[inaudible conversations] >> we will go ahead and get started.

welcome today to the briefing breakfast i lead africa healthcare practice here in washington d.c. we have a continued partnership to help advance knowledge of key policy issues today's topic is that of pandemics one of the challenges we face is preparedness for the pandemic outbreak of infectious disease and no one better to speak to the threat and the challenges and what the future may hold than our speaker today the director of the national institute for allergy and infectious diseases. thank you for being here is a b in interesting discussion and we have a lot to learn so now i will turn it over to the president and ceo for the alliance of policy.

>> good morning thank you for being here and i am president and ceo of the alliance of northern policy and if you are not familiar we are a nonpartisan organization dedicated to expanding knowledge of health policy issues. also for the support and partnership in their series asking questions for reporters on key policy issues and our speaker today doctor felt she for being here today. and with a 1918 flu pandemic pandemic killed more than 50 people locally and 100 years later contending with the rest of the influence outbreak as well as others while making headlines for the severity with a pandemic flu outbreak

so we are pleased to have t5 as well as a director from the national institute of health and health policy organization we don't normally get these rock stars that he barely needs any introduction overseeing and extensive research program and dr. fauci is a key advisor to the white house and one of the principal architects of the urgency plan for aids relief aids relief happy and dr. fauci will give some background and we can get

into some q and a and discussion. >> it is a pleasure to be here this morning and as sarah mentioned i will run through some background and leave it open for some discussion anything else you would like to discuss. . . . . it will become obvious to you what i think that is what i'm going to show you hopefully with convince you of that. so as you look at the artificial separation of seasonal and pandemic influenza is it's

interesting when we talk about influenza it's highly predictable and highly unpredictable. the highly predictable as we will have an influenza outbreak for certain every winter in the northern hemisphere in the southern hemisphere in the winter. it occurs naturally and since seasonal flu change very little but change from season to season there's always a degree of residual background immunity and the population and that really is critical to why the seasonal flu isn't a pandemic every year. let's take a look at the numbers and the unappreciated mortality with influenza seasonally. in the united states if you look at the left hand side of the slide it's between 12 and 56,000 death cases per year up to 700,000 and anywhere from nine

to 35 million cases that you see throughout the year. globally on the right-hand side the economic cost is substantial. it's about 10 billion in direct medical costs and indirect costs about 87 billion per year. the thing that sometimes isn't complacency with the flu since it at cures every year they came into the mortality and morbidity is really quite substantial and we are getting to that in a bit. this is a very telling slide because focus on the red line that started off with the beginning of the flu season and worked its way up. it was paralleling the purple line which was 2014/the teen and prior to this season 2014/15 was the worst year we have had in about a decade. when i say worst the cdc has

only been carefully quantitated with metrics and metrics are the number of hospitalizations 100,000, number pediatric deaths which they record in real-time as opposed to total deaths which is an extrapolation after-the-fact. look what happens at this particular point. instead of turning around in 2014/15 this is when we knew we were in serious trouble because it started to do this. several weeks later did it peak and now it's actually on its way down. the bottom line is when it got to h3n2 this season is unquestionably one of the worst if not the worst and we don't like to declare it until after the season and we look at all the numbers but this was a really bad here. that is jolted us into telling

you something that i'm going to discuss in a few moments. in contrast to pandemic flu is completely unpredictable. people used to see it cycles. you never have any idea when there is going to be at pandemic flu. what is pandemic mean? pandemic means widespread number one. number two it's a new virus. new in the sense that the population in general has never experienced this particular virus as opposed to the seasonal flu or maybe you didn't see the same h3n2 last year but the want this year is very similar in their cross-reactivity. with a pandemic almost no one in the population has had any prior except maybe very old people who may have experienced something 40 or 50 years ago. as you heard in 1918, they

called it the spanish flu force strange reason which we can discuss later but it had nothing to do with spain. spain was an innocent bystander. there were 52-- million deaths. the reason that's important because in 1918 the population was one third of this today. the important thing is for a single season this is the most cataclysmic public health event in the history of our civilization. if you look at key militant deaths of smallpox and cumulative deaths of measles there were a lot more deaths than this but to have it happen in one season and a half we have never seen anything like that which tells you of the threat and the importance of respiratory borne diseases that have the capability of spreading readily but also have high mark of the deante mortality so to

get back to what i started off saying we think about the pandemic flu interconnected with each other. what we do and respond to influenza? as some of you know we do basic research openly to develop countermeasures board diagnostic therapeutic vaccines. vaccines are the most important medical tool. obviously there are public health tools, washing your hands, social distancing, getting out of crowds when you have a vague outbreak but medical mediated tools means clearly the most important. i have three points that i jokingly refer to as-- because what gets people concerned about my discontent if you want to call it that with where we are right now is influenza. i'm going to go through each of these individually. starting off with current

influenza vaccines are not consistently effective. before we even go one second further i have to give you my statement so that i don't get into trouble. it's always better to get vaccinated them not to get vaccinated. if you have a 10%, 20%, 30% effective vaccine could still better to get vaccinated than then to not get vaccinated so having put that aside and let's take a look at the numbers. if you look at the efficacy of the effectiveness of vaccines over the last several years at best the influenza vaccine is 60% effective. on a really bad year when there's a mismatch it's about 10% effective. why is that disturbing to me? because when you are dealing with vaccines historically take a look at some of the big killers. measles is 97% effective.

polo is about 95% effective and in yellow fever is 99% effective yet the best we can do with influenza is 60% and at worst 10%. now the next thing that bothers me. pandemic stuart kerr and the response after-the-fact is usually not effective and that relates to how we get vaccines for the flu which we will get into in a moment. it's really time honored on the one hand and antiquated on the other hand and i will explain what i mean by that. this is the swine flu of 2009, the h1n1 and what did we get wrong through no fault of our own i believe? in 2009 in march just like we have here today in march so right now you saw the current

going down print something unusual happened in 2009. as the current was going down in california and mexico we started to see people getting sick with an influenza that was really strange because no one has seen the type and they were asking what is that? anybody focusing on china and the far east for the next pandemic we were seeing in california and mexico infections of humans with a brand-new virus that we hadn't seen before. that was one odd thing. the second odd thing is that it was march when the flu season was supposed to be over. the bad news is we have a problem with the new virus and the good news is that we have time to make the vaccine because as we are getting into the

summer it's likely the virus will cause a pandemic the following winter so what did we do? he found out the next month in april didn't stay in california and mexico. why is that? because respiratory borne viruses with the way the-- we travel never stay in one place. so this was highly predictable. what happened? we went before the appropriations subcommittee and we said it may take six months or so to make a vaccine. you have to grow the virus in an egg to make the vaccine so april, may, june, july, august, september, october. we will have that are not sober. we know that influenza generally doesn't start happening until november, december and into

january. however when the children came back to school, what happened? we had an outbreak in september instead of in january so this is the slide that we call the embarrassing slide yakusa blueline is where the red line should is where the blue line should be so the blue line is the% of illnesses that started in september and peaked in october just about the time the vaccine was ready which means that the vaccine although we made it reasonably quickly was still too late for the pandemic so that's what i'm mean when i say pandemics occur and even under the best circumstances with our technologies that we have today which will be the big argument and why i'm going to push for why we should change our technology. finally we continue to chafe at

the potential pandemic outbreaks. what happened you may remember started off in 1997 and then in 2003 and then in 2005 the famous age five and one, the bird flu that was the bird virus jumping to humans. he did and efficiently spread from humans to humans that was a 35 to 40% mortality when it did -- did get into the human so it was really needed to make a vaccine. we spent hundreds of millions of dollars in fact billions of dollars to prepare ourselves for a pandemic and then we found out and by the way age five and one never turned into a pandemic. we stockpiled vaccine. still stuck but we don't have a pandemic and then we realized the most recent was h. seven and nine which is still smoldering around. we made a vaccine for it and you

can see in 2013 at the far left of the slide we said this is another word for lubitz jumping from chickens to humans and killing humans. isn't spreading efficiently from human-to-human but we can't take a chance. we have got to make another vaccine so we invested another few hundred million dollars to make a vaccine against the h. seven and nine and everything was fine. we had outbreak in 2014 to teen comes 16 what happened in 2017? the virus that emerged then was so different in a very small way that it wasn't protected by the vaccine made in 2013 which means what? so that's what i call chasing

after a pandemic. you have to do it as you can't ignore it. so quickly let's get into some of the challenges. there too old challenges that overlap. the first is how we produce a vaccine. we have eight-day vaccines which means you have to grow the virus in the egg and it usually takes about six months. there are many steps associated with that. we made an improvement by saying let's go from the egg to the cell which was a modest improvement but you still have to grow the virus which then tells us maybe we should do something that is much more predictable and that is technology. this is the flow sheet of what i was describing a moment ago that you make a decision in february or march in deciding what you were going to do. right now we have already made a decision about what's going to

go into the vaccine for next season so now we are wrapping up for that virus so the horses out of the four-- barn. for the six or seven months that it takes to ultimately have it ready things can happen. what could happen? antigen mismatch is a well-known cause of decreased vaccine effectiveness. in other words we make a decision in february or march, we start making the vaccine but the viruses out there circulating and it may mutate by the time you have a vaccine ready. the virus is a little bit different and that's exactly what happened in 2014 and 2015. we made the right choice in what virus wanted to put into the vaccine but the virus didn't cooperate. it changed as we were making the vaccine. what about the years for the

match was a good one where you made a decision and he decided on the virus and the virus doesn't change. what can possibly go wrong? in 2016 and 2017 something did go wrong. the very process of growing the virus in the egg fooled us. what do we mean by fooled us? you take the right virus and you put it in the egg to grow in order to grow well in the egg it has to adapt itself to egg grow so it mutates. it's understandable so can grow well it eggs. the bad news is it happens to mutate as that part of the molecule produces a protective response of this is what is called an accidental mismatch and whatever you want to call it the virus in the environment didn't change. the virus that went into the

eggs changed, another stumbling block which is the reason why all though we have gone from egg race to sell based the ultimate goal is to go do dna technology we can sequence the virus pull out the gene you are interested in and put it in the vaccine. these are vaccine technologies that are now gradually and hopefully completely replacing needing to grow the virus. viral factor, nanoparticles, i don't want to go into great detail but these are all things that don't require growing the virus. i wrote an article in january and we titled it chasing seasonal influenza for the

universal flu vaccine. what do we mean by universal flu vaccine? he held the meeting in june in maryland and we reported on the proceedings of the meeting. we just recently published on line in our strategic plan in research agenda for developing a universal flu vaccine. their number of targets for flu vaccines. the common denominator is you walked the body to make a response against the part of the virus that doesn't change. we know there's a part of the virus that always trips or changes from season to season. we want to make a vaccine that uses a response as part of the virus that doesn't change. these are several of the targets the nuclear protein and just for the sake of example and this

isn't the only one i'm going to pick out the hemoagglutinin molecule b. the hemoagglutinin molecule has got what we called ahead in the stem. if you look at it when i don't have the pictures and fir told the audience to think of a block with the head or a stock or a mushroom. there's a big difference between those two components. the head which is the one we have been concentrating on directed to make an immune response those little red dots are points of mutation so the head mutates a lot from season to season and really changes when you get a pandemic. if you make a response to the head and you happen to hit it right it good to go by from season to season back in change which is exact to the reason why

each season we ask you to get a flu shot every year. we don't want you to get at measles vaccine every year we don't ask you to get a polio vaccine every year but wait ask you to get a flu vaccine every year. one of the strategies is to look at the stem. that doesn't change from season to season. very few irritations so one of the many strategies that would produce a response and one of the ways you do that as an example is by him molecular biological techniques, taking the gene out making it expressed hemoagglutinin and removing the head stabilizing the stem and putting it on its nanoparticles or a virus like particle or putting in the factor and have the body make a response against that particular component.

there are number of therapeutics for influenza, unfortunately most of the viruses now are a and the ones that are left are the ones known as tamiflu and drama fear. right now for example there is a new drug that has been developed by a japanese company that works by a different mechanism. i can't help, i show this one i want to get more money for basic research. i will tell you anyway that this is a drug that was developed in japan that is against a different part of the virus cycle. the way they got to that was many years ago and an r. h. investigation crew determined that a purely basic science a

company came along and made it drug that was a promising new drug, just another shout out to biomedical research. also monoclonal bodies that are protected from her or pandith standpoint as well as a therapeutic standpoint. let me stop there and use that as throwing it out for discussion. it reminds us that emerging infections have been around forever. they are here now and they have always been around and that's the reason they are such a perpetual challenge and if there ever was one that was the mother of all perpetual challenges it's certainly influenza. let me stop there and i'm happy to answer any questions. >> thank you dr. shulkin.

doctors fauci. >> the outbreak happened when all the kids went back to school in august than july. i happened to know that the chain of camps had doctors and nurses on a public health call comparing notes every day. the reason i know this is because my kid was one of the kids who got sick. did you all go back and make contact with these camps that have been working with the disease all summer in september and october? >> that's not what we do. we do the research. i'm not sure they did because when it started to occur in september we were saying oh my goodness we were hoping this would happen but it happened. i can't speak for what the epidemiologist did.

>> that i could ask a follow-up question which is knute briefly describes the role of knight at your agency and cdc and other federal federal agencies that work on these? >> that's, macbeth but totally reasonable question. the overriding umbrella agency the department of health and human services so within the department you have the nih the cdc the fda the secretary for preparedness and response in another component of hhs. when you're thinking about pandemic repaired and is the cdc aren't the disease detector. they monitor disease and detect disease predicts disease and follow disease. that's way they have they eif which is a famous group that

goes out when there is ebola or influence it. the nih because we are the infectious disease institute our job is to use basic and clinical research to understand the disease, described the disease and develop countermeasures for the disease or do the research that allows pharmaceutical companies to ultimately make the countermeasure lack of basic research on vaccines and basic research on therapeutics and diagnostics and then to collaborate with the pharmaceutical companies to do that. the fda is the regulatory institute. it's really quite synergistic. we have worked work very closely with the cdc because whenever there's an outbreak that's the reason during ebola and zika you saw tom friedman and i talking about it. >> when you show those maps of

the outbreaks in the models that the cdc created? >> yeah. >> thank you. >> you talk about moving away from the tech base but how long do you think, how long will we do this particularly what do you think it's save-- gets you there? >> that's a good question and it's a combination of the science proving that the other methods work. if you look this year we have one candidate using molecular biological techniques and that is the flu block vaccine. only about 3% of all the vaccine doses that were administered this year in this country were of that type. the overwhelming majority were

egg-based and a lesser amount of cell-based. the first step in answering your question is have a few platforms that prove that they are as good or better than the egg-based and i think it won't do that much of a rovlin. there's no reason why they should not a as good or better. the second is can you scale that up and be able to make doses for 150 million plus people. although there are many weaknesses in egg-based there are massive factories that make millions and millions of doses. once we do that then it's going to be an interesting little dance that's going to occur and how we convince the companies to pull out from what they have been doing in a time honored trial over years that they felt comfortable with and another

thing that will require a different kind of a plan, different kind of production. the latter of the three steps is probably the most problematic because it's sometimes difficult to get companies that have investment in doing it a certain way that sort of works even though you think you can do better. that's the problem but the first step for us is to prove these different platforms work well. >> why was this year's flu so bad question mark or perspective why did we have such a spike in cases? >> two reasons. one is there was an dominant h3n2 strain which right from the get-go is a bad actor and whenever you talk about strains in a situation where you have complications and when you have more hospitalizations in more morbidity and more mortality

it's a bad actor. that's the first thing. the second thing is if you look now at the statistics that have come out from the cdc overall all the vaccines of all the age groups was 30% effective. specifically for h3n2 it was only 25% effective. if you have a bad act your virus to begin with a vaccine that is only 25% of overall then you've got a real problem and that's exactly what we had. one reason or other it is complicated, children from six months to eight years did better their effectiveness overall was 59% against h3n2 was nifty 1% so combination of two things, a bad virus and the vaccine not being very effective.

>> maybe just go back to ebola and seek a recently. if you can go back and update where are we now in terms of vaccines for people with zika and are we making progress on back? ..

>> so if there is an outbreak next season you will get the efficacy statement. if there is no outbreak, we can use that with the safety data with the animal data that proves it works in animals then we work with the fda you never want to jump ahead of them because they need to make their own decision but at least they are willing to discuss the possibility of an accelerated approval based on the safety of animal data. we are looking into that. you don't read about that in the newspapers because there is no zika virus right now but in regard to ibo law we had one vaccine showed to be

effective in the trial not designed to show this right now there is a trial going on in west africa comparing the vaccine with a virus and that is ongoing accumulating safety data so the short answer is we are on the road to a vaccine even i don't hear about it because we are not in the middle of the outbreak. >> i was interested in hearing about access and affordability in terms of vaccines and what

about the vaccine for ebola or zika and additionally who is targeted? >> and are you working with an opioid vaccine or a fentanyl vaccine and then who would you target for that vaccine or to the certain populations or how they could afford access. >> you have gone beyond my memory scope to remember all your questions. >> that is interesting right now because we have been going

back and forth with proposals with the office of the director about collaborating in a real way on those aspects of vaccines for opioids in the answer is yes. second it depends on the epidemiology of who you would vaccinate and certainly people who are at risk to develop addictions you would want to do that. but it is fairly complicated. so with access and cost i cannot comment i can for zika and ebola but we are not there yet to think about that. with regard to zika and ebola b have a policy that we have a

company the federal funds cdc if we get involved in any aspect of the vaccine, we make sure we have an arrangement with the company it can be made available in a reasonable way. so just in west africa and also to have agencies like others and to be concerned to have a vaccine and those are the arrangements that can be made. and the ethical issue to make

a vaccine food you give it to? that is one of the reasons why we have such a problem to make vaccine such as a childhood vaccine everybody gets measles and mumps but that situation with the gut it will depend on the epidemiology right now you would vaccinate no one for zika but if you are in a situation with a chronic outbreak certainly would want to vaccinate children those are the ones you want to protect talk about south

america i wouldn't do it now but to have a low level i would. the other is travel related. and for those to go to south america. and then to go to an area like that but you would vaccinate everybody in florida and texas it just isn't worth it to have 200 cases and 60 million people the issue isn't worth it. >> what is more likely as far

as improving the efficacy? >> and then get back to the slide with those arrows that connected each other we need to make better seasonal to get the right match of the 90% efficacy. so that realm alone to get better. with the molecule and closely related to that is the issue of universal and to make your seasonal vaccine with that

response that part of the virus and with that universal flu vaccine. actually working your way because one of the ways to make it better is to make it that the response is the part of the difference not shifting from season to season. and then to develop a group of a universal flu vaccine. >> in addition to the efficacy itself so it is always better to get nothing but.

>> you mean the number of people? absolutely. there is a lot of mathematical formulas that show if you have a certain percentage of the population vaccinated is the transmissibility from one to another you can get that degree of unity to compound in a positive way the effectiveness of the vaccinate 150 people in the united states so we are nowhere we should be with universal vaccinations so the more we do that we get better protection.

>> congress right now is considering the authorization. >> all hazards of preparedness? maybe there is a discussion. >> this is much more towards in the department with that diaspora without advanced development as the research component but clearly it is involved to have that

comprehensive comparing is to get that reauthorization but we don't comment on pending legislation so working on gene editing. >> we have a number of collaborations a different kind of a mandate so we do

more that is long-range so what daca did as their big stuff and then we take some of that quick fix for the influence. >> so with access and looking ahead with the flu vaccine are you confident this will continue to be affordable like our current vaccines?

that means more effective things that could be more offensive and a blockbuster as a universal flu vaccine but in some cases if that is appropriate? >> you are sort of asking two separate questions. but the whole issue of exclusive licensure when you hear about exclusive licenses it is almost a knee-jerk response but has gouged the public. but generally that is not the case because when you deal with the development of the countermeasure there isn't a great incentive for companies to get involved.

vaccine work is not one of the most popular areas for pharmaceutical companies which is the reason why you only have a handful involved in vaccine research. even though exclusive license feels like it is risky getting out of control but often that is the only way a company will make a financial risk to even get involved with vaccine development. i have not seen a correlation at all between the exclusive licensing company and the company taking advantage of the exorbitant price in the area of vaccines. i cannot speak to others but i have not seen that with vaccines. i haven't seen vaccines that were exorbitantly expensive because of exclusive licensure.

>> it is a good question but if you are more effective you don't know how effective it is when we make a discovery we do that licensing before and we know the efficacy and the trial but we don't know how effective in the community. >> so right around value -based care and pharmaceutical companies so does that model make any sense with vaccines and what doesn't look like if

not. >> what i think is irrelevant because i don't get involved. i like to give you my opinion of value -based but since i am a public figure my opinion could be taken out of context i will tell you about it over a beer but not here. [laughter] >> i have a question about the timeline she had anything when we could get universal flu vaccine or evil? >> you like multiple questions. [laughter] it is much less exact when you

talk about universal flu vaccine than zika virus or ebola because there is still a lot of discovery left in developing a universal flu vaccine whereas we already have a solid candidate for zika and a couple for ebola. so time frame right -- wise maybe two or three years but you cannot say that with universal flu vaccine because when you are dealing with the necessity of discovery before you can actually make a product and sense that is unknown when you can get it, you don't know if you will get the answer to the discovery part but having said that it

will not be today we don't have a flu vaccine in tomorrow we will. it will be a process that will be improvements on various versions so describing that 1.0. that means you make vaccine that will protect against the subtle changes that will occur and that i would call universal flu vaccine 1.0 it isn't universal but it is sort of four age three and two that could take five years of trial to get there then 2.0 not against all the age three and two but each one and one and a couple of the chickens then the next level is a number of

years so when do you think we will get a universal flu vaccine is when you think we will get the first version that is better than just the single seasonal flu? but the home run is many years out maybe the first version is about five years out. >> so with that iteration there could be years that people get more than one? >> they can do that right now. you were vaccinated against h1 and one maybe 1d or 2d.

so we are already vaccinating people with more than one vaccine so what i can't imagine is that component in the year 2022 or 2023 is universal but not yet to h1 and one. >> so that would not necessarily be annual? >> no no no i'm glad you asked the question because it is called breath and durability it is two different concepts and that protection only last for one year but then the strength goes down. her once you get the breath

and work on durability so for example like tetanus we recommend every ten years because that durability getting tier eight, nine, ten so is it really good still? yes because the strength of the response that is left. so i hope i'm pretty sure we can get away from the yearly flu vaccine but maybe every ten years. but i doubt very seriously if it is one or two vaccines at one year older four years old then you are done it would be intermittent.

[inaudible] and often misinterpreted and to prove that that vaccine works and it is a gap of several years so with zika vaccine tested if we get an outbreak and to show that is

the efficacy signal so maybe three years from now if that vaccine does or does not work? >> and we still don't know. >> but that there were 3 billion more nih? but as you know. >> yes. [laughter] or if there is an earmark to spend this much on that with that fundamental basic

research to get a promotion like the other institution with that five or 6% for the influenza vaccine and to develop an universal flu vaccine but what about

congress. >> i'm sure you know how the appropriations process works because in 2018 the presidents budget also calls for a sharp cut in the nih but congress budget supersedes that so it is an interesting thing what is going on with the president asking for a cut not only is the congress not cutting but increasing and ultimately that is signed by the president. so in 2019 it does call for a cut. >> there are is a lot of challenges there.

>> so we have put out a couple years ago a strategic plan for antimicrobial resistance goes contributing the pipeline of new drugs to modulate the immune system by vaccination or a variety of other ways to prevent or ameliorate to be worried about resistance or to manipulate microbial communities not going up against the toxin itself and a variety of others and with that post and pathogens? but that goes to developing new drugs with the repurposed

seeing of old drugs that have not been used in a long while that is effective like bacteria and others we have a whole strategic plan and agenda. >> i thought there might be some sort of miracle? >> i wouldn't call it a miracle but yes. is there work at looking at commonalities of bacteria to have a molecule that can inhibit those classes of bacteria? yes. we don't have that yet but we are working on that. it is not broad bactrim but mostly in a class of bacteria that those molecules can block

any -- everything was in the class. >> so to do those missions and there are a lot of areas that the community is working on so how much are you working? i never work for many. put that on the record but to give in on facetious answer to the question so traditionally with my institute to historically work very closely with the department of defense. some really cogent examples

the hiv vaccine trial in thailand was a close collaboration with the military hiv program the work on the virus started at the walter reed army institute of research. malaria is with the department of insulin -- defense. . . . .

>> when you talk about preparing for the unknown, different groups embrace one or both of these. the first is to try to anticipate what that new thing is going to be, and preemptively make a vaccine or a therapeutic or diagnostic. they have picked three -- they want to go after that. but the other way which they're also doing, but that we concentrate more on, is what we call developing and perfecting platform technology. in other words, vaccine platforms that are not against pathogen x but that can be readily adapted to pathogen x. if you perfect the dna or mrna

platform technology and you know how to use it, the fda is comfortable with is, you know it is -- its false and advantages and then disease x comes along, you sequence what you can do in a day, pull out the gene of whatever this protein, and insert it into the platform and you have saved six months. son stead of guessing which pathogen it's going to be, you perfect your response to pathogen and that's what we are doing aggressively now. >> let me ask you. you have spent your whole career fighting infectious diveses. -- diseases. what kind of advice would you have for people who are entering this field, who want to work in the field?

>> well, again, i obviously have a personal prejudice because i have shown it, it is my career, but first of all, science itself and particularly biomedical signs, has to be up one of the most exciting things you can do. so for young people interested in getting into it, i would just suggest and encourage them to just follow that desire, because infectious defense -- there is certain characteristic that are exciting in general but that fit in with my personality profile. it's something that is acued, you can do something about. it's serious, it kills people and you can prevent it and -- their diseases that is truly

global it's infectious diseases so my advice or encouragement -- i want say advice because that's a presumption but the to just confirm that the field of infectious diseases, particularly the field of emerging and reemerging infectious diseasees, has to be one of the most exciting things. enthough it was enormously stress -- >> all this white hair i got from ebola and zika. when you deal with a formidable foe in the form of inheck sunday diseases that has amazingly potential impact in a negative or positive way, you can do something. so i encourage people if they're thickening about this to give it serious consideration. >> we have -- go ahead. >> thank you for your presentation. i was wondering, you talk about the diseases that spread

naturally, moving through the -- but what about terrorism or man-made diseases that affect people? how does naid prepare for that our preparedness for deliberate release of microbes is very, very much incorporated into our approach toward naturally occurring microbes. it really is the same thing, the same platforms we talk about, the same surveillance, the same ability to develop countermeasures, the same collaboration with the cdc and others, it really fall -- i often say and will say it here, that to me the worst bioterrorist is nature because if you look at what nature has done to us compared to bioterror, it's like not even

close. >> okay. last question. >> [inaudible] hiv and infection and the increase because of the opioid epidemic and is nih doing anything in terms of education, awareness, how things are pushed, and any interventions that could help curb the increase we're seeing in hiv infection because of opioids. >> yeah. we are -- we work closely withna iida in our area of hiv-aids that relates to injection drug user. n aye ida has the lead but clearly the kind of preventions of infection with hiv in people

who are exposed because of the use of drugs that started off with opioid addiction, is very clearly things we do. we don't primarily do opioid work, but our work with hiv certainly overlaps in the area of prevention of injection drug use. >> aside from the opioid epidemic, which is huge. would you have a comment on the trajectory of hiv? we head made huge strides in treatment. >> well, hiv, i have spent the last 36-1/2 years work on if hiv. if you look at the medical advances, particularly in the irene practice of treatment, it's not -- arena of treatment, it's breathtaking from the standpoint of dish still see hiv infected individuals but when he first started seeing them in the summer of 1981, the median survival of people who would come in with advanced disease

was between eight and 15 months, which means that 50% over the patients would be dead in a year, and maybe 98% of them would be dead in two or three years. as the years went by and he we developed first single drugs and now combinations of drugs, which are there multiple combinations of three or four drugs in a single pill, if someone comes into the same clinic i saw them in 1981, who, let say, 25-year-old person recently infected and i put them on antiviral drug combination, doing actuarial curves, i could predict if they take their met sane they'll live an additional 50 muss. >> one of the most important medical advances in memory, something as dramatic as that. so the science has been fantastic. what we have right now is an interesting situation where we have -- if you put vaccines

aside, which the vaccines would be the nail in the coffin of hiv, but even apart from vaccine, if you look at what we have now, we have more of an implementation gap than we do of a scientific gap. so there are formulas to show that since we know that if you treat someone with hiv infection, and you bring their level of vies through below the detectable level it's on impossible for that person to transmit the virus to somebody else. if you give someone who is at risk, proexposure forever lack -- prove pfaff fix -- if you theoretically could identify everybody in the country, or the world, but let's just take the country -- put them on earn viral therapy and bring it to below detectable level, by

definition you would end the hiv epidemic so even in the absence of a vaccine, you can end the epidemic, but theoretically is a far cry from reality because of all the difficulties with healthcare delivery and healthcare systems. but we're at the very interesting point in the epidemic where we already have the tools to have a much greater impact than we are having, and one of the greatest things our country has ever done has been the law when george w. bush created the program because right now there are 13 million lives have been saved blame started by a president of the united states. that is very impressive. >> well, i think on that inspirational note we clearly have a lot of work to do but have made great strides. thank you for joining us tonight. i feel like -- i want to thank them for their partnership in

this series. thank you all for coming. and we hope you'll join us on april 26th for the next briefing, which we will get into some of the more in-depth issues surrounding prescription drug pricing and affordability and innovation. if you have a minute to fill out your blue evaluation form for our own quality data purposes, we would appreciate that. again, thank you, doctors. >> you're welcome. thank you. [applause] [inaudible conversations]

>> monday on landmark cases, a challenge of the law banning birth control. the supreme court ruled the statute to be unconstitutional and established the right to privacy that is still evolving today. our guests are helen, a law professor at george mason university's antonin scalia lawsuit, and rachel, law professor at temple unit. joint the conversation. our #landmark cases and follow us at c-span and we have resources on the web site, a link to national constitution center's interactive constitution and the landmark cases podcast at c-span.org/landmark cases. >> next a discussion about school shootings with opening

remarks by the commissioner of the kentucky department of education, steven prewitt. on his experience with the school shooting in his state: he emfa identifieses the important of prereigns and crisis management and the aftermath of a tragedy. >> eye stephen prewitt, commissioner of okaying for the commonwealth of kentucky and it's pleasure to complete you. not to the most uplifting part of the program but our most personality. this year we have had major instances of radical tragedy and radical crisis we have dealt with across several of our states. in kentucky, we had a shooting on january 23rd, and of course we have been discussing the horrible shooting that happened in parkland, florida.

so, i'd like to start this morning with us just taking a moment of silence and acknowledgment of the students, the educators, that lost their lives, both physically and through the trauma of something that has changed their lives forever. so if you would just join me for a moment in a moment of silence. thank you. on january 23, the worst day of my professional life. january 24th through the 27th changed how i will look at my job forever. and that may sound a little

weird, but i'm going to share with you at bit about what happened in kentucky and what happened to me personally. i studied health ed on january 23rd and the phone rang. normally i'm always thrilled when my phone rings in the middle of health ed, forcing me to get up but we were in the middle of a bill so i hit ignore. the phone rang again which is signal you need to answer that. i stepped out and i took the call and few we had had a shooting in benton, kentucky, in marshall county. i went back over to the office, and we waited for news of what happened. of course, you can imagine media descend, all of that. i made the choice to not go down to marshall county because i felt it would be more of a

hassle for the people there than not, so i stayed in frankfurt, and decided i would good down the next day. i took with me my chief academic officer, who had been a principal, who had dealt with crisis before, and i shared this with the chiefs this morning. what i think is probably one of the best policy decisions i've made as chief was i hired a person to marshal and coordinate work with our counselors across the state. so, i told them, we're going to go down, do not bring the traditional things that katy wears in these situations or into schools. don't wear business suits and ties. bring your jeans and your sweatshirt. because we went to work. and i'm going to share with you at bit about what i learned with that, and hopefully encourage to

us think about this a little differently. what i went down there to do was not to go down there to be a chief. went down there because there were people who needed to work on focusing on their kids, and they needed somebody to do something, the stuff they didn't need to be doing. so i went down in any sweatshirt and jeans, we moved book bags. we collected them, moved them to one place for the state police to do a review and ten we moved them to a place for them to be pick up i made a run to walmart to pick up paper products to feed the teacher. we met with counselors and died the stuff that needs to be done grunt-wise. we did it without media because that was not a media op for us. i had one media outlook that ring niced me. oh, can we -- no, you can't. we're not here for those

reasons. and we go in and on that wednesday, when we first got there they weren't real sure what to do with us. they said can you hold on? i shade -- said sure. so we sat outside the superintendent's office. we talked later and incredible strength in trent lovett. nod only had he dealt with this tragedy, it wasn't too long ago he dealt with his own family tragedy of losing a daughter. a daughter sitting in the cafeteria during the shooting of this incident. he actually had to answer the phone of one of the students who died because he was friends with the dad. they go to church together. he had to answer that phone the next day and tell the dad it was bad and he needed to get there. they asked to us go meet with the counselors. four high school counselors for

1500 kids. those four counselors were jennifer bonham, jennifer jackson, jill boon, and cassandra newsome. i share those name with you because in a minute i'll tell you what courage looks like. so we've got there and we begin -- asked to us meet with them and then we sat and worked through a plan for six hours. we have spent a lot of time over the last few weeks since parkland, talking about prevention, and that certainly is something we need to be talking about. but, friends, what i'll tell you today is i learned in those four days, i there's some things even more important than that. i'm not going to be here today to talk to you about gun control or talk about those political things. i'll talk about our responsibility as chiefs and as

state education agents. we sat with these folk is didn't know what to expect. if we would have four people with deer in the headlight looks. for those who don't have deer in your state, turn to somebody and ask what that means. they had an incredible plan. they had a plan that set for three stages of grief counseling stage one, seemed to be managing approximate pretty well, all the way through to stage the for students who witnessed the sheet organize had friends who died in the shooting. an area to counselor parents which i thought was a brilliant thing. because as we brought kids back in on that friday, parents came with their kids. there was a separate area for giving counseling to the adults in the building. to the teachers.

the administrators. four counselors. for 1500 kids. and at least that many parents. so we sat there, and they had this great plan, and i said, how will you going to pull this off? i'll tell you what is sort of funny, i walked into the room, and my counselor coordinator, who has made a huge impact in the state think saw her and, oh, robin, you're here. and she introduced amanda and said you know who this is,. we didn't expect you. they were so happy to see robin. was like issue'll take being the second bill with that every day. they said, but so we're in the conversation they said, we don't really know how we'll pull this

off. so we had spent a lot of time in kentucky -- we have a center for school safety in kentucky that does a great job of helping evaluate and work on prevention, but what we didn't have, and i think still we're working four, is what do you do after? in this process i learned that crisis prevention is huge. crisis management is a different story. and even a further different story is crisis resolution. so, i sat there and they said, well, we could use a few more people how many you think you need? she said, do you think you can find us ten? i said for 1500 kids. really? what about 15. made fuel phone calls and we had 31 people ready do show up by

1:00 the next day. we sat and met until 10:00 that night, and having conversations that i had never thought about having to have. where willout allow kids to put the memorial? what will the memorial look like? what will you do if someone puts the shooter's name on the memorial? see in kentucky, this wasn't the kid that sat by himself in the cafeteria. this was a kid in the pep ban, that by all outward signs didn't show this was something that could really be an occurrence. we had to have really hard conversations about how to manage that. and then resolution. i sat there on friday morning, with kids came back into the school, and some of them -- all of them scared. all of them nervous.

parents, scared to death. they walked in and hugged kentucky state policeman they had never met before and thanked them for being there walked up to a principal who had such an incredible influence on this school, the kids were asking how she was doing. how was she managing? and i saw a child that we helped get into the counseling, saying that stood four feet from the shooter. and saw from that perspective her friends be shot and was so scared and so fearful, she couldn't muster the ability to even hit the ground. she stood there, and she watched from his perspective. and would not be alive today had

he not run out of bullets. and yet she was at school on that friday. almost catatonic. i don't know how she was able to put one foot infront -- in front of the other but she did and there was a plan there to help her. so, as chiefs, as counsel of school officers, we have a responsibility and it's time we make a change in how we think but things. we'll spend time today talking about assessment, accountability and that's important, we should. but this has to be the forefront of our minds. we have to change how we think but what we're doing to help our kids. we have to stop thinking about just prevention and start thinking about crisis management and crisis resolution. we have to go to a new place. so, whatever happens with the

debates and the politics, we have responsibility to take care of our kids and our adults. i'm going to be remiss if i don't just very quickly, is a end here, share with you, courage comes in a lot of different forms. courage comes in the embodiment of a principal that runs toward this bullet, not away. comes in the form of two cafeteria workers that pull six kid behind the cement barrier and help them crawl to safety to get outside of a building. it comes in the form of two counselors that city in their offers just outside of this fish bowl that this incident happened in, that pull these two wounded kids in their offices, take off their garments and stop the bleeding of two wounded children. it's the counselor who runs into the woods when hey see kid running into the wood, just to

give them that comfort and get them into a safe place while her husband makes phone call after phone call after phone call, who was in the building and for 17 minutes couldn't find his wife. it's about counselor that seize kids running blindly into the street, and jumps on a school bus, that she has never driven, by the way, and drives those kids to safety. it's about a principal who speaks in front of her teachers and the attention given to her is in such a way that you would have thought that fdr or jack kennedy or abe lincoln was speaking to those teachers. but it's also about the courage of an organization like ours, realizing that we have a responsibility, to and as much as we need to talk about achievement, with the don't take

care of the social and emotional well-being of our students in no way can we hope to change our country ever hope at that time we close achievement gaps and off that stuff, knowing the world we live in today is different than the one we grew up in. january 23 was one thief worth days of in -- one of the worst days of my life. january 24th through the 27th restored my faith in humanity. i was proud to be a kentuckian, and i was proud to be an educator. so, i want to encourage you. i want to push us. let's now take the next step. i don't care what your political persuasion is. what i care about is we have children that need us, and as

state chiefs we have an incredible role to play in partners with the districts and educators. so from the bottom of my heart, thank you all for what you do every day. but i want you to know i'm not going to let this go. i don't believe that this organization is going to let this go. we're going to do what we have to do to take care of these kids. so thank you for what you do. i don't know if went over time and i don't really care. [applause] >> pam, wherever you are, our heart continues to go out to florida and i know that we have had it in a lot of different places, tom, in california, you have death with some stuff.

and i know we have had the different things in connecticut and -- wherever dana and i know pedroes not with us but thank you for what you do. >> you're watching booktv on c-span2. with top nonfiction books and authors every weekend. booktv, television for serious readers. >> tonight on booktv, highlights from recent book festivals. next action discussion about immigration and race from the tucson festival of books. then an interview with one over the panelists from the discussion, former foreign affairs senior editor, sasha polakow suransky, a panel on the presidential race. from the savannah book city of, the communication strategy. in the book we need to talk. from the rose