involved into the don't know how those dynamics work in the ecology of the disease but we don't know if they are potential risks with companion animals and so there's been a little bit of a question about what to do with companion animals into this is simply a picture of one of the nurses with her dog both of whom sent home on friday and the other one after being quarantined for 21 days. so there are basic strategies and public health he is to prevent injury and people from receiving harm and the environment and arranging from of course trying not to create a hazard of the first place of reducing or preventing or modifying a hazard all the way through some of the things that could be done in the future like increasing resistance and

improving emergency response and care and rehabilitation. but here we are really focused on these three things in the middle ground, separating time and space and modifying the basic structures and finding ways to separate people who might be at risk from the hazard it in particular we are most concerned about again responders and care providers of all kind whether occupationally involved in providing care or family members. and when we think about occupational exposures and potential interventions that we can use to get lemonade or reduce exposures, we think about these as occurring on the hierarchy where we know that it is far more efficacious if we can engineer the environment or change the process to prevent the possibility of exposure in

the first place, less effective is to take administrative for programmatic behavioral approaches where we try to change the way that people work together, the behavior of the cases and the least efficacious they use a personal protective equipment. this is a personal protective equipment is really 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. we have a lot of information and there are existing criteria. we are here to review the spec just to remind you we are not starting from ground zero. these are the protocols that every university currently has on their website which are labeled draft, which i think that means even for emory is

experienced with treating these kinds of illnesses. we currently have waste management protocols. we have the u.s. department of transportation has many regulations and there's an enormous patchwork of state and local regulations about the management and handling of the bio hazardous waste. so come at the same time the few cases that we have in the united states have posed in the challenges in terms of the quantities of the ways that have been generated. on the one case the entire truck pulled up after the appointment to haul off the waste and in dallas with one patient 140 barrels 55-gallon barrels

were generated and in fact there were controversies about how the ashes were incinerating the waste would be handled in for the competing not to take those actions so we will produce a workshop report that will be prepared by the institute of medicine. this will be publicly available what transpired here at the workshop. there will be further deliberations by the planning committee. what will be in the report well emerge from what the speakers at the workshop brings forward. it will be published by the national academies and the decent ideas will be those that the workshop participants and lost the national academies of the planning committee and there will be no former consensus findings and recommendations coming from this activity.

>> said, with that and to conclude once again by being here i would now like to turn to doctor the coal who 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. >> thank you to all of you for coming. in. and for tuning in on the web and other ways. and thanks very much to the planning committee for rapidly putting this together. i thought that i would take a quick step back and get a bit of perspective. i came into this position in 2009 just as the h1n1 was ramping up. i ended up on a phone call around the country each talking

about the temptations that are in the icu. and a group of us listened to them and thought if we could get a download of cases to this it should be possible that if people survive this disease we go out to the nih research network and to entity agreed to modify the protocols for sending the identified data and we felt that we were on our way. it turns out that it took six months for the human subjects committee of the respective universities to approve the changes to the protocol and we completely missed the window to know how fast to treat people. 18 months later we learned from the work that about 40% of the children who died died right

from the resistant staph and not from h1n1. and it was with that that i said we are not as equipped as we need to be to do science and to do the kind of research that needs to be done in an emergency either to affect the course and trajectory of the emergency or to be sure that we are never in the same situation twice. it's in the spirit that we are holding the workshop today. my office has launched a fairly comprehensive science response initiative which is now across the hhs. one immediate outcome is that there is a public health emergency and it is they send that it could be used in an emergency. another immediate outcome of that work has been a process that is set up in a meeting. in any emergency it's important to get the groups of experts

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

in december. a number have been developed and are in various phases the various phases of testing and will be subject we expect to the rigorous clinical trials. those are not the focus. similarly the group has put together a finishing the development of the practice guidelines. i want you to understand that is the kind that science is going on and it does not need to be the focus here. but the focus really needs to be on impacting the public health and medical response for this and for the future. during the people are rising or after deepwater horizon, we put together the different federal agencies that were involved in doing the research during that event. we learned that there were 17 different federal agencies all

of whom were involved in research or science or one way or another they largely didn't know about one another. and because of the way that they collected a lot of the 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 the science technology policy at the white house all the different agencies ranging from hhs to the department of transportation to the department of energy and beyond have come together to identify what it is that they can bring to the site and what it is they are doing and identify both priorities and opportunities for the collaboration. however, we do need to hear from people outside of the federal government about this and that is a part of the genesis for this. when we planned this workshop we were in a very different situation in the epidemic and we are now. we have not yet had a case or cases in the united states and so we are going to be a little bit flexible today in terms of

how we think about this agenda and how we identify together with the science parodies are but regardless we started seeing that the public and the healthcare workers had many concerns about how to protect themselves but in west africa and here. environmental issues always come up in situations like this both to guide the public health response and to address the public concerns. i don't know how many of you saw the piece in the news this weekend about some of the challenges not only with the patient's apartment in dallas but the fact that right now the ashes remain in limbo because there's not any there is not any place that will accept them. in the interface between science and dealing with public policy and dealing with public concerns

this is not an exercise in the could have come should have, would have. it's not an after action report and i want to stress that. i am hoping today that we can focus on actual work. it will help us move forward to protect public health both here and potentially in west africa and work that should be prioritized now. i want to stress i'm working at this from the set of priorities and not just good issues and ideas. some of the prioritization process will have a time element. what needs to be done now eager to answer important questions or to be posed to answer those questions in the future and that involves the collection of data and specimens or whatever and it is both of the others let's keep in mind that this is a workshop. it's not a consensus process or process to develop the formal recommendations but it is a

process to give us and federal government and the scientific communities around the world a sense of what you think the priorities are. so thank you for being here and i look forward to the deliberations of the day. it's now my pleasure to bring forward the first speaker. the professor of medicine and director of the galveston national laboratory at the university of texas medical branch. he is going to talk to us today that the characteristics of the virus in the u.s. environment and what do we know and are there assumptions being made based on the science. thank you for being with us today.

let me thank the organizers for inviting me. but they say the disclaimers number one this is not a comprehensive overview. there are so many examples and we are all going to be talking about them so i apologize for those in advance. what is heavily influence on the experience since we worked through the key issues that we will be discussing today. i check the numbers and we had nearly four team thousand cases

in the mortality rate of 70% said the outbreak is out of control going in the wrong direction and i think that this is important to realize the number of health care workers is astonishing. it decimated and as a result of the international community's responsibility is to provide the resources. this feeds back into the national strategy on how we manage the returning volunteers and i think this is an important key to keep in mind. if we volunteer for a month overseas and then have to add three weeks in quarantine a lot of people will think twice and i think that this is a real issue. what is the risk of the introduction we are all aware of where it occurs.

this is a recent publication just just on where the fights from africa go. and we got a whole lot of places including significantly to asia as well as europe, south africa and the united states. so there is lots of opportunity for dissemination as we go forward. what are we really worrying about? there are maybe three groups of individuals we could consider into nationals. mr. duncan is a good example of that category and the people that have been effective and end up in our shores completely asymptomatic and become infected. international travelers there's a lot of business people to go around the world and i'm not aware of this example yet but i do know that we saw that on more than one occasion. and then finally, the returning volunteers and healthcare workers and these are the folks that are in the news today and

are an important part of only four above response but also for the national discussion as we go forward. what do we see in the united states, we see mr. duncan who arrived and was hospitalized and was unprepared. i submit to you the experience in dallas is exactly what would have happened in the other hospitals around the country. but we simply were not ready. the hospitals in general were not ready to answer this kind of case and as a result a couple of the nurses became infected and they were treated well at every debate co- emory university and nih and established the ability to treat these patients. we have seen five american workers that have returned from africa. back for treatment in the united states to go to every debate co-

emory university and has been survived well. the point i will make later on is if the hospitals are aware of the ebola cases they do a very good job of that. i think that now, having those hospitals having seen the experience and i'm certain they are prepared now as they were a month or two ago the last example last example self identified and followed the rules as we articulated in them and as soon as he became clinical in the hospital at bellevue. so what have we learned? the context doesn't appear to be as great as we had feared. in the best of my knowledge we found no secondary cases from either the nurses or his family and we recall that he was quite

ill so there appears to be a standard for the transmission that's fairly significant. we have gone in and decontaminated the two presidents that i am aware of three of them but i don't know the details. the two i do know about, we really did a cleanup. in the case of mr. duncan's house they even took the toilet. so you heard that there were drums of waste taken from that. we really don't know how to manage this quite well. similarly, we have nearly 155-gallon drums of medical waste associated and how to manage that was a significant problem in texas. we subsequently worked through it but it was quite challenging.

and then we have already heard about the pets and how to manage them and so what did we learn we haven't seen anything that is out of the ordinary and it seems to be following the same rules that we seem to have all along. specifically we have seen the importance of the appropriate to avoid the contamination of the individuals. and we have seen some challenges associated with. what is the national strategy we are aware of? we are screening people as they enter the country. in west africa we are using the traditional interventions trying to separate those infected from those that are not infected in the drug transmission.

who has aggressively set up with a collaboration from the cdc so that prior to leaving they are trying to exclude any patient in the entry in the united states we are doing the same thing and discussion about how to quarantine is continuing. so this is fine for the focused outbreak that comes from africa and if it is to become transmissible in asia or another place how would we manage that? this is a challenge that we hopefully will not have to face. several hospitals are well-prepared to safely manage the patients and nebraska and others and have proven their worth and clearly we can do this if we know the risk. on the hospital doesn't know that it is a patient and they are handled just like every other patient and we have a problem down the road.

we know that self monitoring works and that we have a few examples now where people have self identified and have gone to seek clinical care and have been isolated in treatment and hasn't resulted in the transmission. so this is important as we go forward with our discussions. there is no scientific evidence so far or observations to support the risk of the transmission prior to the onset of the clinical disease and i think that this is important. and we have been fortunate in that the mortality rate has been low for. and than we've seen in west africa and other outbreaks which is attributed to the care from the modern work. out of an abundance of caution i've come to hate this phrase because you know what's going to follow after that and you are just going to shake your head.

it is insufficient. nerc just so there's no questions and i'm sure that you all have your examples of the school systems and somebody flew on an airplane and all this so lots of issues and of course the whole discussion that continues today about how do we manage the travelers and what is the science behind it and lots of discussions and lots of observations. i'm not going to read all of this to you but you have seen the headlines i'm sure.

then, the most recent nurse who said enough already there's no scientific basis and this is continuing to be discussed but nonetheless it is in my opinion at least a personal observation and a welcomed push back on this discussion. a very thoughtful editorial this is from arthur caplan 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 the scientific papers. i could come across this the basis and many of the authors are here today and i will refer to them for the details.

i'm sure that many of you saw this most recent addition of the new england journal of medicine and i think that this is the 16th of october. this is an overview of the situation in west africa. so let me draw your attention to the frequency this is the integration period between the index case and the onset of the disease. you can see the nice curve here. 21 days is the cut off. there are a few cases that occur after that and you will recall that who criteria for calling the country free is 42 days and that is exactly the reason and we've always known that this is biological and there are some occasional outliers. and the numbers appear this is 9.4 days average. we have the shedding of the

viral load with me start with the paper from the outbreak in 1995. so this goes up very quickly and again, this is on the days on the onset of the number of samples at the adage and then the curve that is in the paper. this is based on the refinement of the date the data the data "-begin-double-quotes he that it's starting low and going up as the disease progresses. and importantly, here, the dark bars represent a fatal outcome in the open bars are those that survived. and you can see that there is a strong correlation between the

outcome of the disease. the assessment of the risk of the ebola virus transmission from the bodily fluids come and again this is the only paper that i could really find and damn can explain a little bit more. but i wanted to highlight a couple of things. number one, this column is the pcr positive. you probably can't read it at the bottom line is if you have the positive samples there are a whole bunch of different categories and so on. there were a total of four positive and importantly of the 42 of the specimens were in semen and breast milk. we haven't talked about the transmission after the recovery

and this is something that needs a little further discussion. he also did a very nice study of one of the awards sampling a whole bunch of different sites and attending both the virus culture and the pcr. you can see a lot of the negatives and i will explain what that means that there were some positive results and samples and all that. many of you have seen these papers on the persistence of the virus in the various services highlighted here is ebola. and this was looking at the survival of the virus over time and this is an hour this is 134 hours to concede that the virus

survives longer than one might assume and this is a similar study based on the storage of material and the scale is in days. the result are 4 degrees. ..

it is based upon controls from france, and so i am not sure exactly how to interpret this, but nonetheless in the ebola index villages they're is a fairly significant number of animals positive. so what that means, i don't really know, if it is really anti virus, who knows, but it is an area for further investigation. we have talked a lot about aerosol transmission. this is the only data that you will see from my laboratory and coincidentally was just completed with nonhuman primates, and you can see very low doses of that 100- 200-500 virions easily

infected and killed primates and there's a lot of information regarding that surrounding the ebola virus. you all i'm sure have seen articles on this. raise a lot of discussion, is it airborne, all of this. nonetheless, i think that it is important to remember that this virus has now been through an enormous number of human-to-human transmissions. we really do not know how the virus has adapted, if at all. i do not for one minute think that it has become airborne, but there are some characteristics it would be nice to know more about. unfortunately we do not really have that information we have talked a lot about the importance. in 1995, you can see at that time.

another photograph -- i'm sorry. and many of you will have seen the article calling for a review of ppe and new ppe equipment. i think this, again, is an area where we may well benefit from the review of what is being done and are other improvements to be made. okay. what do we know? well, we have confirmed previous observations on the lack of transmission ability before patients are symptomatic of a confirmed the value of monitoring of potentially exposed persons. no question in my mind that this is very important. we know that the risk of transmission can be mitigated by ppe, but we need to do it right. and that is an area for continued investigation.

to some simulation study shows that it can go a long way. what we don't know, the impact of unprecedented number of human-to-human transmissions which i mentioned already, but i think is significant and reflects another problem we have and don't have access -- the global scientific community does not have access to the virus. and so our research efforts are somewhat hampered. and how to clean apartments, we can clean them. how clean is clean? how much should we do? this is ongoing. the duration of interactivity, bodily fluids, we talked about that. the risks associated. we do not have any diagnostics that can be used pries into medically. last but not least, we really do not have a good strategy and how to communicate with the public. i think with that i am done.

>> thank you very much. [applause] [silence] >> well, what we are going to do is proceed with a presentation from our panel about the existing research, landscape. one other talk, and then we will bring up the speakers and panelists back to the stage for some time for questions and interaction. and so, it is my pleasure to invite someone from the center for by a defense and emerging infectious diseases at the university of texas medical branch to come forward to talk about existing research landscape on ebola passed an ongoing initiatives.

>> thank you very much. unfortunately, our information technology people seem to feel like part of their mission statement is to be sure that no one on the faculty can use the internet, so i do not have any slides. let me tell you what i will tell you, what i wanted to tell you anyway. our mission is to tell basically the truth, the whole truth, and nothing but the truth. and the truth is to include, i don't know. and if you do not work in that context, you will find that some of your troops will be bound to be -- found to be wanting and your credibility will go down the tubes. the first truce, i think, is

the incubation time frame. it is advertised as 21 days. as many of you who have worked in this area before we will know, they are a distribution and usually it is an abnormal. if you look on the internet for ebola incubation, you will find a number of papers thought only using the law of normal but the gamow function and so on. and you will find that the incubation period varies according to who calculates it by which formula. so 21 days is basically the longest interval that was found between cases pin 1976 mekambo outbreak. it is almost a sure bet given the way that the other calculations workout that we

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

compare therapeutic modalities to include drugs, others, and then it will go to something that no one has talked about in general terms. that is patient care. if you looked at a ebola patient post-mortem, they are full of an antigen. and generally the case is do not have much of an immune response, so you are left with a difficult situation, and my thoughts would have been that management of fluids and electrolytes would probably not make a great deal of difference, but if you look at the cases we have in this country, it apparently has. we have had very low case mortality here compared to west africa. that should be formally looked at.

the other thing that is on the menu for prison modalities' is coagulation, evidence of this is present in every place that has been tested. so i think we can figure that is one of the problems. there were some studies done with a drug that has actually been in people in the works for embolism, so it is not used widely now. but in the monkeys' it was very advantageous in preventing eventual coagulation and improving survival and the mean time of death for monkeys who did not survive nematodes,

accessory, protein, familiarity epilepsy. and what -- a study had a very interesting outcome. the virions were lower than they were in the controlled monkeys, consistently and significantly lower. how dic plays in with virus production is not clear to me, but perhaps it destroys sites of replication. it made allow more effective immune response to prevent clotting in this plane, but forever -- for whatever reason it really recommends itself for a disease for which we have no established therapy.

speaking of established therapy, i am worried about two things. one is enthusiasm for potentially worthless products given to someone who will survive anyway which may well be plasma. this is no experimental system went that really works. you do not seen suppression the rainy and monkeys getting off and walking. has not worked that well. the only report where it seemed to work was a report to add to gidn99, some work that was done while we were there, and one of the things that was most striking about that was, hey, there were no controls, and it, become law when you looked at the deaths that occurred in the rest of the

code word of infections, you saw that these people were destined to survive in any way. they were in a high survival group, that is young women. late in the epidemic were deaths were somewhat less and received their convalescent blood at a time when most patients had already declined whether there -- declared whether they would live or die. so it was sort of like desert after you finished the meal. and that has given rise to a lot of hot -- thought that has led to a lot of wasted effort and wasted patient time. i believe that the -- we would be better served by testing some of the things

that i just mentioned, but if we do use convalescent plasma, then it should be subjected to a rigorous test, like anything else. one of the -- i am thinking back to a syndrome here in the u.s. when things were actually a little easier, but in a situation like this people do not want to do a controlled trial. they do not realize that without a controlled trials you will never be able to bring the full force of what you have been working with to bear on the disease. you will not be able to get the money. you will not be able to get general acceptance and so on so i think it is important that we support the drugs and therapeutic procedures proposed by a controlled,

randomized trial. there are certain other obstacles, and that is that this is not a common practice in africa. the general attitude that they have that you find when you go to the minister of health and, say, kenya, sierra leone, the responses, well, if it works let's give it to everybody. if it does not, let's not give it to anybody. and that is a good philosophy. if you do not know whether it works until we have a trial. the answer is this, the impulse and 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 did not make -- the electrons did not make it across the wires was

the issue of staffing. i mean, who is going to do all of this stuff? well, i do not think you want to pull volunteer action to a trial like this. we have terrible problems with staffing. and the others will talk about that later. but we ought to be able to recruit staff and be able to release the people who are involved in patient care and so on, who are capable of doing these types of trials. also reminds me that one of the things that we absolutely must fix is, we have to do the clinical virology of ebola. in other words, we have to understand virions day-by-day, antibody production day-by-day, as well as excretion device to

the outside. i do not know if any of you have seen anything in the literature about the virus involvement. if you looked through the literature it is often described as one of the ways to get infected, vomiting. so we need that kind of clinical virology. for that, we have got to fix the export simple system. you can do it on sight, but that is not the same. another related issue is quarantine because if you knew what was on the outside of somebody you would know whether or not you should think about quarantining or how effective you think it would be and how soon it should be. well, many years ago i went

to bolivia to work on an outbreak of it ebola hemorrhagic fever with interpersonal transmission, and i could say several things. one is, i was -- my wife worked in the clinical lab, and everybody in the clinical lab said camacho, we are so sorry to see c.j. peters go. we like him. he is not coming back, and i think that is one of the messages that we do not want to send. i think there have been some attempts at this. after the outbreak i was communicating with my boss by ham radio -- there was no internet at that time and no telephone lines.

i noticed that when i was talking about coming back that he was strangely silent so i finally found an airplane that would break the site which would come to pass while i was there, and i flew back to the pause. their i got on the military net and discovered that i was not wanted. panama did not want me. the u.s. did not want me. the canal zone did not want me. i just did not know whether to air to a backstroker out to see or what to do. very, very persuasive guy persuaded them to let me come back if i would undergo a 3-week quarantine. does this sound familiar? the laboratory had some rooms in the top floor, so i

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

ebola. inevitably there will be some assumption we have made that will turn out not to be true, but right now of the dogma is, you are not infectious until you are sick. this sicker you get, the more infectious you get. that is based on three things. one is faith. number two, the old diagram which has been partly verified 44 in monkeys. the initial growth is in the lymph node and subsequently there is viremia, and subsequently it reaches the target organs. presumably this is the point where it will become infectious. i do not think that this is proven. and it also raises the question, where is the epidemiological evidence to back this up.

end the only thing i have been able to find is a study that scott found that was done in secret on families and looking at transmission in family groups of indexed patients. and that showed that there was very little transmission, if any, in the early periods and later at home when they were sick there was some transmission. and later as they became sicker there was even more transmission, but about 25% were infected. so i do not know how we will devise an information strategy which will impact the public that believes if

you go to dallas and come back you should be quarantined because they had a case there, but we do that and we need to look for a scientific basis for many of the things that we are using thanks. [applause] >> the next member of our panel is dr. john howard, director of the national institute for occupational health and the centers for disease protection. and dr. peters, if you don't mind, you can stay up here. we will bring up the other name tags. >> thank you very much, and i wanted thank the national resource council for getting us all together. what i am going to do today for you is rather 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 is that while today we are talking about a ebola virus, it is important to know that all of the issues that i am going to raise really have a broader applications for pathogens. certainly, if we see in this and nationalization of the world in terms of infectious diseases, we see more of these events, all of these issues, i think, will be extremely important. so the five that are ppe issues, one, how we quantify worker exposure to match appropriate ppe with the required level of exposure protection, what research is needed to determine appropriate test methods to demonstrate that a given type of ppe will protect the worker, the most effective procedures to prevent self contamination. are there a novel ppe designs that will be more

effective for health care workers to use in patients settings? lastly, it is not just fedex that is interested and logistics', but how we can 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, you know, the issue is proportional protection, and i think it is an important research topic. the point of want to emphasize, the observation i think is important, we have 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 do not think that we have 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 are talking about the scientific basis for ppe, for identifying,

validating, determining test methods. a lot of ppe recommendations are really not associated with a national standard, international standard, a consensus standard, and there is a lot of concern regarding whether appropriate test methods are being used to evaluate, for instance compromis asian. so there certainly is work that can be done in this area. we are doing a lot of work at our laboratory. we have a sweating manikin that some of you have heard about looking at stress studies coming determine appropriate duration for wearing ppe, permeability studies to look at ppe according to the american society of testing and materials standards to my glove degradation in terms of the effect of bleach and alcohol based sanitation on gloves, fluid penetrations studies of both niosh certified respirators, fda clears surgical 95 and other things

like surgical masks. three, the most important, effective. and here the emphasis not so much on the dawning, but in use, during use, and especially during doffing, several people have spoken about this before. it is important to preserve -- prevent self contamination. the fourth, are there novel designs that will be more effective for health care workers to use in patient care settings, very unique settings that are very stressful settings, both for the provider as well as the patients involved. president obama announced a grand challenge to design improved 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 amounts of stress associated with each. at the white house you syad

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

referral centers, as they are added to the system. the three biological behavior knowledge generation priorities of want to put on the table today, how long does the ebola virus remain a viable on surfaces, including ppe considering different body fluid, what kind of disinfectant and contact * are needed to inactivate the ebola virus, what are the best sampling methods to detect viable ebola virus on surfaces and ppe. so this issue about how long this virus remains viable on different surfaces, and especially on ppe, is one that we are very interested in in terms of the high-risk body fluids. it may differ. the various mediums, air, water, wastewater may differ a viral annotate -- viral penetration through protective clothing, how long it lasts, the contact

*. what type of disinfectants and contact * are needed to inactivate. there are issues in the various types, the concentration, the contact time that they need to remain on the ensemble, garment, or device in terms of disinfection and how would studies informed decisions on ppe decontamination and waste in activation and lastly, what are the best sampling methods to detect a viable ebola virus on surfaces and ppe. certainly the need is great, but i want to emphasize today that research needs to be done in a controlled laboratory settings to develop the science to be able to go out and use in the field. so it is an important first step to make sure that this type of a sampling method is reliable, is validated before one runs out to do field studies. and i think that is where i will ended. i want to thank everyone at

niosh you helped me prepare this presentation. especially our staff in pittsburgh, pennsylvania. thank you. [applause] >> thanks for that, john howard. next we are bringing forth the chief medical officer from the occupational safety and health administration department of labor. welcome. >> thank you, dr. lynn goldman for the invitation to present some of fuse here that come out of the occupational safety and health administration. the meeting comes obviously a very timely and opportune time but reflex to our surprise a failure of planning on the comprehensive emergency management cited implying

here in the middle of response we have done an adequate prepared this and mitigation. that does not appear to be the case. we wonder whether there is some lesson on thinking through how we approach this given the lessons from the august 1999 meeting on biological agents, the sars and h1n1 pandemic. there may be some overlap between failing to think through the reality of working in the real world. in that context, it is worth remembering the lessons from injury prevention involving health care workers early on in reality testing of intervention strategies which has proven important in some things like safer

needles and devices with engineered sharp entry prevention. we did not do that here, as we will get to in a minute. let me thank with you about some problems for hospitals and some problems outside of hospitals. over the last 12 years they have managed ebola outbreak successfully in many countries with very specific guidance. some of that guidance was incorporated into who. some of the other lessons were not disseminated as effectively as they might have been. though the training methods, for example, observers, the buddy system, immediate cleaning and removal of vomit and diarrhea and the implications of a ebola treatment unit design, how to manage float in the real world is an issue.

although most hospitals now have a plan a few weeks late, it turns out that many of those hospitals are still struggling not just with the process flow, but the real infrastructure, some many hospitals right now are doing construction to replace walls, figure out how to manage your flow and how to have enough space to stage without contaminating the body, the worker, or the room in which they are moving around. so how much space is needed in reality? how much training is really needed to do it safely? there are a number of courses out there. ucla just looked at, how effective training with 16 hours over ten days would be , and fewer than one-third

of their staff were actually able to pass their internal test. that suggests that the training is pretty hard, and if you remember the focus, the question of why, you know, why two physicians who came back self contaminated and became ill is not so surprising. if you are not used to doing something irregularly and energetically it is just not going to work that well. what are effective ways and competing strategies to manage waste and a modern hospital? so, everyone has heard about the management strategy at emory with an autoclave unit of the award. many hospitals do not have a large autoclaved. they do not have portable autoclaves. so the question is how to move that waste around that

is generated new discussions between agencies that had not been involved. dr. james leduc pointed out some of the borderline ludicrous problems that have arisen, but these are all failures of preparedness in thinking through upfront how to manage something. aha what are just in time management structures for hospitals? should then nurse at the tree gosh desk call an infectious disease, salt or implement the emergency management system and most hospitals have not thought that through. given the effectiveness of the approach to infection control, where is the boundary between appropriate use of surgical masks and respirators? the cdc has meanwhile put safeguards up, but they come

in different strategies, the protection factor of 25. protection factors. the latter were those identified as necessary in the work around contaminated patients, and many hospitals can purchase those. what is, in fact, needed for appropriate protection? and finally, in hospitals what is the perspective of front-line health care workers on managing the infrastructure? it turns out, if you read in fs documents, the non hierarchal team approach to health care worker protection and leader commitment are likely essentials. how we come as a system get to involving health care workers early into that process and then thinking through problems outside of the hospital, where does the

virus my great, as we think through use and destruction. so, as we think through to a critical infrastructure and key resource sectors, where are their process seized or engineering failures generate exposure. hospitals, a widely discussed phenomenon. when a fix leaks, is that a hazard? how do airplane cleaners cleaned toilets in the airplane? how do truck drivers transporting waste deal with accidents? so thinking goes through in a comprehensive approach is essential. what kind of ppe are necessary in each one of those prophecies. and then what do we know about the levels of ppe necessary for each of those. finally, based upon all of this, what do we think, how can we better define ways to

communicate the use risk to workers in ways that they understand and act appropriately. remember the lessons from sars in toronto. if we had not invested the working people who run the risk in developing the protection strategy, in fact, they will not come to work. that was one of the big toronto lessons. and so, how do we create a safety culture that makes people feel comfortable and lets them come to work. thanks. [applause] >> okay. the last member of this panel is with the epa office of research and development. their national homeland security research center, and decontamination and

consequence management. welcome. >> thank you, dr. lynn goldman. i am honored to be here. i am primarily going to be talking about treatment of waste, but this is a big, integrated incident that involved as many different considerations that impact other considerations, like how they approached the infection control affects how the waste is generated, what disinfectants you use affects how the waste is generated. so everything affects everything else in this situation, and we need to be able to be thinking about all of it at the same time. when people talk about waste management, there is a number of steps in waste management, some of which can result in potential exposure to the waste management workers.

there are technical issues associated as well. i am going to focus on the treatment aspect of it, but people need to remember that there are people that package of this stuff up. there are truckdrivers that transport it when it arrives at the treatment facility. they may have to open up the packages. that department of transportation has stringent requirements for how test package category eight bio agents which impacts how the treatment facilities can operate. then you have to transport them to your ultimate disposal facility, of which it has been mentioned that there is a stigma attached with some of this waste -- it is not a technical issue, but the waste management facilities, like the landfills, there typically publicly held companies. and you know how vostok market can fluctuate based upon the unreasonable assumptions

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

hazardous waste depending upon the characteristics. you have decontamination residues from cleaning up personnel and pets. ppe, potentially a lot of waste water in rinsing that you may have to deal with. the limited information that we have now suggests 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, 35-gallon drums packed in 55-gallon drums packed in 98-gallon drums. that is a lot of material that has a lot of potential for worker exposure. only a limited number of exposure facilities or treatment facilities can actually accept this stuff into them, and it is expensive to manage. when you talk about management of waste, there

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

this is an example of the spaulding scale where typically the bacterial spores are the most difficult to disinfect. you know, viruses are much more easy to disinfect. that is kind of in general, though. the matrix they are on can impact the ability to disinfect them. if they are bound up in a porous material, the porous material may react with a disinfectant resulting in you may need to hit it longer or hit it with a more concentrated solution. well, thermal and activation, which is the way that we deal with the waste, it is analogous to disinfection. the spores are much more difficult to the family tree, and the virus is much more easy, but there are considerations with the matrix they bound on. we have done a lot of work on waste treatment. so we have been testing with

the sport-based organisms. the organisms of concern are much more easy to destroy. when we look at the options we have we have consideration and autoclaving, incineration -- the dallas materials got sent to a hazardous waste miss -- hazardous waste incinerator, and they were able to accept the barrels of waste and feed them directly into the incinerator. so they did not subject the workers to any additional potential exposure. they can accept large items. they may not be allowed to accept biological waste. they may have to get a permit modification, or the state may not let them at all. 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. if you send a mattress, you

are limiting yourself as to where you can send it. again, worker health and safety options there. autoclaving, some hospitals have on site autoclaves or incinerators, but it is only a small fraction that have that. they are centrally located medical waste autoclaves that you send materials to . they can take large items. they are pretty large. there are about the size of a gasoline tanker truck, so they can take some large items. you may have to slightly adjust the operational conditions in order to make sure that you can successfully autoclaved some of the more difficult items. again, there are worker health and safety concerns. incineration, we are talking high-temperature combustion, typically around 1,000 degrees centigrade. a lot of these incinerators have two chambers are the

first one process is the solid waste, kills microorganisms, releases combustion product into the gas and generates fly ash. then it goes into a secondary chamber which successfully destroys any of the toxic combustion byproducts in any microorganisms that got out of the primary chamber. then they all have pollution control devices to catch the particulate matter and that acid gases as well as fly-which is of concern from a public health standpoint. a lot of incinerators have very tight regulations on that dioxins. abel get to why that is important in a minute. we have been doing work looking at different aspects of incineration of the years back in the early 90's, the epa was trying to figure out how they would regulate medical waste incinerators, and one of the ideas 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 serried materials, you know, like hundreds of thousands of dollars to get enough material you can feed in in the hopes of being able to get something over your detection limit at the outlet. so we looked at those data and tried to do a statistical analysis to see the important parameters. we have also done some tests at our facility and research in north carolina to look at incineration situations with boris building materials because that seems to be one of the big knowledge gaps. so we did ceiling tile in particular, particularly pernicious. it is very heat resistant,

porous, and what ceiling tile, we were pulling live spores out of the incinerator after 35 minutes at 1,000 degrees centigrade because it takes so long for the heat to transfer into some of these materials and boil out the water before you start eating it up properly. we also did some work looking at, what is the impact of using bleach disinfectants on some of these materials to see if the combust emissions change from using those materials. here is, in brief, the results from our test. we found that pretty much if you can get that material up to about 350 degrees centigrade we were able to successfully killed spores. that means you have to leave things in long enough. potentially you do not want to wrap them up too tightly when it sent in so that they are not insulating the inner parts of the solid mass, but

you can pretty much kill all of the micro organisms, if you get the material hot enough. we also found that, at least in the pilot scale test, that there is the potential for increasing the dioxin emissions if you use large quantities of bleach in the incinerator feed, so 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 the 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 for things like metals and leetch ability to make sure they can send it off to a given

landfill. packaging is extremely important because this is all heat transfer limited. you want to make sure the material you feel and are not inhibited from being heated up by the process, especially if wet because you have to get them up to the boiling point of water. the second option is autoclaves. we are looking at large pressure chamber where they put the material in, close it up, a poll about 10 pounds a vacuum on it, then pressurize it would steam up to maybe 30 or 40 pounds per square inch of steam, hold it for maybe 45 minutes or an hour and invented. they tried to maintain about 250 degrees fahrenheit for at least 15 minutes. effectively kills microorganisms. there has been an extensive history of using these things for non porous materials, and then

typically you then take the residuals and they either go to an incinerator or landfill depending upon the state permitting requirements. we did some tests about nine years ago in a commercial autoclaves up in new york state. it 96 times a day autoclave, and we were focusing on the porous items, we used wallboard, ceiling tiles, carpet. we embedded thermal particles and biological indicators trips which is the normal performance test to insure they are operating correctly. we embedded them into these materials, some on the outside, some on the inside, and then we very the time, temperature, packing density in the autoclave to see if we were able to successfully kill the bug when we started doing these tests, we saw some strange results on the thermocouples during the first run where

it looks like it looked like all of the signals were converging on a single point. so we did some additional tests to look at the effect of multiple cycles and ended up with a fairly profound observation that you normally do not see in a field test. usually you have to wait until you get home and analyze the data before you see anything really interesting, but what we found was that rather than going for a longer autoclave cycle where we were still not able to get all of the material up to the temperature. you can see the autoclave, this black line at the top was our control, essentially the freeboard temperature in the enclave, the rest are the thermocouples down bin wallboard, and running a double length autoclave cycle we still had may be one-third of our thermal couples were not even close to being up to the enclave 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's step again, you essentially pull all of the water out of the pores of these material. so when you hit it with steve the second time they are hot already and you do not get this water condensing and it brought all of the temperature readings right up to the other place temperature within a couple of minutes. and this was borne out with the biological indicators trips. if we did is we killed all of the bi strips whereas in the one above we did not. so we found the second cycle is much more effective than running a longer cycle. we also found that cutting the bags prior to autoclaving improves penetration, and separating the items to improve steam

penetration. so with limited capacity, the incinerators should use of preconditions to make sure that they operate properly. and there are some potential improvements to improve health and safety concerns for workers. finally some of the data gaps, trying to identify how we can operate the archives when using the department of defense regulated packaging. there is testing being planned to try to look as some of these issues. we need a good surrogate. you cannot be doing disinfection tests and waste management tests in a level for facility. we need something in a level to facility that would be appropriate for whatever type of experience we are doing . they're in our waste water issues, how do you measure it in the waste water, what is the fate of the organism

as it goes from the point of origination down to the waste water. as it goes through this to work you might have sector issues with the rats in the sewer might 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 , like microwaves, there is no data on those. and i have some resources. thank you. [applause] >> so we have one last presentation. professor at the tulane

university health sciences center and other department of topical madison and the u.s. medical research unit number six in lima, peru. he will talk to us about observations from africa that may inform the research agenda. thank you. >> thank you. thanks for inviting me, and thanks to all of you for coming to listen. i would love to have time to delve into the many very fascinating scientific questions that come up, but my job here this morning is 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 valuable observations that, of course, we hope to us not have more opportunities. so the research that needs to be done. so i will give you basically

a glimpse because most people, of course, have not really been on sites. i have not been on site in the last 21 days fortunately or would not be here. and so it really gives you an idea of the challenges and a glimpse of how things work. a first of all, we need people, and c.j. peters alluded to this. this is one of our biggest challenges. taking a country like sierra leone were the medical school was closed during the war. after that, graduated about ten medical doctors per year. probably half of those are drawn off to begin with. and some estimates are 20% have already died of ebola. you ask the question, who will do this work. there is the competition between the work that needs to be done and the public-health response and patient care and research. we try to get around that with issues of -- i will come back to that. so do we use local labor? how much is there?

of course to all we have international labor. a photo taking of the first training we did last month in trying to get some of the international people trained to work. but, of course, this is a difficult task to get those people trained and over there. you know, volunteers, how many people have the time and interest to go and take care of patients who might look like this. these are very dangerous patients, sometimes it is hard work, stressful work. so trying to do this and be in a situation, if you are a doctor in a hospital in the united states and tell your chief of staff, okay, i want to go and work in west africa for a little while degrees difficult to begin with. they say, well, who will cover your patients while you were gone? if your wife or husband may not be really excited. and now we are adding 21 days where you will not work

once back. so it is a big challenge. and so out of water a little bit here, but -- yes, as i mentioned, that 21 days added on, we need to fight against that and try to inject some reasoning into that. ..

what we have with the capacity right now and if some of these are much less treatment centers but a place to go to get more rehydration solution. some have a place to die out of circulation cannot infect other people. where we need to draw blood samples or before ours have a chain and electrolytes it's not that it can't be done so i don't mean to say that it can't be set up that we just need to be realistic about the challenges ahead of us. this is another photograph at a treatment center in sierra leone. i'm sorry, this one is a gimme. not really how you would want

this to be. we don't like to have the beds together. we would like separate rooms but this sort of place you may have read about where the nurses were going on strike and healthcare workers getting sick and dying in this area and we had at times the times we had to 70 patients with people -- with ebola. so again trying to do research into draw and draw blood and monitor this or that when you have this sort of setting of course is very difficult so we need to increase the capacity. it can be like this. this is much more ordered. this is in from the outbreak. it's from uganda and this is the sort of thing we would like but of course today we would end like to have them all together but sometimes that is the only choice we have. a lot has been discussed about the personal protective equipment and leaving the safety issues and what is the right

beside the matter what you use this is very cumbersome work to do. so if you use this as prescribed you can stay in for about an hour and a half until your temperatures get up to dangerous levels. this is closer to what would be advocated by the who. we recently had guidelines that just came out yesterday that you might be interested in looking up. there is the obama challenge to try to innovate into new things beyond that of regardless this isn't the sort of setting you can say let me go in and work for five hours at a time and take all the samples i want. it is cumbersome and stressful work and there are issues in place. then also in the laboratory side this is a setup by the european union so these exist in a couple

of different places. the cdc can european union, public health agency of canada. various places set up these libertarians but they are mobile and meant for diagnostic purposes and right now they have many samples coming in so not only is it the capacity of the treatment centers but the treatment of the laboratory as well so we also have the same situation where we need to think to the personnel who are going to be working in the laboratories and can be dedicated to the research and are there priorities between research and the routine public health diagnostics that need to be done. also just an example to monitor and take some of the data in the laboratory we were using this device some of you may be familiar with. it turns out this device doesn't really like the heat and humidity in the west africa so we had a difficult time using

this and most of the places. you can play with it and get it to work if you put it on a bed of ice but of course you know how many beds of ice defined relatively readily available when it isn't the is in the sort of thing that is routinely there and electricity and water is given. these things get set up and it's and others to get this together. we found what you put on the table top is better for this and not quite as sensitive to the and humidity and this and humidity and then the data collection and transfer is the whole point of doing research but when you are collecting data you have to have a way to get it outside of the ward so you can't just -- gone are the days years ago i used to throw that patient charts out the window, spray them with bleach and let the sunlight hits them for a while and move on but i don't think we can do that any more.

we have to have higher technical ways and this can be done using cellphone technology and tablets and electronic transfer and it's possible that there are many steps we need to go through and again you can see the gloves this person is wearing its not that easy to write this down in the heat and all the other things going on this is an example people are getting the information on the patient's and then they are just recounting it on defense to other people that can write it down so there are ways to do this. and then on the ethical consideration of course the approvals are not only in this country but probably more challenging in the countries that we need to work and. they do have pics committees but not necessarily ones that are used to sitting and expediting the things rapidly. that's being approached these

days because of what is going on. placebo were not placebo is a huge contentious issue trying to find the right talents of what is research we need to do and obviously talking about therapeutics and vaccines and what is the research we need to do to collect the information on the clinical trials that are done so we come out of this with solid data about the expectations across west africa that are much more in compassionate use. we had a meeting a month and a half ago now at the who and many representatives from west africa to figure out how we go forward with some of the use of the potential therapeutics and vaccines in icann told you all the people from west africa i think an afternoon or evening they got home from the meeting had a call from the minister of health and decide which one did you choose and is your suitcase

full like it did there today or will it come tomorrow so they aren't thinking so much clinical trial but where are the drugs to help people, that's an understandable way of thinking. then the out break response to the patient care and research are a balance that we would have to find. lots of logistics getting to the site. of course this takes a lot of vehicles and airplanes to get through the remote areas. this is using the bicycles that are using the surveillance and so that is one of the things although that isn't mentioned that we need to improve the surveillance and other areas that needs to be approached. but there's a strain on their resources because the vehicle is needed to surveillance but it's also needed to get your research staff around to do different things so those are the challenges and then in many of these places the physical security. you've read about this there

were some healthcare workers that were killed last month. i can tell you some stories from new guinea and sierra leone. everybody that's been on the site has a few of those stories. when we have sometimes a resistant population and one of the ideas that's frequently spread around about that resistance is that it was either created or introduced for people in authority from overseas from the foreigners to do research on people and now when we are doing research how does that feed into it and of course we will do ethical research but we have to be aware of the perception of that and that there are some issues that we have been struggling against and then what do you do if one of your research staff gets sick and you need a backup plan will they get cared for on site or to the united states there is a significant cost and implications to all of that.

we can't necessarily send people if you send a bunch of people to a battle zone then here and there somebody gets shot so you have to be ready for that. i do think that it can work about it's not the sort of thing as jim said earlier its not the sort of situation you want to say here is your patient with ebola you have two hours of training now go you have to set this up. and then i mentioned the society resistance and cultural barriers. language barriers first of all wide-area and sierra leone are anglophone although if you get into the rural areas and to some of your staff depending on their training it's very common that people speak much more of the local languages rather than english even though english is the national language of some of those countries so there are cultural and linguistic barriers to get over.

i think i did it all in 15 minutes or close to it. thank you very much. [applause] we have time for questions and discussions and to engage the panel. there are microphones in key locations. please come forward. i wanted to start with a question and i'm i am kind of inspired by a couple of the presentations. what it has to do with this for the purpose 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 and survive a under various conditions that doesn't

require laboratory facilities to run experiments? do people have any ideas about that, doctor peter's? >> there's a species of ebola that isn't pathogenic for humans and can be downgraded and in addition to that, his colleagues have produced a ebola virus by genetic engineering that lacks the genes to ward off which ebola has in quantity and that probably is not pathogenic although i can't imagine any board giving a provision to use it. >> other ideas about that?

>> there are various viruses that could potentially be used. you do always get into the question of you do those experiments and then say yes but does it react the same way as the real virus but that would be another idea. >> from the point of view of doing studies, we would like a surrogate that fluorescence. [laughter] >> some of the surrogates are used with bacteria which isn't appropriate at all in terms of size and other characteristics. it's been a part of the problem is that needs to be selected for the type of experiment you want to do. if you want to look at persistence on environmental major seas and how it interacts with bleach you may look at a totally different surrogate. if you want to look at thermal incineration you might look at a

different one. it is selecting the right to surrogate is difficult and it is not going to one fits all. >> to follow up on that, having some surrogate as it was pointed out, wearing the half mask is different from thinking about the question of what you're doing with the testing and/or trying to evaluate what the filtration effectiveness works or whether somebody that content in a the skin is a very different question so thinking through what question you are asking requires defining what you want in the surrogate. >> they are commercially

florescent and are not visible until they are hit with a uv light. that seems that would be very agile to training the people if they put on their gear and then they had this applied and after they got it off you could see where some of the breaks might occur. >> the first question at the microphone if that the microphone if you could please identify yourself and the microphone is a little bit high, isn't it. >> it's fine. >> thank you. i'm the safety health director for the afl-cio. thanks to everybody for being here and for your great presentations. in the last presentation it

brought it home in terms of the crisis being faced and i think one of the things that is really important as we are thinking about research in the same way that we are thinking about how to stop the virus we have to look first and foremost that africa for what are the research needs as well and one area that would be very helpful for us to focus on 527 healthcare workers have gotten sick in the 250 that have died due we have any more information on those workers, who they work with their occupations were, but the potential exposure is because it does seem that is going to be at the heart of the response and protecting those people that finding out as much as we can about the exposures and also as michael said go to the front line workers in africa and find out what do they need and what do they think the questions are

that have to be answered for them to do their job would be critical as we are going forward with some of the immediate needs that we need to identify. >> great quest. so looking at this, we tried to investigate this as attentively as we can with healthcare worker infections and in my time in africa when we had healthcare workers i've gone to those people as awkward as it is and say okay what happened, can you identify anything and it is extremely rare there is an event somebody could say i had applied to/in my eye. most people have no idea. they can say there's one small irregularity that happened here or there or one case for example he got all dressed up, went into the board and then have to go to the bathroom so he didn't recognize any breach of protocol that recognized he did things

very rapidly. we don't have an easy answer to that. again very few people have something discreet and we focus on the part of this that is most difficult although there is certainly the potential for infection in other parts of the process of the war and although it seems logical to us and hard to believe a lot of these healthcare workers still do hope delivered care on a private basis at their homes and other places so there is a potential for infection that is unrelated and to some of them are in the recognized transmission elsewhere. i don't think we are going to have the existing data inclusive evidence. >> two questions first for the doctor.

i appreciate your comments regarding the need for what i consider applied biosafety research for the contamination systems including others. but how do you develop the risk of the specimen justification and explanation to these on some of the technical nuances that we have in the sterilization and the reduction versus decontamination to the acceptable level etc. as folks grapple with the fear of the incinerators it and an envelope virus for example. to follow up, doctor peters how well developed are the systems less than ebola as a model in terms of pulling the work out of the biosafety?

>> the whole issue of the risk communication is a huge gap across the whole spectrum of everything especially on the waste management side they 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 that is a definite need for us to prove how we can take these scientific nuances and explain them to the not just the general public that this is largely an interdisciplinary effort and you may have the

jargon from one group of scientific experts who don't understand from another group of scientific experts goes beyond just talking to the public. >> can't agree more with out actually. doctor peters? >> the viruslike protocols can be made with ebola and look like ebola and are the same size. i don't know what it would cost to scale up. in terms of the risk communication, well first of all, the public understands about as much about the microbiology as they do about the integral. they are not taking it in a while. but i wouldn't know much beyond that. so, what i've usually done is taken to her three reporters who

seem to be interested in have some background and spend time educating them and trust their abilities in real speech. >> i should say there are several reporters in the room all of whom are above average. [laughter] stanek other comments? >> i wanted to ask so if this is going out to 700 people, let's say you are on one of the major news shows tonight and have to explain in terms of the risk communication challenge that we all have the differences between the 21 day integration tier code in a graph that says 42 days how would you explain that to the general public? >> that is the >> that is not a fair question.

i think that it clearly demonstrates that we can identify the vast majority but not all cases within 21 days. so, when we are talking about declaring a country free of disease, than twice that in 42 days as a criteria that has been used and i think that that into that intuitively, you can run but grass and you can see that there are no new cases. so it seems to me that additional safety precaution is there. >> one more response, yes. the roundabout of the 14 days it

looks like there was a small second peak. and i wonder if an overt reporter were to alert reporter were to ask you does that suggest that the .1 should be later and therefore the true doubling is to take care of unexpected and underrecognized outbreaks or is it the doubling its >> i think you need to keep in mind this is data in the field and you don't always know exactly when you were exposed. just as with the clinician that became infected themselves so i think there is going to inherently be using real data and variability and assumptions that we just have to take into

account we started to present some of the work we were able to accomplish in the human specimens and in terms of the environment and a little bit more for the group is what is the research concerning some of the understanding of the various fluids i've seen a blood sample and many have a viable for up to 30 days etc. in some comment about aerosols. >> so, the study that we did we just went around and took

convenient samples i think that visions for that were some very sick people who do. they the seamen of course is one that we know the virus persistence is there for a couple two or three months after words and the latest that we found a the viable virus was h. days after the onset of illness so it may be longer. we didn't necessarily have the fluids from people at every time point. what desperately needs to be done as a similar thing but much more prospective and so we are taking samples where we code on-the-fly. we really need to get in there into an isolation ward and say let's take samples from blood, urine, sweat and every sample that we can from day number one and then every day or every other day so that isn't

complicated and that would be very illustrative. much has been made about the virus and sweat but the only two studies that i know of where it has been found was one that we found it in a very sick patient and the postmortem studies founded in the glands but those are really sick people and since we can find it in those it is on the bowling ball or on the chair or the subway in new york which isn't necessarily true. it may not be completely illustrative of the things were under control.

much has been made about aerosols. it just depends upon how you view the data and i think it is very clear's people get infected from direct contact and bodily fluids but any study you're going to have 15% of the people and others are going to say they just didn't recognize the direct contact show me the data to back up their opinions is in there which is of course why we are all here. one of the studies in the '90s showed about 20% of ebola patients cough. there's at least one case report

of a likely airborne transmission if one of the lessons we still don't know whether it is the geometry tract or the liquidity of breeding across membranes is a reasonable question that warren's protection. >> you sort of dropped this interesting concept of these many transmissions that have occurred with 14,000 patients into the viral behavior. did i misinterpret you? the >> my point is that we don't

know. this virus has been human to human transmission. we do know that the virus is adapted. of those are scientific facts. we don't have the detailed observations that would allow us to associate any genetic change that may or may not have happened because we don't have occurred and virus information on themselves and we don't have the detailed epidemiological background to put the observations in the real world with the molecular analysis house we just don't know. >> we are going to move to the next question. ..