we did some additional tests to look at the effect of multiple cycles and then ended up being a fairly profound observation that you normally don't see when you're out on a field test. you usually have to wait to yout home before you see anything real interesting. but what we found was that rather than going for a longer autoclave cycle where we were still that able to get all of the major up to the temperature of the autoclave, you can see this black line at the top was our control which was essentially the freeboard temperature in the autoclave. the rest of them will were all the thermocouples bound in wall border. running a double length autoclave cycle we still and maybe a third of our thermocouples were not even close to being up to the autoclave temperature. what we found though is when you run the second autoclave cycle,

after you release the pressure from the first autoclave cycle and run it through the evacuation step again come you essentially pull all of the water out of the poorest of these materials so that when you hit it with this scheme the second time they're hot already and you don't get all this water condensing in the pores and about all of the temperature readings right up to the article of temperature within a couple of minutes. and this was borne out with the biological indicator strips. if we did this we kill all of the di strips were as in the one above we did not. so we found that the second cycle is much more effective than running a longer cycle. we also found that cutting the bags prior to autoclave improves the penetration. and separating the items improves the steam penetration. so there's limited capacity.

the incinerators should use appropriate conditions to ke sure that they operate properly and there' there some potential improvements could improve health and safety concerns for workers. finally, just some of the data gaps. trying to identify how we can operate the autoclave when we are using the dod recommended packaging. do some testing being planned by new york state to try to look at some of these issues. we need a good surrogate. you can't be doing this infection tests and waste management tests and a dsl facility. we need to have something that we can use in the bsl 2 facility that would be appropriate for whatever type of experiments we're doing. there's wastewater issues. how do you measure it in the wastewater? what is the fate of the organism as it goes from the point of

generation done to the wastewater treatment facilities, you know, as it goes through the sewer you might have better issues where the rats in this room i potentially pick something up. and the idea of getting mobile capacity in order to not have to transport these items in this complex packaging, if you can inactivate it on site you can then go through a much less rigorous waste packaging and waste management process. also, the potential for innovative treatment options would be nice, like microwaves. there's no data on those. and i have some resources. thank you. [applause] >> we have one last presentation. daniel bausch who was the professor at the tulane

universal sciences center and the department of tropical medicine and -- the u.s. naval research metal unit number six in lima, peru, where he has urology and emerging infections department come is going to talk to us about observations from africa that may inform a research agenda. thank you. >> thank you. thanks for inviting me and thanks to all of you for coming to listen. i'd love to have time to delve into the many very faceting scientific questions that come up at my job here this morning is really just to give you a glimpse of how things are going in west africa. we have had some opportunity of course with patients here in the united states, and to take some very valuable observations but, of course, we hope not to have more opportunities. and so really the research that needs to be done if we're really going to delve into this endeavor difficult area of the world to work in west africa. and so just going to give you

basically a glimpse of how this is because most people of course haven't been on site. i haven't been on site i in the last 21 days fortunately or i probably wouldn't be here. and socially getting an idea the challenges and a glimpse of how things work. so first of all, we need people, and cj alluded to this and this is one of our biggest challenges, the labor to do this. we take a country like sierra leone with a medical school is close all during the war. after that graduate about 10 medical doctors a year, probably i would guess half of those are drawn up to the brain drain to begin with and in some estimates of 20% have died of ebola. so you figure, you could ask the question is going to do this work and, of course, the to competition between the work that needs to be done and the public health response and patient care and in the research. we have a big problem there. we try to get around that with some issues of national of come back to that. do we use local labor? how much of that is there?

of course with international labor. this is a photo taken of the first training we did last month in trying to get some of the international phs and dod under the people trained to work in this. but, of course, this is a difficult task as we'll to get all those people trained and over there and the volunteers also, how many people have the time, the interest to really go and take care of patients who might look like this. is a very dangerous patients sometimes. it's hard work, stress to work. so trying to do this and be in a situation. if you're a doctor and hospital in the united states and you tell your chief of staff that okay, what to go and work in west africa for a little while, difficult to begin with. they say, well, who's covering your patience while you're gone? how is that working? your wife or your husband may not be really excited and, of course, we're adding on 21 days where you're not working after you get back. so the labor both internationally and locally is a

big challenge. so i'm going out of order a little bit here, but and then, yeah, as an agent for 21 days added on, we need to fight against fat and try to inject some reason to the. then the infrastructure. so i've been kind of not intentionally but finding myself playing a role a little bit of a spoiler in some of the meetings like this. it's not that i'm opposed to the research or opposed to clinical trials, but sometimes there some unrealistic expectations of just what we have and what it might take to do this in the field. so these are the sorts of settings the this is an ebola treatment center, the upper one, and the lower one in guinea in the epicenter of the outbreak. there are many other pictures of course. these very a lot. so here's kind of something that you might see in the beginning of an outbreak, very rustic

settings. sometimes unfortunately still the rustic settings that we have in west africa not what we want them to be but just what we have with the capacity right now. and some of these are really much less treatment centers but just places for someone to go, hopefully get more rehydration solutions, some tylenol and a place to die out of circulaticirculati on cannot infect other people. so when we have this sort of setting and then we contemplate something where we're going to do studies, where we need to draw blood samples every four hours and have a electrolyte and the sorts of things, it's not that they can't because i don't me to say that this can't be set up but i think we need to be realistic about some of the challenges that are ahead of us. this is another photo. this is a treatment center in sierra leone. of course, again not really -- i'm sorry. this one here is sierra leone. this is in guinea. again not really how we would want this to be.

we don't like to all these bits together to we would like to have separate rooms but this is the sort this is the swordplay this is the sort of wish of may of right about where the nurses were going on strike frequently. we had a lot of health care workers were getting sick and dying in this area. we had times when we had 70 patients with ebola here, mi7 one of their health care worker to try to take care of them. so when you talk about, again trying to do research and say we need to draw blood, we need to monitor this or that, when you have this sort of setting a course for difficult. we need to increase the capacity. and it can be like this. this is a much more order setting but this is not from the present outbreak. this is from uganda but this is the sort of thing that we like. of course, today we wouldn't like to have those beds altogether but sometimes that's the only choice we have to. a lot has been discussed about the personal protective equipment, and leaving the safety issues and what's the right tv aside, just a matter

what ppe you use this is very cumbersome work to do. in that ppe. suffuse this, the msf prescribed ppe that really you can stay in for about an hour and half really and tell your core temperatures get up to potential dangerous levels. this is closer to what would be advocated by w.h.o. we recently did toss us at w.h.o. to new guidelines on ppe that just cannot yesterday but you might be interested in looking those up and, of course, there's the obama challenge for ppe to try to integrate into new things beyond that. but regardless this is not the sort of setting where you can just let me go in and work for five hours a at a time and taken the blood samples i want. it's cumbersome work, stress a worker to our other issues that are in place. and also on the laboratories i this is a mobile laboratory set up by the european union in, this was in guinea, but, as are

these exist and a couple different places. so cdc, european union, public health agency of canada, there is places set up these mobile laboratories but, of course, they are laboratory. they're meant for diagnostic purposes and by now they have many, many samples coming in. phone that i sometimes is the capacity of the trade considers overrun by the capacity of the laboratory as well. we have the same situation where we need to think where the personnel who are going to be working in these laboratories and we dedicate them to the research and what is, are their priorities between research and the just routine public health diagnostics that needs to be done. also just an example, trying to monitor and take some of these data in the laboratory. in guinea we are using this device, some you may be for me with a. it turns out this device doesn't really like the heat and humidity in west africa and so we had a difficult time using

this in most of the places. you can play with it and did it to work if you can put on a bed of ice but, of course, somebody beds of ice defined readily available in these places which don't routinely have -- that's not the sort thing that is returned there, and electricity is not a given. running water is not a given. msf is the group that used to doing it. they can be done by other groups as will and is being done by other groups but it takes a lot of energy to get this together. we found the people you put on a tabletop is better than this, not quite as sensitive to heat and humidity. in data collection and transfer of course that's the point of doing research. we want to collect data but when you're collecting data inside a ward you have to give it outside the wards we just can't -- on are the days years ago were just used to throw the patient charts out the window, spray them with bleach to let the sunlight hits them for a while and then move on. i don't think we could do that anymore.

so have to have ways, although higher tech ways and this can be done using cellphone technology and competent of ethics and electronic transfers so it's possible but again there are many steps we need to go through. and again, that this is, you can see a love this person is wearing. it's not easy to write all the second in heat and only other things going on. this is an example where people, they are giving information on the patients, they wrote it down inside and just recounting it across the fence to other people who could write about an that ht outside. there are ways to do this. and then ethical considerations. of course, irb approvals, not only in this country but probably more challenging in the countries that we need to work in. they do have ethics committees for irb's but not necessarily ones that are used to really reg and expediting these things rapidly. i think that's being approached these days because of what's going on.

to placebo or not placebo is a huge, very contentious issue and trying to find -- find the right balance of really what is research that we need to do, obviously talking about therapeutics and vaccines here. what's the research we need to do to collect information. scj said clinical trials that are formally times would come out of this with some solid data by the expert stations across west africa which were much more on compassionate use. we had a meeting a couple, month and a half ago now, at w.h.o., doctor lori was there and many representatives from west africa and initial stages to try to figure out how we go forward with some of the use of potential therapeutics and vaccines. and i can tell you all the people from west africa i think the afternoon or evening when they got help from the meeting probably had a call from the minister of health and say which one did you choose? is your suitcase full lex is

that there today are will come tomorrow? tomorrow? so that they do so much clinical trial. they're thinking where are the drugs to the people? and understandable. way of thinking but and then the version of labor from outbreak response to patient care and research are a balance we would have to find. lots of logistics getting to the site. of course, this takes a lot of vehicles, a lot of airplanes to get through remote areas. this is using bicycles that were unloaded to do surveillance and then that's one of the things also that's not making as much as kind of the operational research that we need to improve surveillance is another area that needs to be approached. but again there's a strain on resources because of this vehicle is needed for the surveillance but it's also needed really to get your research staff the rat and to do different things on site. so those are challenges. many of these places the physical security. you've all read about this. there was some health care workers that were killed in

guinea last month. i can tell you some stories from guinea and sierra leone of intense moments that i think of but who has been on site has a few of those stories. especially when we have some kinds of resistant population and one of the ideas that sprinkly spread around about that resistance is that we are there, the bold was either created or intentionally introduced for people and authority from overseas, from foreigners to come in to do research on people. and now when we are doing research and people, how does that feed into a? of course we want to end with the ethical research but we have to be aware of the perception of that, and there are some issues that we've been struggling against. what do you do if one of your research staff gets sick, you need a backup plan. are they going to get care on site or get evacuated to the united states? there are significant cost and logistical implications to all flat. we can't necessarily send people

if you send a bunch of people into a battle zone, then here and there somebody gets shots we have to really be ready for that. i do think we can do this safely i do think it can work but it's not the sort of thing that you can come as jim said, a dallas hospital, it's not the sort of situation where you want to say here's your page with ebola commute two hours of training and not go. you have to set this up. and think it through in advance. i mentioned the societal resistance and cultural barriers to language barriers, first of all, guinea, liberia and sierra leone are anglophone although he get off into very rural areas and some of your staff depend upon their training, it's very common that people speak much more the local languages rather than even english, even though english is a nationally which of some of those countries. there are cultural and linguistic barriers to get over.

i think i did it all in 50 minutes, or close to it, so thank you very much. [applause] >> okay, so we have some time for questions and discussion, and to engage our panel. and there are microphones that are placed in key locations. i'm going to start. yes, please, forward, dr. leduc. i wanted to start with a question and kind of inspired by a couple of the presentations. and what it has to do with is, for the purposes of working on issues like personal protective equipment, disinfection, waste disposal. has any thought been given to what is an appropriate surrogate for the ebola virus in terms of its behavior an comes to bible undergirds conditions? that does not require bsl 4

laboratory facilities in order to run experiments. to people of any ideas about that? dr. peters? >> there's a species of ebola called reston which is -- not to be pathogenic for us humans and can be downgraded from 4. in addition to that some colleagues have produced and ebola virus by genetic engineering that lacks the genes to ward off interferons which ebola has in quantity, and is probably not pathogenic, although i can't imagine any institutional review board giving permission to use it. >> other ideas about that? >> there are very -- there is

pseudo-type of viruses that could potentially be used. you do always get into the question of, you do those experiments and then say that but is that really, doesn't react, act the same as the real virus? that will be another idea. >> from the point of view of doing studies for ppd, we would like a circuit that floresta's. -- florescent. >> some of the circuits that dbas using with bacteria would not be appropriate at all come in terms of size and other characteristics. >> part of the problem is the circuit needs to be selected for the type of experiments you what to do. if you want to look at persistence on environmental matrices you may look at one circa. if you want to look at how it interacts with bleach you might look at a totally different circuit. if you want to look at thermal and separation you might look at it if one.

it's selecting the right circuit is difficult and it's not going to be one bug fits all. >> just to follow up on that, as doctor howard pointed out, having some circuit and as mr. lemole pointed out, testing the cleaning of an air purifying robber half-mast is very different from thinking about -- one that could put the question is which are trying to do with tbe testing to be trying to protect can't evaluate whether the filtration effectiveness works or whether somebody who is tossing ppd contaminates their skin is a very different question. -- doffing. so thinking to what question you are asking requires the find what you want in a circuit. >> yes? >> there is commercially

available fluorescent powders that are not visible to the eye until they are hit with easy life. and it seems to me like that would be very valuable adjunct to training people in doffing their gear if they put on their gear and they had this powder of life and they were floresta after they got their gear off, you could see where some of the breaks might occur. >> first question at the microphone but if you could please identify yourself and -- the mic is a little bit high, isn't it? i think it's fine. >> thank you. i'm the safety and health the director for afl-cio, thanks everybody for being here, and your great presentations. the last presentation just

really brought it all home in terms of the crisis that's been faced, and i think one of the things that's really important is we are thinking about research in the same way that we think about how are we going to stop the virus. we have to look at africa. we have to look first and foremost at africa for what are the research needs as well. and one area that would be very helpful i think for us to focus on, 527 health care workers who have gotten sick and the 250 have died. do we have any more information on those workers, who they were, what their occupations were, with a potential exposures? because it does seem if it's going to be at the heart of the response and the heart of protecting those people, then find out as much as we can about the exposures. and also as michael hodgson said, go to the frontline workers enough can find out what do they need. what do they think the questions are that have to be answered for

them to be able to do their jobs would be really critical as we are going forward of some of the immediate needs we need to identify. thank you. >> yes, great question. so looking at this we tried to investigate as intensively as we can in health care worker infections, and in my tim time n africa when we that health care workers, i've got to those people, as awkward as it is when they're in the ward and say what happened? can you identify anything? it's extremely rare that there's a discrete event of some of that's okay, i haven't used it or have blood splash in the eyes. most time people annoyed when they got infected. other sega said it was one small a regular here or there. one case works at work i got dressed up come within the ward and had to go to the bathroom precipitously, so we didn't recognize any real breach in protocol but nevertheless he recognized that he kind of did things very rapidly.

so we don't have an easy answer to that. again, very few people of something very discreet. we focus on a doffing part of this as it is probably the most difficult, although their server the potential for infection and other parts of the whole process in the ward there are also come even though seems very logical to us and hard to believe, a lot of these health care workers actually still do health, delivered to on a private basis at their homes and other places. there's the potential for infection that is totally unrelated to the ward, some of them are in recognize change the transition osha. i don't think we are going to have through existing data conclusive evidence for that. >> thank you. next question. >> lieutenant marcie wright, two questions first for dr. lemieux and then for dr. peters. i appreciate your comments

regarding the need for what i consider applied biosafety research for waste decontamination systems including 80 of come a digestive and others. but how do you develop the risk assessment justification and explanation to the lay public on some the technical nuances that we have and sterilization, reduction versus decontaminati decontamination, reducing to an acceptable level, et cetera, as folks grapple with the theaters of how well incinerators incinerate a virus for example? and then to follow on, dr. peters, how well-developed are many genome systems and viruslike particle systems or other systems or using rest and ebola as a model in terms of polling that work out of the biosafety level for containment

and to biosafety level 2, including the use of -- some of the experiments dr. lemieux described? >> well, i think the whole issue of risk mitigation. i didn't have it on my slide but i should have. it's a huge gap i think across the whole spectrum of everythi everything, and especially on the waste management site. they've had to grapple with risk communication for years and years. i don't know that there's a magic bullet for that, but i think there's a definite, a definite need for us to be able to improve how we can take these scientific nuances and explained them to, not just the general public. but this is largely and images with their efforts now that we're looking at it, and you may have the jargon from one group

of scientific experts who don't understand the jargon from another group of scientific experts. it goes way beyond just talk to the public. >> can't agree more with that actually. dr. peters. >> i guess by was like particles can be made with ebola and look like ebola and the same size as ebola. they would be a possibility but they are not at this time they are not economically feasible. i don't know what it would cost to really scale up. ..