfaces including ppe? considering different body fluids. what types of disinfect ants and contact times are needed to inactivate the ebola virus? what are the best sampling methods to detect viable ebola virus on surfaces on ppe. certainly this issue how long the virus remains viable on different surfaces and especially on ppe is one we're very interested in in terms of the high-risk body fluids. it may different. various mediums and air, water, wastewater, may differ. viral penetration through protective clothing, how long does that last? what are the contact times. what types of disinfectants and contact times are needed to

inactivate? there's issues here in terms of the various type of disinfectants, their concentration, their contact time they need to remain on the, on the ensemble, the garment or the device in terms of disinfection. and how would studies inform decisions on ppe decontamination and waist enact at this vase. -- inactivation. what are the best sampling methods to detect ebola viruses on ppe? certainly the need is great. i want to emphasize today, that research needs to be done in controlled laboratory settings to develop the science to be able to go out and use in the field. so it is important first step to make sure that this type of sampling method is reliable, is validated before one runs out to do field studies and i think that's where i will end it. i wanted to thank everybody who helped me at niosh prepare this

presentation, especially the staff at our national personal protective technology laboratory in pittsburgh, pennsylvania. thank you. [applause] >> thank you. thanks for that, john howard. we next are bringing forth michael hodges, chief medical officer from the occupational safety and health administration department of labor. welcome. >> thanks, dr. goldman, and dr. luri for the invitation to present some views here that come out of the occupational safety and health administration. the meeting comes obviously at a very timely, opportune time but much to our surprise, a failure of planning on the comprehensive emergency management of

emergency preparedness and response recovery implies in the middle of response we've done adequate preparedness and mitigation and that doesn't appear to be the case. so we wonder whether there is some lesson on thinking through how we approach this given the lessons from the august '99 meeting on biological agents with henderson and dr. sladerberg. sars and h1n1 pandemic. there may be lessons about thinking about the overlap of occupational health and infectious disease and failing to think through the reality of work in the real world. in that context it's worth remembering the lessons from sharpes injury prevention, involving health care workers early on in the reality testing of intervention strategies has proven important in some things like, say for needles.

and devices with engineered sharpes injury prevention. we didn't do that here as we'll get to in a minute. so let me think with you about some problems for hospitals and for some problems outside of hospitals. over the last 12 years they have managed ebola outbreaks successfully in many countries with very specific guidance on the web. some of that guidance was incorporated into w.h.o. lessons. some of the other lessons weren't disseminated as effectively as they might have been. so the training methods, for example, dofing with observes. buddy system. emphasis on immediate cleaning and remove of vomit and diarrhea and, implications of ebola treatment unit design, how to manage flow in the real world is an issue.

although most hospitals have a plan, a few weeks late, it turns out many of those hospitals are still struggling not just with the process flow but the real infrastructure. so many hospitals right now doing construction to replace walls, how to manage air flow and how to have a space to sage doving with a buddy. or person doffing the equipment in the rest of the room they're moving around. how much space is needed in reality. how much train something needed to doff safely? there are a number of courses out there. ucla looked at how effective doffing training with 16 hours over 10 days would be and fewer than 1/3 of their staff were

actually able to pass their internal tests. that suggests that doffing training is pretty hard. if you remember, the msf focus on doffing and buddy observation, the question of why you know, two physicians who came back self-contaminated and became ill isn't so surprising, if you're not used to doing something regularly and energetically it is just not going to work that well. what are effective ways and competing strategies to manage waste in a modern hospital? so everybody's heard about the ebola, these management strategy at emory with an autoclaving unit on the ward. many hospitals don't have a large autoclave. they don't have portable autoclaves and so the question of, how to move that waste around has generated, you know,

new discussions between agencies that hadn't been involved, dr. leduc, reported borderline ludicrous decisions and failure and these are thinking through up front how to manage something. what are just in time management strategies for hospitals. should the nurse at the triage desk call an infectious disease consult or initiate the hospital incident command system? this is emergency management stuff and most hospitals hadn't thought that through. is there a lesson for us where is the boundary between appropriate use of surgical masks and respirators? the cdc put 95s and paprs up

but in fact paprs come up with different strategies. there are paprs with protection factor of 25. there are paprs with protection factor of 1,000. they were determined with sarin contaminated patients and many hospitals purchased those. what is in fact needed for appropriate protection? and then, finally in hospitals, what is the perspective of front line health care workers on managing the infrastructure? it turns out that if you read msf documents the non-hierachical team approach to health care worker protection and leadership economistment aren't likely essential. how do we as a system get to involving health care workers early into that process? and then thinking through some problems outside of the hospital, where are all the

survivors migrate as we think through use and destruction? as we think through critical infrastructure and in key resource sectors, where are, are there processes or where could engineering failures generate exposure? plumbers in are widely discussed phenomenon. when they fix leaks, is that a hazard? how do airplane cleaners clean toilets in the airplanes? how do truck drivers transporting waste deal with accidents? so thinking those through and comprehensive approach is essential. what kinds of ppe are necessary in each one of those processes? and what do we know about the levels of ppe necessary for each of those? finally based on all of this what do we think how can we better define ways the public

health system communicate these theses to workers and understand those and act appropriately? do we remember the lessons of sars in toronto if we haven't invested the working people who run risks developing protection strategies if they don't come to work? that was one of the big toronto lessons. how do we create a safety culture that makes people feel comfortable and lets them come back to work. thanks. [applause] >> last member of this panel is paul lemieux, epa office of research and development. their national homeland security research center, and consequence management decisions.

welcome. >> thank you, dr. goldman. i'm honored to be here. i'm primarily going to be talking about treatment of waste. this is a big integrated incident that involves many different considerations that impact other considerations like how they approach infection control affects how the waste is generated. what disinfect ants you use is affects how the waste is generated. everything affects everything else in this situation and we need to think about all of them at the same time. when people talk about waste management, there's a number of steps of waste management. some of which can result in potential exposure to the waste management workers. and there is technical issues

associated with some of them as well. i'm going to focus on the treatment aspect of it but people need to remember that there is people that package this stuff up. there is truck drivers that transport it, when it arrives at the treatment facility. they may have to open up the packages. d.o.t. has fairly stringent requirements how to package category 8 bio agents, that impacts how treatment facilities can operate. then you have to transport them to your ultimate disposal facility of which it has been mentioned there is a stigma attached with some of this waste that it is not a technical issue but waste management facilities with landfills are typically publicly held companies. stock market can fluctuate on based on unreasonable

assumptions. so they have a, it may not be technically founded but they do have a legitimate concern about their business assets and their stock price. when we talk about the waste streeps we're going to be dealing with, you have got the personal effects of the people. the conventional medical waste. non-porous materials typically. but in this situation we're likely to have a lot of porous materials. so like linens, scrubs, pillows, mattresses, especially if you have to clean up a contaminated residence or public spaces, buses. other transportation vehicles. there's decontamination residues associated with cleaning up the premises and the hospitals and the vehicles. they may not be contaminated because they have disinfectant in them but they may be considered to be hazardous waste

depending on the characteristics of them. decontamination residues from cleaning up personnel and pets. ppe, potentially a lot of wastewater and rinsate you might have to deal with. limited information we deal with now suggest that these patients generate about 30 to 40 times the amount of medical waste that normal patients generate. so we're looking at, maybe 15, like, 35-gallon drums packed in 55 gal drums, packed in 95-gallon drums and that is a lot of material that has to be hauled around. it has a lot of potential for worker exposure, if you have to open it up because only a limited number of disposal facilities or treatment facilities can actually accept this stuff into them and it is very expensive to manage. when you talk about management of waste, there is all sorts of

different aspects simultaneously have to be considered. how appropriate is a facility? is a facility available? does it have sufficient capacity? there is other issues related to public acceptance. a lot of waste management facilities have worked very hard to develop rapport with their respective communities and they don't want to have to jeopardize that by accepting waste with a potential stigma attached to it. sampling and analytical methods. a lot of states may require you to assure that the waste doesn't have any residual ebola in order to send it off to a landfill. and there aren't, it is a major data gap of how to analyze material-like waste and verify there isn't any of your agent in it. waste treatment, it has a lot of analogies to disinfection. this is an example of the

spalding scale where typically the bacterial spores are the most difficult to disinfect and, you know, viruses are much more easy to disinfect. that's kind of in general though. the matrix they're on can impact the ability to disinfect them. if they're bound up in a porous material, the porous material may react with the disinfectant and resulting you may need to hit it longer or hit it with more concentrated solution. thermal inactivation which is the way that we deal with the waste, it is analogous to disinfection so the spores are much more difficult to thermally treat and viruses are much easier but there is considerations related to the matrix they're bound on. we've done a lot of work in the past looking at waste treatment for bazille la incident. we've been testing with the spore-based organisms and the

organisms of concern are more easy to destroy. when we look at the what are the options we have, pretty much we have incineration and autoclaving. incineration, the dallas materials got sent to a hazardous waste insip rate tore and they were -- incinerator, they were able to accept barrels of waste and feed it directly into the incinerator. they were not subjecting workers to any additional potential exposure. they can accept large items. they may not be allowed to accept biological waste though. they may have have to get permit modification or the state won't let them at all. you have pathological waste incinerators. even the large ones are not set up to take barrels. they take boxes and bags. so they may have problems fitting some of these large items in. if you send a mattress off, you're limiting yourself to where you can send it.

again there is worker health and saved concerns there. the other on option is autoclaving. other hospitals have on sight autoclaves or incinerators. there are only a small fraction that have that. there are centrally located medical waste autoclaves that you send materials to. they can take some large items. they're pretty large. they're about the size of a gasoline tanker truck. so they can take some large items. you may have to slightly adjust the operational conditions though in order to make sure you can successfully autoclave some of the more difficult items. again there is worker health and safety concerns. incineration, we're talking high temperature combustion. typically around 1,000-c. and a lot of these incinerators have two chambers where the first chamber process the solid waste, kills the microorganisms,

releases combustion products into a gas and generates fly ash. it all goes into a secondary chamber which successfully destroys any toxic combustion by-products and any microorganisms that got out of the primary chamber. then they have all have pollution control devices to catch tick late gas and matters and -- particulate gases and permitting standpoint and public health standpoint and a lot of incinerators have very tight regulations on the dioxins and i will get to why that is important in a minute. we've been doing some work looking at different aspects of incineration over the years. back in the early '90s the epa was trying to figure out how they're going to regulate medical waste incinerators and one of the idea that they had was to do some testing where they feed large quantities of a non-pathogenic organism into the

incinerator and measure how much comes out in order to establish some sort of operating regime. they ended up abandoning that because it is extremely expensive to have to use enough of these surrogate materials, you know, like hundreds of thousands of dollars just get enough material to feed in hopes of being able to get something over your detection limit at the outlet. we looked at those data and tried to do a statistical analysis to see what are the important parameters. we've also done some tests at our facility in research triangle park, north carolina, to look at incineration situations with porous building materials because that seems to be one of the big knowledge gaps. so we did ceiling tile in particular, are particularly pernicious. you can probably pile the space shuttle with ceiling tile. it is very heat-resistant and

very porous and wet ceiling tile, we were pulling live spores out of the incinerator after 35 minutes at 1,000 degrees-c. because it takes so long for the heat to transfer. >> some of these materials, and boil off the water before you start heating it up properly. we also did some work looking at what is the impact of using like bleach disinfectants on some of these materials to see if the combustion emissions change from using those materials. here's in brief, the results from our tests. we found that pretty much if you can get the material up to about 350-c, we were able to successfully kill the spores. so that means you have to leave things in long enough, potentially, you don't want to wrap them up too tightly when you send them in, so they aren't insulating the inner parts of the solid mass. but you can, you can pretty much

kill all of the microorganisms if you get the material hot enough. we also found that at least in the pilot scale tests that there is at potential for increasing the dioxin emissions if you use large quantities of bleach and they're present in the incinerator feed. so the facilities would need to be cognizant of that. some of the other implications is that, it looks like maintaining the primary combustion chamber temperature and secondary combustion chamber residence time were the two parameters that most assured the destruction of the microorganisms. the ash is not likely to have any microorganisms but must be characterized in order to determine the disposal pathways because they have to look at things like metals and leechability to make sure they can send it off to a given landfill. package something extremely

important because this is all heat transfer limited. you want to make sure the materials you feed in are not inhibited from being heated up by the process, especially if they're wet. you have to get them up to the boiling point of water and drive the water off before they start heating up again. the second option is autoclaves. we're looking at large pressure chamber where they put the material in, close it up, pull about 10 pounds of vacuum on it. then they pressurize it with steam up to maybe 30 or 40 pounds per square inch of steam. they hold it for maybe 45 minutes or an hour. and then they vent it. they tried to maintain about 250 fahrenheit for at least 15 minutes. effectively kills the microorganisms. there has been extensive history of using these things for non-porous materials. then typically you then take

resid always and they either go to incinerator go to the landfill deend pending what the state permitting requirements are. we did some tests nine years ago at a commercial autoclave up in new york state. it was a 96-ton a day autoclave. we were focusing on the porous items. we used wallboard, ceiling tiles, car theand a sofa. . .