to do their jobs would be really critical. thank you. >> yes, great question. so looking at this, we have tried to investigate it as intensively as he can in healthcare worker infections. in my time in africa, i have gone to those people, as awkward as it is, and say, what happened? it is extremely where that is a discrete event with someone can say they had an accidental needlestick or something splashing their eyes. say there is -- there is one case, for example, dressed e guy got all up and ppe, when into the work, and then had to go to the bathroom. breach anything in protocol. so we don't have an easy answer to that.

again, very few people have something very discrete. adopting part of the most probably difficult -- although there is certainly the potential for infection and other -- in other parts of the whole process. there also, even though it in ms radiological to us hard to believe, a lot of workers still re do healthcare delivery and a private basis. so there our aspects to the the health care ward. i do not think we will have, through existing data, conclusive evidence for that. >> thank you. next question. >> thank you. lieutenant marcy wright. first, for dr. limeoux. for ppreciate your comments

waste decontamination systems. but how do you develop the risk assessment justification and explanation to these lay nuances n some of the that we have and the -- reduction versus decontamination, acceptable an level, etc. -- as folks how ple with the fear of well incinerators incinerate a virus, for example. follow on, dr. -- how well developed are many genome systems and or uslike particle systems systems as a model in terms of parting network out of the biosafety level for and biosafety

level ii? >> well, i think the whole issue of risk communication -- i didn't have it on my site, is a should have -- it huge gap, i think, across the whole spectrum across everything. and especially on the waste have had t side, they to grapple with risk communication for years and years. i do not know that there's a magic bullet for that, but i there is a definite -- a be able need for us to to improve how we can take the and explain uances them to the, you know, not just the general public, but is largely an interdisciplinary events now that we're looking at.

you may have one group of experts who do not understand the scientific jargon from another group of scientific experts. more with ot agree that, actually. dr. peters. particles viruslike can be made like ebola ebola and can look like ebola, but at this time it is not economically feasible. terms of risk communication, i -- first of all, the public understands as much about microbiology as they do about integral calculus. taking it in t while -- they are taking it in well, but i would not go much beyond that.

there are two or three reporters who seem to be interested and more intelligent and have some my kground and i have spent time educating them in trying to use them as an interested what i say nslate into real speech. >> i should say there are several reporters in the room, all of whom are above average. other comments? to ask, this -- this is a webinar that is going out to people. of the say you own one major -- you are on one of the major news programs tonight and you had to explain the differences between the 21 day incubation periods and a graph that is 42 days. how would you explain that to the general public? >> that is not a fair question. [letter]

-- [laughter] the curve pretty 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 than twice that -- 42 days -- as the criteria that the who has used. intuitively, you can see are no new cases at the far end. seems to me that that additional safety precaution is there. >> thank you. one more response, yes. say to what would you that -- when you looked at very nice geometric distribution, round about 14 days it looks like there was a small second peak.

and i wonder if an alert were to ask you, does that suggest that the time be later -- time should be later, or is it the doubling of that? >> that is a good observation that you need to just keep in mind that this is data from the field. accuracy of the you rvations, you know, don't always know exactly when you're exposed. just as dan was saying about the physicians who became infected themselves. will be -- there using observable data, there are some assumptions that we have to take into account. >> thank you. next question. >> good morning.

nihs.bara miller, comment a en to little further about what he was able to do and accomplish -- erms of this sampling in the s of performance environment -- and a little bit to the group, what is the research concerning the understanding of viability of fluids beyond testing? some testing say that it may be viable for up to 30 days. and some comment about aerosols, if there's any information regarding aerosols. thank you. that we did tudy after things calm down a bit to get patient e care and public health response and reasonable order, around and took -- it was convenient samples -- get hatever sample we could from a patient.

from ink the conclusions that was that the virus was basically where we thought it would be. summary was really sick, we could get out of numerous different fluids. seamen, of course, is one where he nor the virus persistence is there for a couple months. breslow, i think that the is est we found viable eight days -- breastmilk, i think that the latest we found viable is eight days. an experiment that desperately needs to be done is a similar thing, but much more perspective. in this, we're just taking samples on-the-fly. we really need to get in there, into an isolation ward, and say let's take samples from blood, sweat, urine, every can from day one and really look at the excretion of this virus along those lines. that is not, technically,

complicated. that would be very illustrative. have now, for example, much as been made about virus two sweat, but the only studies i know where the virus in sweat is in patient who is very sick with ebola. extrapolations are often made find it in we can sweat, the sweat is on the or on the chair or in the subway in new york or whatever it is -- which is not necessarily true. on environmental side, it may not be completely illustrative because that was a very clean water we did it. things were under control. i think it would take some environmental samples, perhaps in the unclean wards, we may find more the virus around. been made much as about aerosol.

it is hard -- it just depends you view the data. it is very clear that most people can infected from direct contact with blood or bodily fluids, but then in any study, 50% of the g to have people saying, no, i do not sort of the contact. summer going to say that they had the aerosol contact with the aerosol transmission. others are going to say that they didn't recognize the bodily fluid transmission. okay, well, show me the data back up the opinion and it is not there. >> thank you. one more comment. said 20% patients coughed, and one of the studies in the 1990's similarly show that about 20% of ebola patients coughed. there is one report of a likely airborne transmission. the lessons from sars

was that we still don't know geometry of s the the airwave or the liquidity of breathing across membranes that actually generates aerosol. is not that there -- it is, you know, it is a reasonable question and warrants protection. follow up that point. drop this of interesting concept of these that have smissions occurred -- with 14,000 patients -- and the viral behavior. i thought you intimated the viral behavior in terms of transmission may have changed. that i misinterpret you? >> know, my point is that we do not know. we do not have any data. we do know that this virus has

been in human to human transmission for a very long ever -- longer than has occurred in any previously known outbreak. we do know that their viruses adapt to the house, those are those ific -- hosts, are scientific facts. a detailed have data -- because, number one, have current genetic information on the virus itself and, number two, we do not have the detailed background to put the world tions in the real with the molecular analysis constraints. so we just do not know. >> okay, i'm going to move to the next question. >> i am from the office of science and technology policy. in listening to what you are comments about the specimens and about the availability of material to is important research questions, i am asking the

be able to might facilitate sharing of access to virus samples so that the world can make use of this material for inform the o leone, nts of sierra develop and liberia to better research practices? be there isn't, should we creating it -- should rethink about creating one? >> well --

>> well -- i go back to the analogous analogies with the sars outbreak. at that time, but the cdc and the who led a very aggressive effort to make sure that the virus was available to the international scientific

community for analysis. that went very well. i was at cdc then and they spent a lot of time packing up strains of sars to share with others. that worked very well. i do not know what the problems are now, but i suspect that it starts with the countries who have ownership of the material. it is more complex than that and i really don't have any -- any answers. >> okay. i'm going to move to the next question. >> thank you all for your work and your presentations. i wanted to also thank dr. good -- i have spent a part of seven years in liberia. i can tell you about another health team members died of ebola because of a lack of personal protective equipment. don it cause they didn't or doff it, it is because they didn't have it. we have had a few cases in the united states and at this point, every hospital in the united states have bought ppe they will never need, which has made the pipeline to west africa dry up. we are about to send several on ebola in rk liberia and we're having trouble finding enough personal protective equipment together. so i just wanted to add that to our discussion because we about where we k need this agreement and make he gets there -- equipment and make changes their. thing i was

thinking is that all this makes for a wonderful research -- lucky we can get bleach sometimes, server could translate how we can safely dispose waste agreement, bodies -- equipment, bodies much more safe level because it is unlikely that we have incinerators cropping up in places like liberia. be interested to hear how you think we can the dly translate some of so ormation that you have eloquently presented in an immediate way to the countries that are suffering right now. >> it is just a reminder that today's workshop, we really are situation in the us, but i think you raise an important point which is the efforts of preparedness in the us on the global supply

chains for personal protective equipment and other things. how hink we can delve into the hould be controlling outbreak in africa because we have not been composed to do that. >> first of all, thank you for all your work in liberia. the point that you're amazing, to me, is the relationship between the us and west africa a global supply chain of supplies. if you have every hospital in the united states prepared to take care of ebola patients -- you're exactly right -- the supply chain is going to dry up where you actually needed. that is one of the logistical issues that i think this workshop is to discuss. how can we make sure that the ppe production for us workers is proportionate to the

prevalency area do not show got the supply chain to other countries who are in great need? logistical at question is as important a research question as some of the other issues we are discussing. >> this one more comment. i understand that we are but ng to focus on the us, it is definitely true that there is no way that we can i bring this back to west africa. you for t -- thank making that. very difficult to just health the ublic -- now you're hearing that every hospital own ebola e its treatment center -- and of not realistic, but every hospital has to be prepared. how do we prepare in the

over d states without preparing which is not only diverting our energies, but art resources from where they are most needed and west africa. i think we also need to be very careful that we do not get solutions to be so high tech that we price ourselves we of it and also that are so ke them so they logistically difficult to implement them were we need them. and west africa, our major is not environmental contamination. not have people coming to say that we think they were infected from the virus that seeps into the groundwater. on think we do need to focus the person-to-person interaction. >> next question. feel a little bit of a split personality here. my name is petty, the director for environmental health and safety and providing support

to the emory unit. cochair for the iso development of an international standard, which the next g off your the next .

few weeks. in addition, i am the global director for a nonprofit who does work in africa -- aand i actually worked with nigeria setting up their response to evil. so -- ebola. so, as a bio management geek, seeing this panel appears phenomenal. it is exciting to see the efforts and the enthusiasm looking at some of the science and technology that is going into it. in my former life, is to do pharmaceutical research. dr. howard, with regard to compound handling -- there is one group that is not at the table, and that is the usda. if we look at our containment facilities for large animal research, you do see a lot of this type of technology with ppe working around large animals that are in containment. the africa issue, it is not just africa, it is a lot of the developing countries. tremendous ent a amount of resources -- billions and billions of dollars on security -- and it security from h a standpoint -- but what we have failed as a global health security's agenda is the we're dealing with --

three have the capacity to, you know, identify, contain, respond to potential outbreaks. whether or not as a terrorist attack or a natural born outbreak. i commend those who are in the front lines. as a biosafety professional, to is an honor to be able provide support you and whether it is here in the united states are not. the concerns i have is what was worse earlier -- how related to developing countries -- bio other area is from a risk management standpoint is that we need to do a better job of risk assessment. the guidelines i came out from our healthcare facilities -- there is no room for risk assessment.

were developing these guidelines -- these are guidelines. we need to be able to teach our staff and our faculty and our students as they are in their skill sets and how you do risk assessment it to u how you equate the workplace. . have those contingency plans in place. then, there was also that was interesting experiences was the non-hierarchy -- i forget panelists he indicated that -- but that was a key component of our success at our unit. if a nurse said to a physician, stop, they had to stop. at the beginning, that was one of the things that was not necessarily, you know, thought

a very positively. but the success of our story was that anybody could stop somebody at any time, and whether he scaled up or scale was a team e, it effort. i commend this panel for what doing and alos, i ask my concern is the impact on research facilities here in the united states and abroad. >> so that was about six questions, but i'm going to summarize them to the panel one at a time. starting with that first point something r there's to be learned from the practices that have been in the laboratories -- the large animal laboratories. you have r. peters, outbreaks ved with

involving large animals and some of you have also worked with animals even though we do fda at the table. on a any comments particular issue -- are there any comments on a particular issue? think the expert here on diagnostics on the ground is sam. [indiscernible] >> very true. not the largest, but certainly large. >> the issue of use assessment as opposed to protocols and adaptive maybe more

ways in preparedness and response and medical facilities as opposed to simply following guidelines. i think that that was the question. and i were son discussing who is going to take the risk assessment question. lot of our , a clinical infectious disease colleagues are not quite as is a iar, but it fundamental principle and it does, i think, have an important role to play here talking about you pment needs because may be creating an inefficient situation if you're not assessing the risk properly. the health nt about security -- i just wanted to puncture that -- as i said in the beginning, i think this workshop is about ebola, but the larger issues we are talking about -- and i hope the iom takes this up -- we are talking a lot of different

hemorrhagic viruses. lot of very serious issues out there, of h internationalization be vel and business, will facing another workshop. so i think it is very we continue t these discussions. >> just a little more detail. risk communication, risk analysis, identifying the hazards and the degree of the hazards using humans as a -- at what temperature, was subjective feeling of illness do you think people start shutting the virus? is at 101.4? those are some fundamental questions where we don't know the answers yet and we are actually giving guidance. risk analysis -- at which point arena which kind of ppe to use? we could study that in a formal way.

unless the people who are going to have to act and that are involved in thinking through the questions in the going to they are not be comfortable with the answers. so involving healthcare workers in the process directly as important. >> the last one has to do with one of the presenters. i know this has been a major concern of the institute of medicine for quite some time in the provision of higher-quality health care delivery. have changes and how members of health care teams interact around patient safety as around their own personal safety. if there are further comments from the panel on that. well, the overlap of employee and patient safety has been in the air since i think the first joint conference, the veterans

health administration, arc, and osha in 1998. at which paul o'neill did the keynote address and talked about that. ebola where the source and recipient are the same, for many diseases, it is not as much of an issue, but clearly, this is the poster child for the overlap of patient and employee safety. and seeing the pictures in liberia of those beds and tents was humbling, as we think about the luxury of how we do it patient safety here. clearly, a huge, huge issue. >> next question? you did a poll everyone in this room would agree that 15 or 20 weeks ago,

none of us would be in this room talking about a situation like this. maybe we could have and should have gone back and wonder why we did not think about this possibility. it raises a very important question about where we move forward with this. when you look at the history of ebola in the human species, there have been 24 documented transmission situations, 28 communitywide outbreaks, 2400 cases. the most number generations has been five to seven. in many ways, this virus is hardly pinged the human species before now. made general observations. some of us have written about the fact that the virus has not changed. africa change. it was all about urbanization and crowding. we arethe things i think really missing on right now is asking ourselves that really hard question again, like we could have asked ourselves weeks ago. is there any difference in this attentional virus -- this

potential virus? we have such limited data to know data. would that begin to change some of the possible conclusions we have had about past outbreaks? we had that for other infectious diseases where we know when we had higher levels with certain other infections, we can see this same principles of transmission of transmission is different. i guess it would be interesting for this meeting because it -- we are making assumptions about previous outbreaks being the model for this outbreak. in the general trend of transmission, it is. but the question is -- could it have changed? and it is not just the fact that his crowding and lack of medical services. for example, the higher viral loads that would result in different levels of transition -- transmission. i guess i would ask the panel

the implications for that, because our week making a mistake by expecting this to be exactly like the past outbreaks, just with more people? >> anybody want to tackle that one? >> i can come in, i guess. valid questions. my gut feeling is that the seeds of this are more related to the cultural factors and logistics of west africa and people going back and forth and all that. but i think we definitely need to be open to scientific inquiry. and we have some of the beginning data. it takes a long time to generate, longer than we would like to we have some sequence data, but that does not tell us what we need to go. we need to put that into cell culture and nonhuman primates. need to see if they have different viral loads. i think those studies, i cannot quote the researchers, but i think that postings are being

done in various laboratories in the united states and elsewhere. it takes time to kind of get those. allakes time to generate those data. if you think about just getting the samples and all the logistics of import permits and getting to somewhere where you can do those types of pet the typical types of experiments, it is a slower process. but it is a valid question, that we need to be attuned to. i would not be surprised if we did not get an answer in the u.s. because in africa, you are so pressured for time. there are so many people, so many different ways you can get ebola. you plop somebody down in the middle of des moines, and you may find out whether there is aerosol transmission that has evolved. >> thank you. two at the mic. i think we have just enough time to take these last two questions. m director of communicable

disease control and prevention for the los angeles county of public health. -- realities in the needs on the ground in west africa. perhaps the domestic research area that we could put some priority to is ways that we could mourn systematically improve the recruitment as well as mobilization of health care workers, both public health and medical to help in west africa. thank you. >> agreed. to any ideas you have to try and increase the numbers. >> last question. >> california department of public health. pandemic, we did a series of studies with colleagues. and we actually went into 15

hospitals in california and nationwide we had 60. and we asked how front-line health-care workers perceive the use of ppe. we did some observation of donning. week interviewed whole series of staff in the hospital. and i think we learned a great deal about the implementation of ground.he i would put a plug-in as putting that as a topic for research in terms of ebola. i think it would be a hard live to do it next week when our hospitals are the midst of figuring out how to purchase appropriate ppe. sometime soon while the members are fresh. because we get a lot of questions at the state level about what exactly to buy. i wish -- i would really like to know how people are using it. and what the experience of the front-line health-care workers

are. i guess this model of more precipitate -- just the tory research to help our local, researchers toal understand what we can learn six months or year from now. >> i guess i will take this one. over the last two or three weeks, who has had a guidelines committee on ppe. the guidelines just came out the day before yesterday. so you could find those. they are helpful. -- we did do some surveillance from health-care workers coming back from west africa and what they liked and disliked in order to inform those guidelines. valuable butare they suffer from what we desperately need. we need some evidence-based. so we came down to one person saying, i think you need this. and another person saying, i think you need that. people could express what they

liked, the one we said what was necessary -- >> we are going to take a last, last question. > >> one small remark. and i do not know if anybody knows, but because ebola's agent dsat regulates experiments on this fires. these regulations response faster some of the research questions addressed. i want to put it out there that if i want to start doing something new, which will take me to years -- take me two years. >> could you identify yourself again? rocky mount labs. comment on that? it is probably true that there are a lot of regulations that govern the ability to even