Transcripts For CSPAN The Next Pandemic 20171119

The next pandemic. Hopefully its not the next pandemic right here. You might think that the Natural History museum is not the best place to have a meeting like this. I would suggest that the Natural History museum is the best placed at the meeting like this. This museum is the largest Natural Museum and has 145 million objects. I say that objects whatever but the reality is collecting the Natural World for the last 300 years and preserving those objects in museums and this is the place where we have what we know about planet earth so the records have collect and over the expansion of humans. In any given year, 400 phd is working behind the scenes. Last year, over 400 new species were described. At the same time, we welcome 6 million visitors. Most of those visitors are tourists which means the next year is a different 6 million so in a decade you might get as many as 50 Million People in this building. We live in Interesting Times with human population is growing. There are so many things happening on the planet where humans interface with the Natural World and where things like pandemics can emerge. Just a couple of examples. Examples. If we were to go to the other side the building into the sixth or you would walk into a collection that is 640,000 birds skins collected over the last years all around the world. The other side of the building 590,000 examples of mammals so huge collection of organisms that carry the genetic code of their species but also carry other features of the environment as they became biological data collectors. Recently several thousand of these birds were sampled for evidence of the 1918 influenza pandemic week as we had words in 1918. We have those birds and we sample 25 of the six tested positive for the influenza. We have in our collections fossil examples of diseases. When diseases break out there are times when those outbreaks the vectors are not known and its an example of the junta virus discovered so we have come to realize our collections arent just historical artifacts with Research Tools and affect Scientific Infrastructure that allow us to investigate emerging scientific issues in areas of diseases and Food Security and Invasive Species etc. So i welcome you here today. We are going to be opening an exhibit next spring called outbreak, epidemics and the connected world and this really will map the Museum Perspective and the fact that human health and Environmental Health and Animal Health is related to one health and the exhibit will discuss a lot of emerging effects of diseases and present them to the huge public. Couple of years ago we did an exhibit called genome about the human genome discovery. Most scientists have a good understanding of whats happening in human shouldnomics but the general public has almost no clue what it is. You take the tools of museum and interpret Something Like genomics for the public it provides a bridge between specialist in the world and it will do the same thing for merging Infectious Disease outbreaks. One of the speakers leader status dr. Sabrina schultz who is the curator on staff here who is the lead curator for the exhibit. So all that said id like to introduce our first speaker who is someone who i just met a moment ago but i enjoyed his work over the years. John barry is an author and historian currently a distinguished scholar at Tulane University where he is focused very much on the state of the gulf coast. I came to know him from his book rising tide the great mississippi flood of 1927 and how it changed america. He has also written a book entitled the great influences the story of the deadliest pandemic and history published in 2004 preview is ranked by the academy of sciences that year as the the outstanding book of science and medicine. Hes the only nonscientist on the federal Infectious Disease board of experts. Was on the team that developed nonpharmaceutical interventions to the pandemic. He is also advice for bush and obama white house, so that i would like to have you help me welcome john barry to the podium. [applause] thank you and thanks for coming and thanks for putting together this conference. I want to give you a very quick summary of what happened in 1918 and what we might learn from it. The estimates of the death toll started 35 million go to 100 million. Adjusted for population approximately 150 million to 400 million today. Most of the debt the deaths were adults aged 20 to 50. Probably between three day of the entire population of people in those age groups died. Certain subgroups, it was worse than that. There were numerous studies of pregnant women that had case mortality rates from 23 to 71 . In populations it was not unusual for 20 to 30 of the entire population to die and although the focus has often been on young adults who died they are not the only people who died. Look at children even in the west were case mortality was the lowest the 1918 pandemic killed as many children aged one to four s. Today die of all causes over a 20 year period. He killed as many children aged five to 14 s. Died from all causes over to attend a 15 year period and remember that well over half the deaths occurred in a period of weeks about 10 weeks in the fall of 1918 so just think of the impact that would have. Today even in nonlethal pandemic could sicken between 60 and 100 million americans, 2 billion people worldwide. That would overwhelm the medical system use of antibiotic stocks from secondary infections, destroy the timing of inventories, devastate the economies so we need to extract every lesson we can from 1918 and the first lesson is we need to put a lot more resources into Vaccine Research particularly universal vaccines but in the interim improving technologies on vaccine manufacturer. Second, to inform policy choices choices. We need to continue to study events therein, the virus itself. We continue to learn more about it. One of your speakers in epidemiology is certainly an expert there and another speaker and we also need to look at it from an interdisciplinary perspective. I believe there is plenty to learn from 1918 still. I will give you three examples of untouched data. I know of studies of several hundred thousand people and institutions that relates to wreck way to the effectiveness of handwashing. That data has not been touched. There is excellent data on quarantine by a brilliant pioneer epidemiologists, strongly, not just suggesting i think proving that quarantines is pretty useless with influenza. Thats untouched. Maybe most important i think the data from 1989 pandemic and from 1918 and 1920 about the first person in a household to become sick with the disease. I think that was certainly deepen and challenge some of our understanding of how disease spreads. But to me the main lessons involve what today we call Risk Communication which happens to be a phrase i despise because of it colludes managing the truth and i dont think you manage the truth, i think you tell the truth. In 1918 chiefly because of the war but not entirely for that reason they did not tell the truth or close to it. The disease was known as the spanish flu. National Public Health leaders called that quote ordinary influenza by another name. The surgeon Surgeon General of the United States that quote you have nothing to fear if ordinary precautions are taken. And what was true nationally was also true locally. The false reassurances were almost everywhere. In arkansas a doctor reported his hospital closed, overwhelmed overwhelmed, doctors and nurses dead, thousands of soldiers sick and dying in barracks and miles of double rows of cots. He says everywhere there is only death and destruction. Seven miles away in little rock the newspaper reported the same old fever and chills. I think society is built on trust and these false reassurances, these efforts to keep morale up quickly lead to a loss of trust. It was alienating, eraza and dating, isolating and as a result society began to disintegrate. As one person said the disease can people apart. You had no school life, no church life. Completely destroyed all family and community life. People were afraid to kiss one another. They were afraid to eat with one another. It destroyed the intimacy that exists amongst people. In philadelphia there was a doctor who lived 12 miles from his hospital or there were so few cars on the road as if he went home every day he started counting them. One day on the drive of 12 miles there was not a single other car on the road. He said the life of the city has almost stopped. On the other side of the world in new zealand and other doctor stepped outside of his hospital and said i stood in the middle of Wellington City at 2 00 on a weekday afternoon. There was not a soul to be seen. It was a city of the dead. There were people starving to death, not because there was an food but because people were afraid to deliver food to them. Victor von who would then the dean at the Michigan Medical School had seen a serious person not given to overstatement said that the present rate continuing for a few more weeks it was safe and could disappear from the face of the earth. Thats what happens when People Lose Trust in each other and in authority. And to test my hypothesis or the hypothesis that the truth does make a difference there was one city that did tell the truth in entirely different experience. In San Francisco the mayor of the labor leaders Business Leaders put their name on a full page ad huge print that said where a mask and save your life through the mask didnt do a bit of good but that is a very different message than ordinary influenza by another name. In San Francisco the city was extremely well organized and certainly nobody starved to death. Blocks were well organized. Teachers when schools close they volunteered as orderlies telephone operators delivering things. The San Francisco paper said one of the most thrilling episodes in the citys history was how this gallantly the city the hate during the epidemic. Thats what happens when you do tell the truth. So i think the lesson is clear. Public compliance with recommendations will be difficult under any circumstances, sustain compliance will be much more difficult. In mexico city in 2009 for example masks were recommended on public transit. Three wins were distributed. Usage peaked at 65 in four days later it was down to 27 . So for expect compliance with recommendations authorities beat to get out front and stay out runs. We need to be totally accessible. They need to stay ahead of internet rumors and the final lesson is not from 1819, term 2009. Planning does not equal preparation. There was a lot of planning done between 2004 and 2009 but when that very mild pandemic hit it was as if at least by Authority Figures none of that made any difference. If you look at rational responses in china, egypt India Britain france, even some to a lesser extent the United States and began planning does not equal preparation which means the biggest challenge is the Public Health community is to get political leaders to make rational decisions in crisis situations and that is where leadership and the Public Health community really matter. Thank you. At afternoon. Im Michael Caruso the editorinchief of smithsonian magazine, the magazine that is not coincidentally seen on your chairs. If you like whats in there we did three stories in this issue all about influence. If you like within their of the efforts of terry the executive editor and jenny griz a Senior Editor and if you dont like whats in there its my fault. I am one of those impossible roles introducing a man who needs no introduction especially to the people in his room but im going to plow on anyway so bear with me. When it comes to thinking about epidemics and everybody wants to talk tony fauci. Hes americas point man on disease for 33 years now. Lead our nation through every Infectious Disease crisis through various years from aids to ebola to seek a. Dr. Connie leyva is a member of the National Academy of alliances. He has 42 honorary doctoral degrees has received the president ial medal of freedom and his citation reads that it is his commitment and enabling men women and children to live longer and healthier lives. With his broad appreciation for the public good and is nonpartisan if they failed dr. Or fauci perceive the budget. The story and the event itself came out of an answer that doctors fauci gave us that was onstage at another friend of ours a couple of years ago. We asked him what concerns you the most, what keeps you up at night and his answer was simple, two words pandemic influenza. Okay we thought lets hear more about that. Ladies and gentlemen dr. Anthony fauci. [applause] thank you very much for that kind introduction. Following that encouraging story from john im going to tell you a little bit about the next step that i think john was very clearly referring to about what we need to do regarding preparation. And thats what im going to talk about in my 10 minutes, preparing for the future and endemic influenza. The first thing i want to do is to make the point that when you look at influenza that preparation for seasonal influenza essentially should be the preparation for pandemic influenza in a Perfect World. In a Perfect World that i hope we get to in the next period of years. We certainly are trying hard for that. Its the development of what john alluded to a universal influenza vaccine and let me tell you why is someone who is an Infectious Disease person that im concerned about our capabilities today against any kind of influenza. I want to break it up into three quick parts. First of all the current influenza vaccines are not consistently effective and that is a fact that we just have to face. If you look at rum 2004 until the last year when you have a bad year with a mismatch as we saw in 2004 and 2005 you have a 10 efficacy at us, as we had in 2010 and 11. You have the 60 efficacy to compare that to other infections that we have vaccines for the measles vaccine is 98. 5 effective. Yellow fever is 99 effective. Polio is more than 90 effective. There are a lot of reasons for that. We all know about the mutations. We all know about the fact that the response brings hemoagglutinin although it can be effective from yeartoyear sometime shipped but this is a stark reality of how we address seasonal influenza. Now pandemics do occur. You just heard from john about the mother of all pandemics but we have had three since then in 1957, 1968 and most recently in 2009. However the response afterthefact is not effective. John alluded to the h1n1 pandemic in which we actually had a bit of a warning. I want to show you what the response was of those of us who were going as quickly as we possibly could. It was the swine flu. The first thing is that we were expecting as we always have that the next pandemic would come out of china or the far east. When in fact it did not. He came right in our western hemisphere somewhere around california and mexico. Now you were called and i have shown im i am sure people in his audience to recall that the end of the 2008 9 season as things were calming down in march the way they usually do and peaks in january, all of a sudden in march and april we started to see a new kind of influenza. So we felt lets make a vaccine for that influenza and this is march. This is what happened in april so wasnt in 1976 shoot from the hip and get in trouble as we did then by the vaccinating everybody. We knew we were going to get a pandemic so in april this is a picture of my good friend ann and i testifying before the Appropriations Committee enables saying and you can go back and see what we said, it takes about six months to get a vaccine going soap we start working now may, June July August september october if we have the vaccine buyout sober then we will be prepared for the inevitable pandemic. However what happened . The children came back to school and instead of having an epidemic or pandemic that peaks in january and february it peaked in september as graphically shown on the slide. Whats wrong with this slight . The blue line is where the red line should be in the red line is where the blue line should be be. In other words the illnesses peaked before we had the vaccine available which became available and it would have been wonderful as peaked in january but it didnt come it peaked in september so even though we had some warning about a pandemic, even then with our current capability it does not work well well. Notice the expression on tom friedman and Jesse Goodman explaining to the House Oversight committee about the vaccine that we were supposed to have in time. We didnt and then theres a third thing and that is chasing after a potential pandemic outbreaks. I refer and others refer to them is as prepandemics. Its costly and it is an effective and let me just give you a couple of examples. You were called the h5n2 one pound the chicken virus that started in hong kong. It had a high degree of brutality but didnt develop the capability of efficiently going from humantohuman. We took this very seriously and what happened during the george w. Bush administration he asked for 7 billion we spent 45 billion to switch from eggs to cells which i dont think its a very major advance is we will get to in a second but we made a vaccine. We put it in the stockpile and Nothing Happened but we did something really good. We put it up. This plan involving what you see on this slide. We approve the vaccine that we have the first adjuvant stock pile. We didnt use it. Then what happened is several years later we had the same thing. The chicken virus jumps from chicken to humans high degree of brutality and not efficient from humantohuman. Started in 2015. Over quick. We made a vaccine in 2013 and we stuck piled it. There was a minioutbreak in china in 14, 15 and 16 and what happened in 17 . It mutated a little and the virus in the vaccine that we had for 2013 strain was not protected by the vaccine we developed in 2017 so we have to go back and start all over again. What is this telling us . Its telling us my conclusion that we need to get a universal influenza vaccine. Its going to be a clemenceau and its going to be iterative iterative iterative but from a scientific standpoint well get there. Just very brief for about 30 seconds there are a number of ways to get a response that is universal against all viruses. One of them and not the only one i want to emphasize is when you look the hemoagglutinin in and the head of the stem region is very clear, sorry this is not working well. Could we go back one . Okay, there you go. Im sure people in the audience are very well aware of that, that the part that is protected to the current vaccines at the head of the hemoagglutinin is the good news. The sobering news is that what parts me tapes from season to season or shifts when you get a pandemic. To make a vaccine for the response against the concerned regions of the stem is one of the ways we are pursuing and another righty are pursuing to try to get a vaccine response that is the work virtually against all strains. I want to close with this light. We have just witnessed for scientific america. If someone at the pessimistic statement. I dont use of our pessimism but to spur us on for the goal of what we need to do because 100 years after the lethal 1918 flu that john just described we are still vulnerable and our Public Health infrastructure has improved greatly but without a universal vaccine a single virus would result in a world catastrophe. Thank you. [applause] thanks very much john for those presentations. That sets first Discussion Panel which focuses on what scientists have learned about the 1918 pandemic and how that knowledge is this helping and they minimize the emergence of a new pathogen. I am andrew from the Microbiology Department at Johns Hopkins. Ive like to introduce our panelists. To my immediate left is the chief of the viral pathogenesis and evolution of section in chief of the laboratory laboratory Infectious Disease diseases at the National Institute for allergy and Infectious Diseases to the laboratory sequence they influenza virus and is investigating implanted a seasoned pathogenesis in clinical studies and models using seasonal and pandemic influence of viruses. Recently hes been focusing on developing universal influenza vaccines. In the center is an epidemiologist from the division of International Epidemiology and population studies at the National Center of the nights. His Research Focus on the transmission dynamics of influenza and respiratory viruses and at the end of our panel leads the Influenza Vaccine Development and she supports efforts to support faxing platforms it can be used to generate vaccines against influenza or any number of potential human pathogens. We will be more than happy to take questions from the group of before you do that i want to start with a few questions for the panelists to introduce you to some of the work they are doing and have them explained the important work that they have been focusing on recently. You led the efforts to determine the sequence of the 1918 influenza virus and investigate why the virus caused such a massive amount of disease to humans. Can you characterize that virus and tell us about that and how it mitigated some of the pathogenesis during that outbreak . Influenza was known or not yet known and recognized. It was thought that influenza was caused by bacterial agent so that started waning. By the time the pandemic came there were no opportunities to isolate the causative agent so 20 years ago we used a molecular archaeology approach to try to sequence the virus from tiny fragments of the genome of the virus present in odyssey tissues of people who died unfortunately the pandemic. The effort to do that was physical with the Technology Available but the reason to was to try to answer the questions of where the virus come from and why did it cause so much disease and why did it affect people in a way differently from pandemics. A lot of these questions are still not completely answered that we have learned a lot of information. Think the most important thing that i would share in a couple minutes that we have here is it does not seem to be specific to that pandemic. They werent pandemic. They werent mutations Justin Allgaier spray their feature there are feature shared with other circulating influenza viruses especially those in birds and we share some of those behavioral features with some of the pandemic areas that dr. Fauci alluded to. The most important thing is not to just understand the historical phenomenon but as an example of what could happen in the future and uses information to help us gear up for how to prepare and predict how bird viruses can adapt to humans what mutations would correlate with a high virulence and what we can do to prevent it. Thanks. As an epidemiology spends significant effort studying how pathogens like the 1918 influenza that spread in the population. Can you tell us about what the investigations have taught us about the spread of the 1918 pandemic and how was different than what we have seen in other pandemics . What made it unique was the data from countries around the world. Some we see was unusual and epidemics running that period. It was just something really unique about the population. The other distinctive feature is the age, the fraction of mortality. We see this peak around age 28 all around the world and thats very difficult to explain. We think its a combination of increased severity and the young age group and protection in the age group that has seen some of the childhood that it was pretty clear. We have also now looked at the historical pandemics from 1889 to 1918 and they are all different. They are a little different. They share features. They come in the summer and they come in the autumn and they affect more of the younger population but they are all quite different so that means in the future we just need to have systems that are in place to get real epidemiological information and what the flu looked like in 1918. David, in 1918 there were no pharmaceutical interventions available to help stem the pandemic. We have antivirals and vaccines as tony mentioned. Efficacy is not as high as we would like them to be. Can you talk a little bit about the vaccine history and where you see the field going in the near future to try to improve those tools that we have two of pandemic . Sure. I think back in 1918 as jeff just pointed out mistakenly working on a vaccine for influenza a. Wasnt until 1931 that it was definitively shown that influenza was caused by a virus. 1933 we were able to grow it in laboratory and by 1945 it was the first licensed vaccine in the United States. There have been some improvements since 1945. There have been improvements in the manufacturing process. In 1945 the vaccine was a bivalent vaccine for influenza type a components in one type the component. We are now moving to more vaccines. In 1945 who used an prenative hen eggs to grow the virus. Now we still use henna eggs to grow the virus for most of our vaccines by this doctor fauci pointed out some companies are moving to cell culture and some are largely bypassing the growth of the virus in the sense in that they are using technology to express the proteins from the surface of the virus to make the vaccine. We have improved vaccines for older adults by virtue of higher doses or by using adjuvants. I think importantly we are using the vaccines more. Since 2010 there has been a recommendation for universal use of the vaccine for all of us from six months of age and older to get it each year. Still, as dr. Fauci pointed out our current vaccines need some work. There is much more that we can do and they are different from other vaccines. First of all the disease where trying to prevent is very prevalent. Up to 20 of us will have an influenza infection during the course of a year. Secondly the virus keeps changing. Thats why we need a new vaccine each year and also the efficacy is lower than for other vaccines vaccines. But on dr. Fauci slide that showed efficacy estimates 2014 and 2015 the efficacy was just 19 . The cdc tells us that year that the vaccine provided 1. 6 million cases of influenza despite relatively low use of the vaccine in the low efficacy. So increased use particularly important to women. We heard from don berry about pregnant women being particularly susceptible group to disease so this all helps. Looking forward i think theres at least two ways we are moving to improve things. Dr. Fauci cover the idea of universal influenza vaccines and if we are successful they are that we have a vaccine for any implements a virus past, present or future, human, swine derived avian derived we are set. This is the kind of vaccine that w. H. O. Is looking for for developing countries. Most influenza death occur in developing countries and very few vaccinations occur there. The second approach is to advance these new Rapid Response platforms. Gfk has such platforms. One of them for example was used to make a vaccine for seven and and h. Seven and nine virus. Took eight days to make that vaccine from the time the chinese posted the sequence information for the virus in tell us injected into cell culture into mice and in talking to the scientist that did that work they tell me they could have done that in four days because there were two snail mail steps in the process. Once we have these sorts of forms that are working it then becomes quality control. So i think there is much to look forward to. We just need the time and resources to make it happen. I encourage anyone in the audience to ask questions. You have a question just raise your hand and try to get my attention and we will try to acknowledge you and get you involved in the discussion. While we are waiting for that though a couple of followup questions. Maybe we will start with jeff. Let me put you on the spot. You think influences the most like to virus for the next pandemic or are there other Margaret Simms microorganisms at pose a greater threat to the population . The future for influence of pandemics is always a good strong set. There are circuit of viruses we did think about and other respiratory viruses in animals for example the one that led to stars and birds, something that is concerning. There are viruses that certainly could be concerning. There are other viruses of course. Insect borne viruses like zika better concerning but i think influenza is something that is the most concerning. You have the enormous diversity of influenza viruses and an incredible number of animal species both birds and animals and wild birds and wild animals and domestic words. Viruses mutate like mad. So that is what i think gives us the greatest fear is that despite 100 years of studying the virus we have no way to actually predict what strange will emerge and how they will adapt from one animal to another and how pearland they will be and that poses a huge challenge. To add to that influences natural vectors present different disease and doesnt cost that much amiss. These animals shed virus over long periods of time and go on migration patterns that take them hundreds if not thousands of miles away and introduce them into new reservoirs. How those viruses move around the world is really mindboggling. All right, cecile u. Been doing a lot of work in understanding and modeling how pathogen spread and populations. This has been particularly fascinating to me as my center is working toward looking at understanding seasonal influenza more carefully. Could you speak to how modeling efforts can inform Public Health responses to the next pandemic and help us come up with interventions are ways to members minimize the spread of viruses . In the context of the new pandemic you have the option. That might give you time and tell new vaccines become available. There were also a lot of questions about closing bottles in the context of a pandemic. They are very useful for that and they are very complex. There is also modeling around forecasting and decades ahead. We are beginning inc. Putting a lot of effort into that and protections of the outbreak on how high is the peak going to be of her season to protection six months ahead of which strain. That is progress and that is quite exciting. Indeed you mentioned briefly in your answer to the first question you started from initiatives recently to generate new vaccines to emerging pathogens including once with Global Pandemic potential. Theres an relatively new facility opening up in maryland devoted to those efforts. Can you tell us a little bit about how the company is approaching this idea of making vaccines to pandemics or potential pandemic organisms . Gfk has been working with the u. S. Government specifically the Biomedical Advanced Research and Development Authority since its inception in 2006 to develop and to produce preparedness products. In our case thats h. 15 and vaccine. We have monaco full antibody for influence and also antimicrobial existence which would be a great topic for another Johns Hopkins smithsonian symposium. Florida is working with other companies. I understand to date they have 21 products in the Strategic National stockpile ready for use use. This is great but its not really sustainable. We need more and more products. The products we have have reached the end of their shelf life and need to be replaced. So gfk and others are interested to move to the Rapid Response plot warms. Gfk was partially motivated by the 2014 epidemic of ebola in west africa. We responded to that outbreak with our primary scientific partners that and my age and it went from the start of the phase one Clinical Trial to the start of the phase three Clinical Trial in five months rather than the usual five years or even longer it was too late. So we need to be able to react faster. Again gfk in many groups are working towards these platforms. In the ideal they would have, continue to have improved surveillance. We would identify a pandemic threat. It would be sequenced, posted to the cloud. Research laboratories would download it, create the vaccine mainly in the computer identified as the gene segments needed for that. Bring it back to the cloud and it would come back to different manufacturing facilities using that platform. Using it every day for a standard vaccines they influenza in many parts of the world. Then when the pandemic threatens they interrupt their routine manufacture and start making pandemic vaccines within weeks or months. Thats the ideal. I think those are the sort of things we can report. Thats an excellent point to make to know that some of the work we have been doing using seasonal influence of virus as a model to set up those real diagnostic efforts sequencing efforts, identify these pathogens and spread the word around and see whats new patterns are coming through. Sequencing is a great way to model would eventually to model what eventually wanted on a pandemic so some of those efforts youre talking about are probably not that far away at least for organisms were we understand it well like influenza. We know what the target should be in terms of ahead of this service do we have a question . Obviously is the most important was the progress on antivirus . John said we have been talking about vaccines that was a progress on antivirals and countering pandemics . There are antivirals against influenza but really only into classes and the problem is that influenza viruses can very often develop a taisha is to make them resistant to these drugs so clearly more classes and newer classes of drugs need to be made and clearly there has been a lot of research both government funded research as well as industries trying to develop antiviral targets for the flu but as far as i know i dont know how close those are two licensure. We are still laced with that really for many strains. The antivirals that are available for physicians to describe prescribed are already resistant. Nothing to add except this overline to the 2000 pandemic are the 2008 earlier viruses were beginning to become resistant to the new h1n1 is acceptable. I do think there is an added realization now that developing one antiviral and having two or three and administering a cocktail as they eye to the situation. Again we did hepatitis c virus when you have a group of the antivirals than the likelihood of resisting has increased exponentially. Thats something to keep an eye on in the future in terms of the development. There are a few in the pipeline and i know there has been one new antiviral drug license in japan but certainly i dont think they are ours many antivirals and development as there probably could be or should be. Question. Im wondering about the data and science regarding the immune response mechanism for protection against influenza viruses. Tony fauci mentioned antibodies against hemoagglutinin however i went to a session where scientists showed a better correlation with antibodies to narrow by the day. I found that really an interesting finding just fairly recent, a few years ago and i wondered whether that has been pursued or whether what i was once told, its all about ctls. I dont really have a feeling for how much is known at this point about what kind of immune response would confer better than lets say the maximum 60 which would not pass muster these days for the approval of any vaccine. Thank you. Im not sure, im sure i cannot completely answer that question. I dont know that much more than what you have stated in your question. They remain were in maine and number of unknowns about influenza and the best way to prevent it. Its complicated with having a series of infection that complicates the history in terms of how you as an individual response to the vaccine. They are different parts of the virus that can be targeted by different means their antibodies through cellular responses, antibodies to neuraminidase will protect them but the current standard is hemoagglutinin hemoagglutinin and to nation anybody which is acknowledged by regulatory authorities. I can speak to the fact that i spent the morning at a meeting where the universal flu vaccines are being discussed one of the first things that come up was to set up studies better understand immune responses to infection and vaccination and the typical antihaa antibodies and to get a stronger sense of what the natural course of infection in terms of protecting antibody responses into no longer fit into that and look at the protein is there one Gold Standard pit is a broader thinking that we need to go back and think about t cell responses and immune responses in total and use that as a way to help us with the universal vaccines going forward. It became very clear that because we had some success with the seasonal flu vaccines that we were okay and there wasnt a lot of going back to the basics. Its almost a little bit embarrassing that we have hemoagglutinin nation assays and thats what we use as the courant of protection when in fact we havent pursued satellite tcells as much as we shed. If we are going to get to the universal vaccine that i was referring to we are always in some respects going to have to go back to the basics and ask the fundamental question of what the true core lift of the immunity and they scope of the core lift that immunity is and its interesting in 2017 we really dont know as much as we probably should. That was the conclusion of the workshop you are at. Absolutely. With that im going to close this panel. I want to thank my panelists for their wonderful discussion that we had and thank you very much for your attention. [applause] [inaudible conversations] at afternoon. And the director of the center for humanitarian help at Johns Hopkins Bloomberg School of Public Health. We are going to talk about the pairing for the worst and is the world ready to respond. Im hoping we are going to get obviously beyond the vaccine to others. Clearly there wont he into roles and the vaccine anytime soon and they are going to be a lot of people who are sick and how Health Care Systems in different ventures fund. We have two speakers. Actor daniel sosin at Deputy Director and chief medical officer of the Public Health preparedness and response or php are at the centers for Disease Control and prevention. In this role he is the lead science adviser and provide scientific representation of preparedness on behalf of php are, in cdc. Serves as a liaison to the cdc programs and external partners and ensure strategy and Program Coordination for php are in the medical and Public Health and prepared his response. Daniel, welcome. Of influenza prevention and patrol. Influenza virus continue to pose one of the worlds greatest Infectious Disease challenges and risk of pandemic influenza remains. Our vulnerabilities relate to the virus, the susceptibility of the population, and the environmental factors that spread the disease. By definition, the pandemic virus is one for which lack immunity and is capable of transmission from person to person and to cause severe disease. In addition to the naive systems come up significant numbers of people today are more susceptible to the Infectious Diseases because of the diseases they have were therapies they take that compromise the immune system. The expanded International Travel for humans to animal reservoirs to increase the risk that a pandemic influenza will emerge with extreme effects in the absence of vaccine that can eliminate the pandemics, time will be of the essence and early recognition of persontoperson transmission of a pandemic virus to make all the difference to an inEffective Response. This is why ongoing Surveillance Networks around the world are so important. Many can cause similar symptoms to influenza come as a diagnostic tests that are accurate and feasible for widespread use are critical to the rapid understanding of the conditions and for specific treatment plans. On the pharmaceutical intervention such as personal protective equipment, respiratory adequate, hand hygiene, social distancing can prevent the disease transmission even when a specific intervention isnt available. Vaccines of course will be an important part of the response even today. Medical treatment and secondary infections can save lives is available in the right hands of the right time. It also requires Effective Communication in the public. And with our health responders. So theres confidence in the recommendations and motivation to all of them. We are lacking in these capabilities. There was no National System of surveillance much less the global surveillance effort. Viruses as you heard there is limited to protective equipment, no vaccine, there are no antibiotics to treat secondary bacterial infections and no antiviral drugs, no mechanical ventilation with intensive care units and the challenges in 1918 which are surely different today with respect to the understanding of Effective Communication in a variety of tools to share information. So, what does the cdc do to lessen the threat of influenza . It works with partners to monitor both human and animal influenza viruses to know what and where they are spreading and what kind of illness they are causing. Cdc supports more than 50 countries to those that find the emerging influenza threats and to respond to them. Cdc studies more than 6,000 human and animal influenza viruses in the laboratory each year. Cdc develops and distributes materials to laboratories around the world so they can detect and characterize influenza viruses. Cdc works with state and local government, the World Health Organization and partner countries and pandemic partners. Cdc evaluates the effectiveness of the pharmaceutical and nonpharmaceutical recommendati recommendation. Cdc helps global and domestic experts choose which viruses to include and guide the prioritization of the Pandemic Development and develops those used by manufacturers to make the vaccines and the cdc monitors influenza vaccine distribution. Cdc also manages the u. S. Strategic National Stockpile and supports Public Health departments across the country to ensure that critical supplies are available when and where they are needed. Cdc also informs Health Providers in the publi and the t influenza prevention and control measures. Such is the age of seven and nine virus essentially initiates a new Pandemic Response as the scientists and partners around the world were to characterize the viru virus, develop and distribute new diagnostic tests and investigate the transmission patterns and severity. Since the 2009 pandemic, the cdc has reviewed and updated tools for the prepared us including the pandemic influenza preparedness response framework which can be used as a pandemic planning guide. The Risk Assessment tool which processes the potential pandemic risk posed by the influenza virus that currently circulate an animal but not in humans. On the factors for the likelihood that it will change to infect people. Once the mobile virus is identified and is found to be spreading persontoperson in a sustained manner. Available measures are used to guide the decisions about which actions the Public Health authorities recommend. What progress have we made due to the Global Investments in pandemiinvestment inpandemic pra global influenza response system with mechanisms to quickly share the information. Laboratory capacity has shown exponential improvement in recent years and we can now sequence the full virus genome in a single day there are Vaccines Available in selected vaccines were stockpiled for the pandemic use. The manufacturing capacity has expanded in the past decade including the development of new vaccine technologies. There are units to care for patients with respiratory failure. There is a one Health Initiative to increase interaction and cooperation between human and animal authorities. While advancements have been made to improve, we need to fill the surveillance gaps. There are geographic apps in global surveillance including parts of africa and the southern hemisphere. We need better surveillance of influenza viruses circulating. Better diagnostics are needed including overthecounter point of care tests. Better less costly influenza treatments are needed and there are large parts of the world that dont have the medical infrastructure and equipment to treat severely ill patients and they must be supported. Even in this country we need creative approaches to manage the demand on healthcare. It is requiring ongoing laboratory work. Achieving the security must read they can remain a priority to listen to the pandemics. Thank you. [applause] he began his career working in the general practice in the high lands and 1987 the point of the regional director and later Deputy Director general of the National Institute of occupational health. He served as director general of the nationa National Defense and Disaster Relief office and the ministry of health and peru. He joined as a shortterm consultant in honduras where he also serves as the United Nations Disaster Task force coordinator for the country. He presently serves as the regional adviser for Emergency Preparedness and Disaster Relief here in washington, d. C. [applause] [inaudible] how does the will t world prepar the next pandemic . The presentation i will give you is in the International Response to the pandemic, so one of the conclusions of the International Response is to improve the coordination with the National Response we have to be complementary to the National Capacity to. Its related to the interNational Capacity, that this was approved in 2005 and began in 2007 but you see that the countries are not there yet. Most of them have requested an extension to the resource capacities and the last was provided in 2014. They have reached that level in the selfassessment aspect, so they say that they are rare. How they are performing in terms of those capacities you see here how the countries have been performing one year to another and for example the first here is 2011 and then we go to 2016. We see that the capacities are increasing in the legislation, coordination and National Focal points etc. So they are coming from 90 now and you see that capacity is also increasing for the first time more than 60 of the countries are now able to reach those capacities and then we see the status of the regions. We see that its still lacking and 80 of the country we see that a certain capacities are very low, but we see also central and south america are very high in terms of most of the diseases and the related capacities and how are they doing in terms of contact with the who . We test those and you see among the years of, activity for sample above 90 in the first 24 hours of that. The next hour it is more than 90 . So we do have connectivity withy with most of the member states, and they are reporting back. How are we doing on the points of entry moving from the 75 ports and airports across the stage with the state parties in the International Relations and we have the procedures that are not there yet, but you see the 64 parts are certified and 78 airports, 22 ground crossings and then we are moving around 500 authorized ports in 27 state parties in the region so we are moving towards the points of entry. We are not there yet. We are moving towards that and most of the countries now are eager to do that. In a couple of weeks, for the third exercise in a row in the point of entry, they are not only in terms of airports and ports but also those that do have entries to tourism for example like easter island. Who is reporting on that you see the National Focus point is dark yellow and you see more or less 40 in 2017 so it is sufficient but you see that there is a large amount of event not reported by the governments. So how can we say that they dont have an outbreak of the government with a National Focal point is not sharing that information . What is the type of event reported, most of this is infectious but there are still issues on safety and the difference that we are going through. This report has been officially up to the 13th of july this ye year. How is the system reporting going in other regions of the see here for ball eight co. For example we see the huge difference in the reporting in americas because we work with the government and the country and br convincing them along with several others in the region so overwhelmingly most of the reports come from the americas and in comparison with all of the other regions, we see that a in the west pacific region, so clearly the americas are overwhelmingly the best prepared in terms of alerting. We have few countries without surveillance they are not reporting actively. How are we doing by our own account oyour ownaccount on the. What are the differences from those falling into tracking how many samples are being tested. This is the number of samples tested by the National Influenza center. Is this enough . They do have the surveillance tools that are being applied on top of the tools. The biggest problem with the insecurity and economic impact. 2009 the United Nations were an important part and were useful but also a. We do have issues there and still have the interagency work. The problem is each of those institutions have their own mandates and their own interests and then when we come, the biggest challenge challenge is o coordination. Why . Because Everyone Wants to coordinate with nobody wants to be coordinated. But also established the operations of the procedures. We are working on that. 24 countries have sent their delegates this week to coordinate in the response to the influenza. So, we need also the crisis meetings without Operational Impact and yes, we have to have the productive implication, we do see that even in spite of the countries. This emphasis we want to be in the photo and the convenience and ambitions not supported by the available resources that the dream it up and we dont sleep enough. The final vote we have National Capacity to respond to the capacity and improve the equality of the assistance. Thank you very much. [applause] we will be taking some questions. I will start off in a little bit and its hard to see with the lights here, but i hope that from the audience you will have some questions to the colleagu colleagues. I wanted to start with you. Youve mentioned the key responses that would occur when the epidemic occurs beyond the backs of the nation. Everything from ventilation to the antibiotics but also talk about the capacity even here in the United States to be able to respond. I had a list of varieties of capabilities we have today. And a lot depends on how severe the viruses and chant miscible the viruses are. To respiratory support and all those. On the modeling of todays therapeutic interventions in Public Health interventions on the population and if the past few decades that we have much greater capacity to respond to and we would expect to respond more effectively. Thats why all this work across the spectrum including universal vaccine or battered vaccines are so critical. One question i have is even within the americas, we see the disparity among many countries in america. Can you talk a little bit about the difference is that you may see what you see in some of the more responsive countries you dont have to name them and the differences both in preparedness and in particular the response. You can use mexico as one example, but the question is to try to get at the differences and the capabilities of the very countries even with the americas nevermind in africa or the others that i am more familiar with. With. The more impressiv importantf the capacity to alert and share information is that the National Focal point where the National Offices that have to report that they are empowered to do that and most of the cases to filter through thhave tofilter throughl channels and immediately it is so even in a pandemic influenza in 2009, we saw many countries did have the capacity to detect. They were not reporting because it was huge and that is most of them were able to detect, not necessarily the specifics, but they can report and in some countries we have got the way not only those that we saw in that picture that do not have the surveillance capacity, but most of them. Mexico showed by example they were able to report almost immediately when they discovered that there was something new and different. The response has been immediately and they welcomed many partners. I was the coordinated response for the first two months and we saw that it was their but some of them that are in charge were moved out of the office is a couple of weeks ago because of the organization and because of political reasons they were not brought into that. It happened also in 2008 in the yellow fever outbreak in paraguay. They have to convince the minister to appoint the person who knew more about the yellow fever. So the Political Economic make a difference in my opinion. Opening up for questions please raise your hand. Yes, we have one in the back. Yes please. They are coming to you right now. Please introduce yourself. From the smithsonia from the smithsonian magazine, the question if you could comment on the impact if any of the Current White House administration on the ability of the cdc to respond to future or near future influenza pandemic. Sure. Pretty much everything i talked about. The type of work that we are doing continues to be supported. There are many potential changes coming in the future that i cannot predict myself, much less a pandemic. So, i feel that kind of work that we are working on continued today as they did two, three, four years ago with the same sense of urgency that we have that this is really important work and we are going to figure out how to keep doing it. So, i cant speak to the changes that may come in the future budgets. I just hope and pray that we get the resources we need to continue to do the work we do. And if the resources change, we will figure out how to adjust and do the best we can with the resources we do have. Are there any other questions from the audience before yes. Two questions. I will name one of the countries that was slow to report, and that was brazil. I know for a fact that there was a bad channel feeding information from epidemiologists in brazil to the white house during 2009 coming in the white house was telling the source that they were getting information two weeks after the government. Cause brazil to have the highest fertility of h1n1 in the world. So they modify their procedures up to last three or four years they improved a lot. Yes mexico was punished, haley was punished, proved, make country was punished after we were reported on time. Punishment is economic punishment. Its irrational. Because of the fear. Fear causes all these decisions to be made. Extreme fear related decisions. Stopping all the importations of product not related to that. Stopping tourism. Mexico spent 100 million and have response to that incidents. The overall cast was 9 billion. When who was coordinated the response. The minister of health. Thats nonsense. For preparedness, it is security sector, other sectors have to be there to respond. We have that on paper. The National Emergency officer in mexico was not allowed to enter the coordination meetings. I have to negotiate to let her get in. Does the fema like director. So we see those type of things and we see where the fears coming from. The thing is most of the countries are prepared but not at political willingness to control the economic impact. Its overwhelmingly large. Thank you. I have one more question with a few more minutes left. Any more questions from the audience . My one point is what youre saying. It is the Health Response is one component of much broader. If scene was happened and polio the economic and political response are essential. And john mention this, the Community Response. Although i know its extremely different, what we saw on a bola was a Community Response was just as if not more important. I like briefly, we have two minutes left starting with dan talk about their experiences and how you can address the community to make sure they are supported in a decent response. I saw jim here from the association of state health officer. Cdc works domestically to provide guidance to Health Officials who have authority to do the work at the state and community level. So this is the nonpharmaceutical interventions that could delay or stall certain aspects of the pandemic, prevent disease and spread it over time. We have more data because of the 2009 pandemic. There were confidence in these measures. Will bit more information as to when they might be most effectively apply to take action at an appropriate time. I believe strongly in the message john barry gave us about communication. We know more about working to get political leadership. Lastly, want to respond to the point that the Health Leadership kept out the rest of the response. The United States we been working to get Public Health a seat at the table. Spent important and challenging. I dont see us ever having the lead of this nature but having a voice and let a scientist be at the table has been very important. Community participation is crucial. The first thing to have is the trust and the authorities telling them what to do. If they dont trust their Health Officers or government on an everyday basis, why will they trust them in a crisis. Its very complicated aspect. We have to build it. Telling the truth is important that telling the truth all the time. Not just in times of emergency. Those things happen. And also if we can convince persons from different perspectives with the same message. During the cholera outbreak in peru we had one of the lowest fatality because we convinced academia in the college and media to help us. We began first with 12 or 24 recommendations. The we came to three recommendations. So Risk Communication will only work if we do crisis communication. Telling people we are taking care of them, but telling the truth. Not diminishing the risk. That will build the community participation. Communities are not able to respond to all. Thats a dream. That transforms into a nightmare. This crisis communication and trust the government that will make a difference. C130s to tell the truth all the time. Thats wonderful. I want to think you very much for your insightful comments today. [applause] hello. And the director at the department of health. It is my pleasure to introduce her next speaker, doctor Sally Phillips was Deputy Assistant secretary for policy of the office of assistant secretary for preparedness and response. Sally is responsible for policy development, strategy and coordination of activities within that Office Others are in the federal family working on these issues. Before sally was in the role she worked at the department of Homeland Security and on the hell prior to that for number of years. Its fair to say that if youre working on pandemic in washington you know sally, and sally knows you. [applause] you can all relax, there are no power points. Doctor bob is our assistant secretary for preparedness and response. His hoping to be here but he sends his regrets. Im delighted hes not here, because i am. I wanted to share some of his view and ideas since you havent had a chance to listen to him. In this landscape his view a pandemic performance articulated position for strategy implementation and evaluation of progress should be based on Threat Landscape rather than program base. Under his leadership when we say threat, we need any threat to the american people. They could be naturally occurring, accidental. Recent accidents weve had. Or deliberate. Cyber attacks in the Healthcare System. We recognize in order to have an Effective Response the systems we put in place must adapt to whatever threats were faced with. To achieve this we develop health and healthcare Defense Strategies that focus and hone in on resources and was to stakeholders as they identify risks and capabilities. Doctor came to do this through four key priority areas. Provide strong leadership including clear policy direction, and proof threaten situation awareness, second, create a National Healthcare disaster system by augmenting programs such as the Hospital Preparedness Program and dms. To create a more coherent system. Third, support the sustainment of robust and reliable capabilities including an improved ability to detect and diagnose Infectious Diseases. As well as the capability to dispense medication. Also capitalizing on advanced biotechnology and science to develop and maintain a robust stockpile of vaccines, medicines and supplies to respond to pandemics, chemical, biological incidents and attacks. Our mission is to save lives, protect america from Health Security risk threats. In june hhs released an update on the pandemic influenza plan. It is a collaborative process and expands our concept outlined in the 2009 plan acknowledges the advances made in science and research continued improvement from across key domains. These are development counter measures, domestic and International Response policy. In 2017 weve made progress addressing needs for payment pandemic preparedness and are better prepared now than in 2005. We worked with partners to expand the definition of who can vaccinate, and in what settings. Ten years ago he had to go to the dr. Hospital to be vaccinated. Now you can go to your local pharmacy for the flu vaccine. Were allowing for wider distribution of countermeasures the authority has been working with and has developed cell based vaccines for seasonal and pandemic influenza. This was created to bridge the valley of death. With flexible number authorities to promote innovation in partnership with cuttingedge expertise. Over the last decade they built inhouse expertise, developed 34 licensed products in their ready for emergency use. The expanded pandemic influenza pandemic capability. We increase from 60 million to 600 million. Thanks to significant United States investments as well as antigen development. With respect to Healthcare System, the Hospital Preparedness Program release new guidance. Documents for awareness and Healthcare Coalition. The cooperative agreements were released in outlined requirements for hbp and jointly with the cdc. The healthcare preparedness response represents the ideal state for readiness. These build and improve the pounds the capabilities incorporating a greater focus on healthcare. They cement the Critical Role of Healthcare Coalitions during pandemics and other emergencies. For example, to achieve have to deliver timely and efficient care to patients when demand for Healthcare Systems exceed available supplies. Requires coalitions to take specific steps towards enhancing their preparedness for disease outbreaks that could overwhelm the system. Emphasize standards of care. When demand for healthcare exceeds availability. When the planning is difficult its crew critical to have inclusive planning process. The National Training Education Center was created during the 2014 ebola pandemic. They partnered together through a joint cooperative agreement and will end in 2020. Its a consortium of three Healthcare Facilities that safely and successfully treated a confirmed patient with people i. Ebola between 2015 and 2017 they develop metrics to develop facility and Healthcare Worker readiness to care for peter with Infectious Diseases. They trained over 3000 people and decide assessments. Created a suite of resources for care patients with a bola and established a phone line for federal partners to provide emergency consultation. Lastly, they launched the pathogens Resource Network to create a platform for study of special pathogens. 2018 is an increasing milestone and important to recognize. However key gaps and challenges remain. Will continue to develop new ways to prepare for not only pandemic up outbreaks but outbreaks of other Infectious Diseases thank you. [applause] either. We talked about the Healthcare Program that is being managed in federal government. Could you say more about what we all learn in the experience of ebola we tried to take care of highly contagious individuals. In some ways it caught us o f guard. We have Infection Control nurses and systems in place to monitor and track diseases by bringing something forward as unique as this put a challenge on to how its transferable and was the other levels of care but we dont really know the cause or something we havent dealt with. Its been a wakeup call to go back and revisit. When i was a nurse we had Continuous Education classes on a weekly basis. Many programs were not in place in hospitals where were reintegrating their knowledge base. Ebola gave us little wakeup call to put an emphasis on Infectious Disease. The challenges of this and there is fear involved in providers trying to get ready into the right job. Placed in a challenging ones on education and training. For people familiar with how hospitals are involved, can you explain a Grant Program or program how does the federal government interact . The Healthcare Coalition funding informs in and had chances the ability of communities to build coalitions. It was a Hospital Preparedness Program and weve realized that preparedness is a communitybased, longterm care, and trying to build a coalition of people in the community or region that when a pandemic comes up you can have to pull in and share resources to meet the health care needs. The program rolls out to those coalitions around the country. Is that related to the program that sends Emergency Health care workers to hurricanes and to response. Thats a National Disaster medical system. Thats a separate program for shortterm employees physicians, nurses, pharmacists from all over who volunteer to be temporary employees with us. We have teams activated during a response. They go in for two weeks, provide care when needed and do a rotating system. The last three hurricanes challenged our abilities. All teams were activated to meet the healthcare needs. They come into supplements support medicare needs. One question we heard from the first panel about Influenza Vaccine Development. What is the role of bartok in your office and how it relates to the nih and cdc. Barter is the later term entry. They take the work of nih and roll that into advanced Research Development bringing it to final manufacturing. Their partner from and ten strategy so nih starts the process, fda does the regulatory part of the barter takes it towards the end. Thank you. [applause] let me invite that spindle up to the stage. I am happy to be moderating the panel on strengthening pandemic preparedness on the front lights. Im here with two at the respective people to talk about the issues. On my immediate right is the Deputy Commissioner of the office of Emergency Preparedness of response. She directs the programs, operations, strategy for the Emergency Preparedness and response work including oversight related to the Healthcare System. Shes responsible for directing pandemic preparedness. To her right is jamie the Program Officer for bio security at the open philanthropy project and organization dedicated to making grants. Shes been leaving the program for the past 18 months she gives grants around the country and world to diminish pandemic risks. Prior to her work at open philanthropy she worked at the department of defense and at hhs among other institutions. I will turn in a moment with questions. I will start with some observations. Just to place the pandemic in the local contexts worth looking back at 1918 in baltimore were the institutions. There 600,000 residents of baltimore. Over one month, one in four people became you with influenza. 2 to. So more than 3000 people in baltimore died from influenza. Every sector of the workforce in the city was affected. Communications was impaired, trade was impaired, it was devastating to the Healthcare System. Overall it was a major event. Its tempting to think that today we can escape that but a model from her sensor concluded the pandemic of the scale of 1918 at its peak would require seven times the number of ventilators than we have on hand in terms of who would require that medical care. Lastly, no matter how you slice it, how people in the front lines respond to a pandemic has enormous consequences. We have to talk about the global and federal issues but we also need to focus on the state local systems that are doing much of the work to prepare country. With that, what i want to ask marissa bob, maybe you can take us through the pandemic efforts at high level in new york city. Its worth saying that we conducted health and Public Health analysis and pandemic flu ranked number two after coastal storms on the heels of sandy. This is a threat we take seriously. We feel certain this is what well see in our lifetime. The point was made about the Health Department taking the lead and thats the case in new york city. Its a collaborative effort. We cannot respond alone. Its a citywide response. Its very much in partnership with the fire department, police department, Emergency Management and health system. We plan for both mild to moderate as well as severe scenario. We do not assume that we will prevented from entering its about how we limit the spread. We break it down to surveillance, healthcare support, Mental Health and communication and outreach. The other point i want to make is that its a living document. We started writing the initial plan with federal funding in 2006. Much has changed. Weve also learned a lot from many other. We did exercise in 2013 that informed our planning. Finally, this is very much dependent and cdc Public Health funding as well as asper funding. Without it we would have the resources to focus on this planning. You have spent the last 18 months or so in time before the wandering the country and world looking for the most impactful way to prepare. You talk to people in universities and laboratories. What surprised you the most . What have you learned was the least appreciated. That much surprises me in the space. Several one thing. We find ourselves in the system of panic and neglect. While there is an acute response and reaction to pandemic like h1n1 the highest level of leadership, as soon as it passes it doesnt continue to be a sustained priority. Whats surprising is how quickly that happened after the apollo crisis faced away. Weve seen warning shots in recent years. The 2009 h1n1 outbreak. An hour dealing with the zika upright. I would consider these warning shots. Its incumbent upon us to maintain sustained attention. When i talked to my colleagues a number say were in the neglect stage. Its surprising were finding ourselves here this is not the first time we been here. Were very focused on the biological threats after the anthrax attacks. As time went by, attention diminished in the priority of funding diminished and were repeating that. Im hoping we can learn from this. In terms of whats least appreciated,s productive to have conversations about direct impact about the disease and Public Health. Inmates remember there will be secondary effects especially for dealing with an extreme pandemic. Will strain the Hospital System and maybe other systems like food, water, electric power. It be useful to draw lessons from the past of how these play out. What are critical vulnerabilities and how can we be resilient to the disease from Critical Infrastructure perspective. What would you consider new york citys greatest challenge and pandemic performance . As part of that, in terms of plans to get medicines to people should we be fortunate enough to have medicines available what you think are most likely to go wrong and how do you deal with that . I think for us its population size and density that comes into play. Being a port of entry. Anticipate this will hit us early and will have dramatic spread. Is one of the major strategies being social distancing that will be challenging especially with the public on mass transit. The other challenge is getting back to the resource issue. It the award has been cut dramatically since its peak in 2005. Spent a 37 cut in on the hps piece side a 38 cut. This is concerning. This is funding we depend on to get the planning done. Its also training and exercises. Its not the Health Department alone, springing together colleagues and what we invest in personnel. When the funding gets cut thats what gets jeopardized. For a general challenge what we been looking a lot at has been issues of equity in health disparities. You see them in emergencies and day today. When you talk abouts Case Resources and how theyll be allocated to parts of the population may be challenged and having daytoday access. How we get medication to the people is a multistep strategy. We have relationships with city agencies so we can take care of our first responders. Relationships to get providers to schools. In a robust dispensing plan. In 2014 we did a no notice exercise we over 30 pounds in less than eight hours. Were excited to see a culmination of a decade of planning to show that we could carry it off. Were proud of the robust relationships with pharmacies. We have many pharmacies and for working on getting Contact Information thinking through how we can utilize them. That just in a pandemic but other scenarios. Challenges its challenging for staff when its a vaccination scenario. During h1n1 it can be challenging but not insurmountable. Then how to maintain adequate supply levels. Concerns about trust, governments and people doing what we need them to do. You really need to have those relationships built in advance. In your view, what you think the committee is doing well in one of the biggest on met challenges with the organizations he been working with . The number one thing i would point to is the global Health Security agenda. Was an international initiative. Theres launched during the obama administration. Focused on reducing global risks globally. Theres things that are exciting about it. One is it was a focused effort to develop a shared set of goals across countries and different sectors, to prevent detector respond. A number of actionable steps were highlighted. Funding was committed by the u. S. Government to take those on. The intention was to have measurable progress were governments can be held accountable for results. Another aspect is that it recognize the ability to look at Infectious Disease outbreaks and respond is largely the same respective if its a natural, deliberate or cost outbreak. Read together Public Health community and the National Security to Work Together to build one system. Those were really productive aspects. Its good to see at the recent high level theres been a renewed commitment. The question now is if the resources will be there in the next five years. On the healthcare side, drill into that a little bit more. How do you think any city of the Healthcare System could respond to an event like a pandemic. What kind of bed and ventilators to rehab from National Stockpile, would that be part of it . As is true in the jurisdiction emergencies support system is the linchpin of all health and medical coordination. Weve been using hpp funds to build up the preparedness of the Healthcare System. The way we look at it the funds are used to bring the sectors together to address systemwide gaps both within sectors and across sectors. Provide support to facilities. We work with Nursing Homes and provide support for the primary sector. Pandemic was one of the things we work on. In 2013 we didnt exercise to test and were tested with 55 hospitals and all hospitals were able to discharge up to one third of their patients. Those for mass casualty. In terms of number of bed of ventilator capacity, and 22057 hospitals. We have 2000 bedside ventilators for adults in a thousand for pediatrics. We have an ongoing contingency contract which will be important to decrease health we been doing intensive work with Healthcare System on Infection Control including mistry patient drills worry bring in a patient document what the reaction is we check to see if theyve made changes. At a high level were finding that these could be strengthened especially around hand hygiene. When patients are getting the mass there is a delay. The bottom line is Infection Control needs to be more testing of staff to make sure its just the way the hospital is doing daytoday business and to maintain vigilance. In terms of the work that youre doing, can you talk about the opportunities for improvement where you see greatest opportunity for foundations like yours and focus on technologies. What technologies are worth investing in . For the community as a whole theres opportunities to get stronger in the prevention Detection Response areas. In particular because im thinking about deliberate misuse. Weve made progress in recent years in terms of advancing policy but we have a long way to go. On detection we have an opportunity to improve system for Early Detection and in particular the technology thats rapidly emerging. Theres innovative ways to integrate the and identify unanticipated outbreaks earlier and apply that technology in different settings. It could be a way to detect outbreaks early and enable us to get on top of those situations. For medical countermeasures something we need to think about as were not sure where the next pandemic is going to come from. We should be prepared to be adaptable. The technology that you think is most useful are ones that have broad spectrum. So potential viruses that could emerge particularly directed at the host immune response as opposed to the virus itself. Swallows platform technologies we heard from to enable us to develop new vaccines in response to novel pathogens. We have time for one more question each. But i like to ask is, how do you think other cities are doing . Where is here about new york because its a high performer. What is your sense interacting with the rest of america . To think other cities are doing as well . Do you think its a challenge for them . Whats most important thing for the federal government to be doing for cities and states . I started at the beginning of the program and its growth. Something ive learned so its valuable about planning is the process of the document. You should have tools that people can reference but its about the process. And thats something that weve learned is theres a lot of policy issues that come. Many you can work out in advance. Requires resources. There was dedicated pamphlet planning way back when. Often times with different scenarios you have a focus then it goes away. Truly about building all hazard capabilities that are flexible built systems that you can leverage for many events. The requires continued investment. The capabilities need to be maintained. For the gaps weve identified you have to address the gaps. Thats been challenging. I think we do have more resources than other places which tried to share what we develop. But ive talked to many colleagues across the country there really struggling to deliver on the baseline capability. Will u. S. What it is we need from the federal government. Continuing to preserve the hpp funding which is critical. Thats at the top of the list. Better defining roles of federal agencies in the scenario. This is not going to be daytoday business. Understanding what this is. We did Something Interesting after ebola, gutter federal and state and local partners together in a room and talked about what went well and what we could improve with a specific focus on coordination. Finally, guidance is coming faster. s. State and locals should be consulted. We found in ebola, some of the guidance came out when not being synced with urban settings and created problems around public communication. Jamie talked about this, beyond pandemic influenza your organization has an interest in preparing for the broader range of serious biological threats. What else are you worried about . In addition to pandemic flu . In addition to pandemic flu we think about engineer and manmade pathogens they could emerge. Were they could be engineered to be more resistant to our measures. We feel that could pose a severe pandemic risk. Its relevant to our interest in these events were concerned with. Thank you for being with us. [applause] [inaudible] good afternoon. Im a curator at the National Museum of Natural History where you are, where we have the wonderful mission of understanding the Natural World the place of humans within it. One of the great privileges of being a scientist in this museum is our connection and service to the public. At the smithsonians our mandate not only to increase knowledge but diffuse it. So there exhibits we reach millions of people per year. Im the league curator that serves a critical function of public communication about pandemic risks and threats. Its called outbreak. It opens in may next year. Outbreak places influenza and other viruses, ebola, zika hiv and others in an ecological context. We present human health, animal and Environmental Health is one health. We show how pandemics can result from a failure to recognize and respect that connectedness. We do this with stories. We demonstrate the principles where human impacts on Animal Health and Environment Health can be linked to human health. Such is the virus spilling over from livestock and causing an outbreak. We explain the human drivers, the activities that spread deserves such as Global Travel and trade. And how they can cause an african you are and threaten the health of people everywhere. We show the effects of a pandemic on human health and society. And the efforts needed to fight back by science and activism in healthcare policy. We illustrate the importance of community and breaking the curve of an epidemic in the cultural factors will always be a part of that. Last but not least, we explain the fundamental goal of research and the vaccines in preparing us for the next pandemic. Outbreak is a new kind of exhibits for us. Thats because Public Health is a new space for us. As part of our work as stewards of Natural History and a curator for collections. Its motivating and while it is true that our collections have value for research as we show the table, thats not the only strength were using in the situation. We have convening power which is demonstrated by this event. Its also show by the many free Public Events so we want to raise awareness. We want to motivate behavior change and catalyze conversations about pandemic risks and the public. Because pandemics are global were trying to convene a global audience outside the museum and city. A break will not only be in a subject, but a new model. We designed a second version that will pop up in a community anywhere in the world. Using free resources will provide digitally including a guide to develop Educational Programming templates to customize exhibits. Thats important to allow communities for vulnerable to epidemics to have us tools. To communicate reach their audiences. But the most effective messages in the most appropriate way. Oprah could not be possible without the support of partners. We been really fortunate. Our donor partners are listed here. A few of our content partners are shown in the photo. Some of our partners are here today is thank you to our partners will hopefully successfully bring to audiences thank you for your attention. Now, going to introduce her final speaker. Doctor Ellen Mckenzie is the dean of the Johns Hopkins Bloomberg School of Public Health in the school of emergency medicine. In addition to hundreds of publications and honors she was named as one of the 20 leaders and visionaries who had a transformative effect prevention in the past 20 years. Thank you. On behalf of the Bloomberg School of Public Health and like to extend my thanks to the panelists and speakers and collaborators. I got here early today and took the opportunity to Wander Around the museum. As reminded i hadnt been here for a while and it brought back childhood memories memories of taking my son here. Based on what you describe your taking it to the next level. Its fantastic. To thank our sponsors, the bill and Melinda Gates foundation and the wellcome trust. Special thanks for you being here and those watching online. As weve heard, Public Health scientists have made progress these efforts can help identify other emergency i methods of global and local surveillance has also improved as our capacity to manufacture vaccines. Reminded of other advances but also pointed to disparage these. In our ability to respond to a pandemic. More is needed to safeguard the population against another catastrophic pandemic. We heard from the beginning the push to develop the universal vaccine that protects against the wide range of strains must be at the top of our priority list given the current seasonal vaccines have limited efficacy. We also heard we might need to go back to the basics of our understanding if were to get closer to the ultimate goal of a universal vaccine. We heard the need for more global surveillance in both human and animal populations. Faster and more equitable vaccine. More research on antiviral drugs. In the use of innovative and exciting technologies and finally the improvement of detection on the Healthcare Systems run the world to respond to a pandemic. Ongoing Continuous Improvement of local Public Health infrastructure with an emphasis on multiple links is critical. We also heard that Effective Communication is critical. Health officials need to communicate Health Threats to the community in a way that can be understood and acted on in a reasonable way. As john admonishes, or officials must always tell the truth. All the time. Done. I am particularly interested in our history and i would be remiss if i did not acknowledge the input to remind me of this rich history especially with this pandemic. So known as the school of hygiene just as that great influence of pandemic from the Rockefeller Foundation it was of launch point for the work it just started the growth with leading of treating an epidemic disease the first chair was already an expert with the pandemic hit to. And at that time data was extremely difficult to collect much less interpret the frost worked with colleagues for those of the representative samples nationwide they revealed one of the defining characteristics of the 1918 outbreak we heard about today that the highest mortality were adults under the age of 40. So that the epidemic spread in this was for all subsequent efforts today the of methods are used to predict and measure those epidemics. I thought they would buy a year that tactic walking from house to house to confirm the diseases in a defined area. The pandemic was for Johns Hopkins students fighting with the epidemics intensified after the alumnus founded the epidemic at the Disease Control. Betty Bloomberg School graduates have gone on to the officers and in turn have since joined the faculty of the school. What of those officers that had a Successful Campaign to eradicate smallpox entered the school was the eighth dean and henderson was also pressured into with his piety your advocacy of the Emergency Repair disk and establish a center you heard about earlier which is now approaching the 28 university a anniversary. To other notables officers were sent to assess the cyclone that decimated east pinball per part of bangladesh. So the goal was to find longterm relief and recovery. That was a springboard for all student achievement for research and training at the school. Doctors ever became the ninth tee and then the chair of the department of over 20 years. This is the foundation for its rise of International Prominence with the valuation and policy. They have continued to work with to be using the issues against influenza malaria, hiv and others and fully established micronutrients to protect against Infectious Diseases. Using the Public Health tools of Laboratory Investigation or biostatistics the school has emerged as a thought leader during that existence along the scope of Public Health with evidence based of Public Health leaders. Were unrelenting in our pursuit of knowledge of type tested publicschool but bids from what we have learnt one day we will measure from Infectious Diseases at one in a million occurrence but again let me extend my thanks to all of you for coming in joining us on time we will continue the conversation on the social Media Channels with the school Global Health now website and now at the reception to follow the event. Thanks for coming. [applause] next, your calls and comments on washington journal. And then newsmakers. After that, attorney general Jeff Sessions testimony to the house judiciary committee. He was wearing military camouflage fatigues with the emblem right here and the initials kkk on his chest. Embroidered across his beret was knights of the kkk. He came in and was followed come right behind him by mr. Kelly, the grand dragon. When they entered the room and turned the corner, he froze. And mr