>> the health commission will come to order. call the roll. >> singer? >> present. >> taylor-mcghee. >> present. >> chow. >> present. >> chung. >> present. >> sanchez. >> present. >> the approval of the minutes of the september second and september 16th meeting, 2014. >> we will take each one in order, the first one will be the minutes of september second, is there a motion for acceptance of those minutes? >> so moved. >> and is there a second? are there any corrections to the minutes? >> seeing no corrections, we will prepare for the vote. all of those in favor, say aye. >> aye. >> all of those opposed, the september seconds minutes have been accepted. >> the minutes of september 16th are before you. >> motion for acceptance. >> so moved. >> is there a second?

>> second. >> is there any further discussion or any corrections? if not, we are prepared for the vote, all of those in favor, of the minutes of september 16th, please say aye. >> aye. >> all of those opposed? the minutes have been approved, for september 16th. >> thank you commissioners, item 3, is the director's report. >> good afternoon, commissioners, for the next several months, we are going to have a disease update for you and that will happen at the beginning of my report and today, dr. ogona and cougar will be providing you with updates. >> good afternoon, commissioners today i am going to give you a quick update on the ebola situation, today, dr. hover will be joining me and also want to acknowledge other key people that are really

working on the preparedness, dr. baba who runs our public health emergency preparedness and response branch and also rachel kegan who is our communication director who has been working closely with us. and what i am going to do today is i am going to go very in the next two to three minutes, go over it the document that says, communical update sxim going to focus on ebola and help you understand the conceptual challenges that we face, with a threat like ebola and then dr. hover is going to give you a detailed update of what is happening in san francisco with respect it preparedness, on the first page here, you can see the summary of the data that is coming out of after cabsinger now this out break in 2014 is the largest out break that we have had in history to date, you will see that in the first table there, we have had over 7400 deaths, sorry, over 3400

deaths, and over 7400 cases in countries, the transmission that occurred in nigeria has been contained and we did have an imported case, of a person who flew back from libera was seen in dallas texas and is currently in critical condition, it gives you an idea of what is happening right now globally. what i want to do for you next is just to give you an idea of the challenges that we face with ebola and i want to present it to you in a framework that we use for containing the diseases and since we are going to give you an update, we give to give you an idea of how we think about the diseases on the second page, you will see two on page 2, you will see two tables at the top, and you will see a diagram at the bottom and this is actually from a training that we have given to clinicians and also lay people on how we think about

controlling the microbial threats, you will see the reservoir or source, right now what we know about ebola s the reservoir starts in the back and currently the source is infection in humans and those are the areas that we focus on, the areas that are bolded are the areas that we move forward and we think about those sources. in the next as you look at the diagram at the bottom there, you will see there under, the first circle you will see the portal of the exit and one of the challenges that we have with ebola which is different from the other diseases is that pretty much, every body fluid is infected and we are talking about feces and bodily fluid and it is in the saliva and it is sweat and so every fluid

becomes infected and they become violently ill, fever and vomit, and diarrhea and so a lot of fluids that expose other potential people. so that is actually one of the challenges that we have in a case appearing in the united states like what happened in texas. under the mode of transmission, column, you see how we think about this and so for ebola we are going to be focusing on the areas that are bolded and there is direct contact and so say that the people who are going to be most exposed to risk are going to be healthcare workers and family members that are taking care of patients who are sick. and the reason is, is because the patients are not infectious until they become severely ill and, so the healthcare workers are the one that are the highest risk and so we contact precaution and we also focus on droplets and developed with a concern of the virus being

arosolised when you have the procedures and they are also help to implement the precautions and i put the vehicle born there because we are concerned about the contaminated equip and this is an issue in africa and that covers the modes of transmission that we think about and then on the right-hand side is what we used to sort of to educate the lay public and we call it the 7 habits of unfekted people, the 7 habits that you can think about how to protect yourself from any inif disease, personal hygiene and focusing on the hand hygiene and hand awareness and covering any portal of exit, coughing, any wound that you have and using protection in the clothes there and because it turns out that the ebola virus is also in semen if any patient were to come here and continue to

excrete the virus it continues to exist in semen something as important of wearing condom ss going to be issued and reducing risks and focusing on close contact on healthcare workers and the last one is infection control and the last thing that i want to cover before it i turn it over to hover is for all diseases that are transmissable person to person including ebola. and there is six core strategis that we use to contain the diseases, and the first core strategy that we use is try to reduce the contact from the people who are infectious and the people who are susceptible and you are going to see a lot is to reduce the contact of the people who are infected and susceptible, the core areas that you will see the people using and the first one sheltering, those are the people who are unexposed and often times, families will tell and keep people at home, for

example, keeping children at home and don't send them out because they don't want to get them exposed the second one is quarantine, a worker or anyone else that we monitor them to see if they develop symptoms and the third area is case isolation and, identifying people who are ill and isolating them, so a lot of the contact tracing in the news and this with unof the biggest challenging is the contact tracing because we want to identify them, so that you can quarantine them, or if they are sick, so that you can isolate them, the dallas case had 140 contacts, and that was just one case, and you can begin to see the amount of person time and man power it takes to do all of that contact tracing. and that is one of the challenges that we have. and then in the last one, there, and in amendment number five, is interrupt transmission, which is transmission control and so as you hear our disease reports in the future, we are always going to be going back to the core

concepts because they are the foundation for everything that we do, whether we are transporting a patient or caring for a patient in the hospital. now the last thing that i want to show you is on the last page and you see the incident command system and it is a diagram that looks like this, this is how we mobilize the health department to respond to a public health emergency. what is really important for us is that the operation section and those are all of the things that we are preparing for, and when we, when we were responding to a disaster or any public health emergency. and there is a lot of details and i am not going to go through all of the details and that is what we are working on and we are fortunate that we have a commitment of the director to mobilize the resource to offer the health department to really help us, because it is and there is a lot of person power involved. and everyone around the country is working on this and this is a challenge, and hopefully nothing will happen but if

something does happen in san francisco, we absolutely want to and we will be prepared. i am going to turn to over to dr. hover and he will give you more detail of what is happening in san francisco. >> thank you. i'm dr. cora hover and i am the director of disease control and prevention in the population health division. and i am going to, and i have some copies of my slides here. so, first of all, just to state although you all know this, we

don't have any cases here in san francisco at this time. we have seen is that many communities across the country have had individual in whom a concern of ebola has been raised and testing has been done, and ebola has been ruled out. and then, in the dallas texas case, unfortunately the person did have ebola but there have been a number of these real out ebola situations in various communities. and i think that it is... he was saying, that it is very important for us to think through how we will respond and are ready for that if we do have a patient in whom ebola is suspected or confirmed. so, the first thing that i am going to talk with all of you about is communication. and this really is i think of it as kind of aa three part

strategy and what you see here on the slide is an accounting of what has happened so far. from our departments, so, cdc and also, the state department of public health have been pushing out increasing by detailed and comprehensive guidance about how to handle a potential ebola case and how to prepare and we have been sharing those as they become available. with medical providers and hospitals. we sent out a couple of health advisories to medical providers here in san francisco. one was sent out in early august and the other one was sent out at the end of last week. we are also in dialogue with the hospital to ascertain the level of preparedness, and for a case and, we have provided resources and information from

medical providers on hour programs, website. and this really builds for the other pathways that we use and we have the shared information with 311 and also, made a more information about ebola that is more targeted to the general population such as a fact sheet, available on our website. and in addition, with a great deal of really wonderful, from rachel, and we have been responding to media inquiries and in addition, there is now a media call-in hot line that has been set up, so that if there are any critical updates, that will be another avenue whereby, the members of the media can call in and get the information.

the partners that we and the department of public health work with, and would be working with within an ebola response, include, occupational health and safety. ems and first responders. hospitals and medical providers. let me, move you to the next. and hospitals and medical providers. law enforcement, and potentially, and also, the dem, the issue of a returning traveler, potentially being the means by which ebola would arrive here in san francisco, points to the importance of our dialogue, and work with the quarantine station and we are

always receiving information and also seeking guidance. i wanted to just talk with you briefly about contact investigation and monitoring. that is kind of the bread and butter work of what the disease control program does, on a daily basis, and we investigate, rather usually rather common diseases, examples would be pertusiss, and those are the kind of things that we are working on every day. and really, the principles that we use in that day-to-day work with would be the same

principals that will be applied and are being applied for example in texas to follow up potential contact of any ebola case and really this public health follow up is what is going to help insure that sustained transmission of ebola does not occur in the united states and we really do not expect the transmission of the ebola to occur in the united states because of the excellent infection control precautions in the medical settings and also, excellent public health follow up. and so obviously were we to have and if we don't have a case in san francisco if we were to have such a case, we would marshal the resources that we need to in order to augment our current staffing and personnel in order to do the appropriate contact investigation and monitoring.

and to accomplish that follow up. and so i am going to stop there. and i am happy to answer any questions if there might be. >> was there any public comment? >> and i received all of the comments for this item. >> commissioners, questions? doctor? >> first of all i thank you very much for this presentation. and i like to hear a comment and i love the department's disease fax, and i look forward to it every week on my machine and through the season f we are in or out of flu season and it is various and director garcia was saying that we need to think about something... (inaudible) likely first. >> okay, and we are a transitioning to do communication by e-mail as well. so... >> so i am really happy that you brought this up and i want to be sure that there is preparedness and you have done

your due diligence and the whole ems system is up and running i want to be is that youer this is an isolation unit available and seeing this case, how fast, in texas that it spread, and you can see that you have one case, but it sounds like you would rue craout for your contact tracing a bunch of people as many as you need, and you just pull in everyone from i am unworking commissioners to everyone that needs to contact tracing and i think that the isolation is... whether you will have enough spaces and the last question that i would have is the flu season and we are going to get a false alerts. and we can separate what is real from what might be a lot of work. and maybe i will just talk about the false alert question really quickly and then i will have nadina boba can speak to the isolation room issue. you know, the really important

thing and the key point i think when thinking about ebola in a patient is their travel history. >> and so i think that once the history of whether a person has traveled to an ebola affected area or has contact with an ebola infected patient, is ascertained and there is... where the ebola infection needs to be ruled out. >> just to be asked for your question about isolation units, there is 102 isolation units in san francisco hospital and so we have a robust system and that might be suspect in a lot of cases. so that is not just like one capacity, every hospital will come on line. >> absolutely, yes. >> >> commissioner singer?

>> dr. aragon a couple of comments and questions. one is that it sounds like we have done a terrific job in pushing the information out and getting information in from the federal, and world health organizations, pushing it out to our community, and it sounds like we have a terrific response ready. it seems to me in these situations that identifying the event, it is critical to linking those two work streams. >> and i was at the general on friday, and it was clear to me that, they really have quite an education system, at least in the er and i am sure that it is in other places where people are aware of it where they have the daily briefing and the staff takes it very seriously and how confidence are you that that attention and connection that we have here at the

department is equally (inaudible) with all of the other providers that may end up at a place where there is a sentinal mode in the city that are not dph institution and kind of talk about that type one and type two errors. >> yeah, so what, and wait that the cdc is thinking about those, is that they want every hospital, every critical facility to be prepared to screen a patient, initially, and then decide where to send that patient next. if it is out of sight that is well prepared to take care of the patient and the patient should stay there, if there is a better location and a hospital that patient should be transported. right now the cdc is in the process of developing some screening tool, and to help hospitals assess how well prepared they are. and the dallas example is for

us a event because all of us have a lot of capacity and a lot of capability, with the details that matter and so the texas case sort of got the people thinking they started to see some of the details, one of the things that we are learning from the patients that are being cured, in the u.s. hospitals is the amount of waste that has to be disposed and the amount of infection control equipment and the amount of training and doing things appropriately because you don't want the workers to become infected and so we are realizing that this is from the cdc now is that it is not practical to expect every single hospital, in the u.s. to have the highest level of preparedness. and that we know and we need to really do an assessment to really figure out which one are going to be better prepared than others and make and so they will probably come out with some stratification to really determine which ones might be better prepared.

and to really think about the details that we need to pay attention to. in san francisco, the hospitals are really beginning to drill in detail including the training and the staff and how to dawn, the infection control, and the personal protected equipment and how to take care of the patient and how to transport them and so having that concrete practice, sthaoe if a patient does show up, they will be more confident. >> dr. sanchez. >> yeah. >> i was just going to ask you, personally, i think that it is an excellent presentation and i just wanted to site that i know that a lot of our crew out at sfgh have been involved and especially this week with fleet week. and with our med core staff and docs from the arranged navy and the coast guard doing various

clinical trials and even opening up and bring in the whirly birds out to the marina greens and out at sfgh and you can't get in there because that is in violation of petrero hill, you can't bring in the helicopter and that was a long decision here, and what i am saying is that sfgh and the department of public health has been involved in what is on the radar pertaining to this and we have a new ship, called the uss america which has a fleet of supportive services and that are involved in surveillance, and obtaining to not only trauma, and but also, infection disease, and the things that will be effecting familiaritilies throughout the world this will be involved in that and the service and gives us a real great network

pertaining to communication both as an example of i know that there is a number of teams from south they were california, and both from the navy and marine corps who have been sharing and continuing education programs with our docs and nurse and support staff and our staff also have been teaching them. it is a two way street and this year is a structural fleet week has been restored and a lot of the focus will be on types of trainings, screening prevention, and do we get from point a to point b, questions about dropping the materials in with some of the new military equipment that will be used on some of these ships. and is a real critical problem, doctors at boarders have been concerned about this, where there is four or six cargos, that have been sitting in a port, for three months, and the materials and could have been used but somehow, it has not

been disseminated because of the problems over there and in essence, the president and others have taken the shortcut and saying that we will look at some ways that we can provide these resources but they are including our county health department and they are including the level one trauma center and san francisco general has been a key player with that and so wuls have a member of the senior offices and the past general folks who are very much involved and i just want to say that the department is involved in this training exercise, and it will continue to be and i really think that it is an excellent opportunity for many of the citizen to go and visit the ships and go out to the greens and see what the protocols there and they are there to communicate and whatever, and so a job well done. and hopefully we don't go to a real case here. and we agree with that thomas. >> thank you, thank you.

>> all right. i was just going to ask in terms of the hospital preparations, and it was mentioned that you were working with the hospital and so what type of work are they doing? and is it that this is voluntary, that hospitals are you know, preparing or are we taking a more organized fashion to see that each hospital has either a process of referral or a process of intake? >> we have not had the meeting yet with the hospital counsel and we are plan thating and there is a lot of federal funding that comes down that goes to the hospitals and so the hospital haves been since 9/11 the hospitals there has been a lot of preparedness happening at the hospitals and just leveraging on top of all of that prepareness that occur, and we had sarses and influenza and the hospitals and the ics

approach is very robust and we are very fortunate to have san francisco general hospital, and because we have the best disease doctors right here in staoet and i would say that we are very strong, okay. >> any further comments from the committees here? >> if not, director, we appreciate the update, and just a couple of things, and we were identifying all of our staff who have the disease control investigation backgrounds and experience, and they are already discussing with them to be prepared if any or that will be part of the ics system and so we are already identifying the expertise of the department. and this is just the yir that i worry the most about, is because there are not a lot of people in the disease area but they have hundreds of team that can support them in the department and so we are working on that as well. just a couple of updates for you, we did, want to acknowledge our researcher from the public health division,

milo, who mas been awarded a national institute of health director early independence award and this is a highly competitive award for scientist and identified them for the award is a proposal for a grapt aimed at intersection for binge drinking men who have sex with men and a five year study to evaluate taking a medication on a as-needed basis to reduce binge drinking and we will also learn a lot from his work, and also we did get an award to expand on the prescribing of aloxon and this was a pilot and to increase it for opiot overdose and considering the length of the last report i will leave it there, unless you have any other questions for any other report. >> commissioners any questions? on the remainder of the report,

was there any public comment on the director's report? >> no, there was no, public comment request for this item. >> so we certainly would appreciate the update, on the virus, and we anticipate that we will get further updates as warranted. >> thank you very much. >> next item, is general public comment and we have several folks who have turned in requests, and yes we will go on to general public comment and public comment will be a two-minute process, please for everyone. today. since there are a number of public comments. we will begin with it looks like george patrick but i could be wrong. and it is from sciu, ten 21 george. and it would be first, and carletta jackson lane, and terry lang and as we get to third speaker i