Transcripts For CSPAN The Next Pandemic 20171121

Good afternoon, everyone. I am the director of the museum and staff director of the museum of Natural History. It is my pleasure to welcome you to the next pandemic. Hopefully its not the next pandemic right here. You might think that the Natural History museum is not 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 frontiers in preserving 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 years 300 years preserved at acceptable by research scientists. Last year over 400 species were described by scientists working the building. At the same time we welcome 6 million visitors. Most of those visitors are tourists which means the next years a different 6 million, the world plus largest collection, visit by the Worlds Largest is the audience, and we live in Interesting Times with human population growing. There are so many things happening on the planet where humans interface in the Natural World and where it seems like pandemics can emerge. Just a couple of examples. If we were to go to the other side the building into the sixth floor, 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 because we had birds collected in 1918. We have those birds, and we sampled 25 of 26 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 the classic example is the hanta 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. It is an interesting time to be in a museum. 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 all related. We call it 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 genomics 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 specialists and the world and it will do the same thing for emerging Infectious Disease outbreaks. One of the speakers leader one of the speakers today is dr. 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 fate 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 influenza the story of the deadliest pandemic in 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. He was on the team that developed nonpharmaceutical interventions to the pandemic. He has 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] barry 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 start at 35 million go to 100 million. Adjusted for population, that would be approximately 150 million to 400 million today. Most of the dead were adults aged 20 to 50. Probably between 30 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 virgin 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, where case mortality was the lowest, the 1918 pandemic killed as many children aged 1 to 4 as today die of all causes over a 20 year period. It killed as many children aged 5 to 14. 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 million and 100 million americans, 2 billion people worldwide. That would overwhelm the medical system, use up 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 and research, particularly universal in 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. Particularly 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 effectiveness of handwashing. That data has not been touched. There is excellent data on quarantine by a brilliant pioneer epidemiologist, strongly not just suggesting i think proving that quarantines is pretty useless with influenza. Thats untouched. Maybe most important i think the data from 1889 pandemic and from 1918 and 1920 about the first person in a household to become sick with the disease. I think that would 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 implies 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 it ordinary influenza by another name. The surgeon Surgeon General of the United States that 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, 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 led to a loss of trust. It was alienating, isolating, and as a result, society began to disintegrate. As one person said, the disease kept people apart. You had no school life, no church life. It completely destroyed all family and community life. People were afraid to kiss one another. They were afraid to eat with one another. It destroyed this context and destroyed the intimacy that exists amongst people. In philadelphia, there was a doctor who lived 12 miles from his hospital. There were so few cars on the road, 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, another doctor stepped outside of his hospital and said i stood in the middle of Wellington City at 2 00 on a weekday afternoon and 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 not food, but because people were afraid to deliver food to them. The dean of the Michigan Medical School had seen a serious person not given to overstatement said that the present rate continuing for a few more weeks, civilization 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 an 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 wear 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 behaved 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. Sustained compliance will be much more difficult. In mexico city in 2009, for example, masks were recommended on public transit. Free ones were distributed. Usage peaked at 65 in four days later it was down to 27 . So if we expect compliance withe totally accessible, they need to stay ahead of internet rumors. Message is not from 1918, it is 2009. Planning does not equal preparation. There was a lot of planning done between 2004 and 2009. ,hen i very mild pandemic hit it was at this none of that it was as if none of that made any difference. Similar responses in china, egypt, france, and some to a lesser extent in the United States planning does not equal preparation. The biggest challenge to the Public Health community is to get political leaders to make rational decisions in crisis situations. And is where leadership the Public Health community really matters. Thank you. [applause] good afternoon. I am michael caruso, i am the editor in chief of the magazine all on your chairs. ,f you like what is in there we did the three stories in this issue about influenza. If you like what is in there, it is due to the efforts of our Deputy Editor and our senior editor. If you do not like what is in there, it is my fault. [laughter] ive one of those impossible roles introducing a man who needs no introduction. Im going to plow on anyway. To thinking about epidemics, everybody wants to talk to tony fauci. Manhas been americas point on Infectious Disease for 30 years now. He has led us through every crisis from aids, to ebola, tuesday got. Ika. Wo z he has received the president ial medal of freedom and his citation reads that it is for his commitment to enabling men, women, and children to live longer, healthier lives. With his broad appreciation of the public good and is l, hertisan nerves of stee oversees a 4. 9 billion annual budget. This event itself grew out of an gave to us dr. Fauci that was posed at another event of ours. We asked him what concerned you most . Pandemicr was simple, influenza. Ladies and gentlemen, dr. Anthony fauci. [applause] thank you very that kind introduction. Finding that encourage following that encouraging story from john, im going to tell you a little bit about the the step that i think it john was very clearly referring to about what we need to do regarding preparation. That is what im going to talk about. Preparing for the future and pandemic influenza. The first thing i want to do is to make the point that when you look at influenza, preparation for seasonal influenza essentially should be the preparation for pandemic influenza in a Perfect World. The Perfect World that i hope we get to we are certainly trying hard is the development of what john alluded to, the vaccine. I am 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 seasonal influenza vaccines are not consistently affected. That is a fact we have to face consistently effective. If you look at 2004 until the last year, when you have a bad year with a mismatch, you have a 10 efficacy at best. Efficacy at best. Compare that to other infections 98. 5 sles vaccine is effective, yellow fever, pouliot is more than 90 effective. There are a lot of reasons for that. We all know about the fact that the response against the hemoagglutinin drips from yeartoyear and sometimes shifts. Y of howa stark realit we address seasonal influenza. Pandemics do occur. Since then. Ree 1950 7, 1968, and 2009. The response after the fact is not effective. Alluded to the 2009 pandemic were we had a bit of warning. I want to show you what the response of us that were going as quickly as we could. It was the swine flu. That the nexting pandemic would come out of china or the far east. It did not. It came right in our western hemisphere somewhere around california and mexico. You recall and i am sure people in this audience do recall that 2009he end of the 2008 season, as things work cal down in march, all of a sudden we started to see a new kind of influenza. We felt, lets make a vaccine for that influenza. This is march. This is what happened in april so it was not a 1976, shoot from the hip, by vaccinating everybody. We knew we were going to get a pandemic. A picture of ais good friend of mine and i testifying before a committee saying that it is april it takes about six months to get a vaccine going. Now, ifart working to we have the vaccine by october, we will be prepared for the inevitable pandemic. However, what happened . The children came back to school and instead of having an epidemic that peaks in january and february, it peaked in september. What is wrong with the slide . The blue line is where the redline should be and the red line is where the blue line should the. Peakedcent of illnesses before he had the vaccine available. It would have been wonderful and peak in january. Even then with our current capabilities, it did not work well. On tom andexpression explainingsses about the vaccine that we were supposed to have we did not. The third thing, chasing after potential pandemic outbreaks. I refer to them as prepandemics. It is costly and ineffective. ,n1 thecall the h5 virus that started in hong kong. We took this very seriously and what happened . It was during the george w. Bush administration and he asked for billions of dollars and weise about 5nd we spent billion to switch from egg s. It ine a vaccine, we put the stockpile at, and nothing happened. We put a pandemic influenza Preparedness Plan we approved the vaccine, but we did not use it. Several years later, we had the h7,n9. It started in 2013. We were quick. We made a vaccine in 2013, we stockpiled it. Ande at the mini outbreak then what happened in 2017 and mutated a little. It was not protected by the vaccine that we developed for 2017. We had to go back again and start all over. What is this telling us . This is telling us my conclusion. We need to get a universal influenza vaccine. From a scientific standpoint, we will get there. We will if i get this. For about 30ef seconds, there are a number of ways to get a response that is universal against all viruses. One,f them, not the only when you look at the hemagglutinin it is very , can we go back one . Ok. There you go. Im sure people in the audience are very well aware of that that the part that is protected in the current vaccine is the head of the hemagglutinin that is the good news. The sobering news is that is the part that mutates or dress from season or drifts from season to season. It is one of the ways we to get aing to try vaccine response that is against the virtually all strains. I want to close on this slide. We had just written this for scientific american. Goal to spur us on to the that we need to do. Lethal 1918ter the flu that john just described, we are still vulnerable. Infrastructureth has improved greatly but without a universal vaccine, a single virus would result in a world catastrophe. Thank you. [applause] thanks very much to john and tony for those presentations. Our first Discussion Panel will focus on what scientists have learned about the 1918 influenza pandemic. From theew Microbiology Department from john hopkins. I would like to introduce our panelists. Jeffreymediate left is taubenberger. Laboratory sequenced the 1918 influenza virus. Recently, he has been focusing on development of universal influenza vaccines. In the center of our panel is cecile viboud. Theresearch focuses on transmission dynamics of influenza and other respiratory viruses. At the end of our panel is david ivanka david vaughn. He supports gs k efforts that can be used to generate vaccines against influenza or any other human pathogens. Towill be more than happy take questions from the group before we do that, i want to rt with a few questions o with the panel. Lab led the efforts to sequence the 1918 influenza virus. Can you tell us a little bit about your efforts to characterize that the virus and what that told us about that specific strain and how it mediated some of the incredible disease we saw during that outbreak . Sure. As aenza was known clinical disease in 1918, but viruses were not yet known. The idea was already waning in 1918. By the time the pandemic came and went, there were no opportunities to isolate the cause. 20 years ago, my lab use the molecular archaeology approach tiny fragments of the genome of the virus. Waseffort to do that difficult back then, especially with the technology available. The reason to do that was to try to understand the questions of where did this come from and why did it cause so much disease. A lot of these questions are still not completely answered but we have learned a lot information. The most important thing that i would share is that the features that made the 1918 virus as venereal as they were did not they arepecific shared with other influenza viruses especially in birds that share some of those behavioral features with some of the prepandemic viruses. Notmost important thing is to just understand 1918 as a antorical phenomenon but as example of what could happen in the future and use this information to help us to a bird, predict how viruses could a debt to humans, whats mutations would correlate , and ultimately what we could do to prevent it. Thanks. Spent significant effort on how pathogens spread in the human population. Can you tell us about what your investigation in this pandemic has taught us about the spread of 1918 influenza and whether it was really different from what we have seen from other pandemics are what we see with seasonal influenza . Yes. The uniqueness was the severity. Data fromw looked at other countries around the world , some involved with world war i, some not, and we see the severity and mortality rate was unusual and higher than what we have seen epidemics around that. Distinguished is thetive feature highest risk of mortality. Ages a very unique peak of 28 and all around the world. It is a combination of increased severity and young age group and protection of the related strain. And that is unclear really unique to this pandemic. We have look at historical pandemics from 1889 to 1918 to 1957, 1968, and 2009. They are all different. They comment odd times. They affect more of the younger population, but they are all quite different. For the future, we need to have systems in place to have information on what this pandemic will look like. Ok. David, in 1918, there were no pharmaceutical injections to help the pandemic. We now have antibiotics and vaccines available. Can you talk a little bit about vaccine and where you see it going in the near future to improve those tools . Sure. 1918, as jeff just pointed out, they were already working on vaccines. They were working on a vaccine for a bacteria it was not until 1931 that it was definitively shown that influenza was caused by a virus. 1933, we were able to grow it in a laboratory. By 1945, there was the first licensed vaccine in the United States. There has been some improvements since 1945. There have been improvements in the manufacturing process. A45 vaccine was eight vaccine for type a and type b. Valentnow moving to more vaccines. To grow use hen eggs the virus for most of our vaccines. But some companies are moving to cell culture to grow the virus and some are largely bypassing s togrowth of the viru express the proteins from the service of the virus to make the vaccine. We have improved vaccines for older adults by virtue of higher doses or by using adjuvants. 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. Doughty dr. Fauci pointed out, our current vaccines need some more. Need some work. The disease we are trying to prevent is very prevalent. Up to 20 of us will have an influenza infection during the course of a year. The viruses keep changing the, that is why we need a new vaccine each year. The efficacy is lower than for other vaccines. On the slide, and show the ferent efficacy estimates the efficacy was just 19 rate , therels us that year are one point millions of cases. Increased use particularly in pregnant women, we heard from john barry talking about pregnant women being a particularly vulnerable group. , there are two ways we are moving to improve things. Uci covered the idea of universal vaccines. Wewe are successful there, have a vaccine for any influential virus. This is a kind of vaccine that who is looking for for developing countries. Ths occur inza dea developing countries and very few vaccinations occur there. The second approach is to advance these new Rapid Response platforms. Gsk had such platforms. One of them was used to make a h7n9. Or h n scientiststo the that did that work, they tell me they could have done that and four days. Ofe we have these sorts platforms that are working, it then becomes quality control, release of product, and the regulatory steps that are on the critical pack. Path. There is much to look forward to. I will encourage anyone in the audience to ask questions. If you have a question, just raise her hand, and we will try to ignore knowledge yo we will try to acknowledge you. We will start with jeff. Do you think influenza is the most likely virus to cause the next pandemic or are there other microorganisms that pose an equal or greater threat . Future for influenza pandemics is always a good, strong that for what pandemics would be. There are some other respiratory viruses and animals in thatls that led to sars are concerning. Viruses insectborn zika that are concerning. The most is concerning. You have an enormous diversity of influenza viruses. Both birds and mammals these viruses mutate and canada and move between species and unpredictable way and can move between species in an unpredictable way. We cannot accurately predict what strains will emerge and that is the huge challenge. That, influenza and its natural vectors is such a very different disease. It does not cause much illness. These animals can be infected anda long periods of time go on migration patterns that could take them thousands of miles away that can introduce them to new reservoirs. How those viruses move around the world is mindboggling. Cecile, you have been doing a lot of work in understanding how pathogens spread in human populations. This is been fascinating to me as my center is working towards understanding seasonal influenza. Can you speak to how modeling efforts can inform our public to the nextponse pandemic and come up with interventions or ways to minimize the spread of viruses . Useful ing is very the context of a new pandemic. That might give you time and to your vaccine becomes available. Models are very powerful to do that. There were a lot of questions round around a pandemic in all of the models agree that there is no use, that the disease was too fast. In 2009, the Ebola Outbreak actives a really beginning and putting a lot of that and the outbreak trajectory and how high it is going to be every season 26 monthsahead to six ahead. Mentioned briefly in your answer of the first question gsk started from initiatives aimed at shortening pandemic potential. There is a relatively new facility opening devoted to those efforts. Can you tell us how that company is approaching the idea of making vaccines . Gsk has an working with the u. S. Government specifically the Biomedical Advanced Research authority or barta. Case, each vaccine, we treatment for influenza and i microbial system. With otherrking companies and i understand to date, they have 21 products in the stockpile ready for use. It is great but it is not sustainable. We need more and more products. The products we have reached the end of their shelf lives and need to be replaced. Interested to are move to the Rapid Response platforms. Gsk was partially motivated by the 2014 epidemic of ebola in west africa. We responded to that outbreak with our primary scientific partners at nih. We went from the start of a phase one Clinical Trial to the start of a phase three Clinical Trial in five months. It was too late. We need to be able to react faster. Gsk and many other groups are working towards these platforms. Have ordeal, we would improve our surveillance with identifying a pandemic threat. , posted to sequenced the cloud, Research Laboratories , createwnload it vaccine mainly in a computer, identify the gene segments that are needed, and then it would come down to different manufacturing facilities that are using that platform. World but the ,hen the pandemic threatens they interrupted their routine manufacturer, start making pandemic vaccine and within weeks or months, we have millions or billions of doses. Those are the sort of things we can hope to look forward to. That is an excellent point. Some of the work we have been doing is using seasonal influenza as the model system for trying to set up those kinds of realtime diagnostic efforts, sequencing efforts, identifying these pathogens, spread the word seasonal influenza is a great way to model what you would want to do a eventually in a pandemic. Some of those efforts you are talking about are not far away. At least for organisms that we understand well like influenza. We know what the target should be in terms of the head give a question . I know there is a lot of talk about vaccine. But what about progress on antibodies . Progress ond about antivirals and their role in encountering pandemics . There are antivirals against influenza but there only two classes. The problem is that influenza viruses can very often develop the mutations to make them resistant to these drugs. Toer classes of drugs need be made and clearly there has botha lot of research governmentfunded research as industry to try to develop new antiviral targets. I do not know how close those are to licensure. We are faced with the many often alreadyre resistant. Nothing to add except, the Silver Lining to the 2009 , the 2008 in our earlier viruses were beginning to pick up resistance to the new h1n1. Is an addedk there realization that developing one antiviral is great, having two or three is probably the ideal situation. In those situations as we have seen with hiv and the hepatitis you have aen cocktail of antivirals, then the likelihood of resistance coming up is decreased. That is some things to keep an eye on. I know there are a few in the pipeline and i know there have been one new antiviral drug licensed in japan but i do not think there are as many in the pipeline as there could be or should be. Im wondering about the state of the science regarding the immune response mechanism for protection against influenza viruses. You mentioned the antibodies against the hemagglutinin, however, i went to a session at a Clinical Center where scientists showed a better in alation with antibodies human challenge study. Ound it really interesting fairly recent, a few years ago and wondering if that has been pursued. There are always people who believe in ctels. I do not really have a meeting a feeling about what is known. T this point a 60 would not pass approval for any vaccine. I am sure that i cannot completely answer that question. I do not know that much more than what you have stated in your question. There remain a number of unknowns about influenza and the best way to prevent it. Having aplicated with series of infection that really complicates so the history is important as to how you respond to the vaccine. Antibodies will protect if there is enough of them. Betterrent standard for dy whichgglutinin antibo is meaningful by regulatory authorities. I can speak to the fact that i spent the morning at a meeting where vaccinesus were discussed and one of the first things that came up was just set of studies to better understand immune responses to infections and vaccination outside of the antiaging antibodies, and to get a stronger sense of what the natural course of an. Nfection i do think there is a much broader thinking that we need to go back and think about antibodies and t cells. We need to use that as a way to inform universal flu vaccine studies going forward. It became very clear that because we are socalled had some success with a seasonal flu vaccine, that we were ok. There was not a whole lot of going back to the basics. In very thing bit that we have hemagglutinin and that is what we use as the correlates of protection when we have not pursued as much as we should. If we are going to get to the universal vaccine that i was referring to, we are almost in some respects going to have to go back to the basics and ask fundamental questions of what the true correlates of immunity are. It is interesting in 2017, we do not know as much as we probably should. That was the conclusion of that workshop that you are at. Absolutely. Close my, im going to panel. I want to thank my panelists and thank you very much for your attention. [applause] good afternoon everyone. Im the director for the center of humanitarian health at John Hopkins Bloomberg school of Public Health. We are going to talk about preparing for the worst and is the world ready to respond. Im hoping we are going to get beyond the vaccine to other areas weather will not be a universal vaccine anytime soon and theyre going to be a lot of people that are sick and how will the Health Care Systems in Different Countries that will respond. We will have two speakers. Dr. Daniel sosin, the director and chief medical officer at the centers for Disease Control and prevention. He serves as a liaison to the cdc programs and external partners and the strategy and Program Coordination for phpr. Daniel, welcome. Thank you, paul. It is an honor to be here and to represent the cbc sciences and staffed who for more than 60 years have worked to address this threat of influenza and to improve the ways that Public Health response to crises. You have heard how the 1918 pandemic was an Unprecedented Health crisis and nearly 100 years later, the world has made major advances in the science of influenza prevention and control. Viruses, however, continue to pose one of the worlds greatest disease challenges and the risk of influenza pandemic remains. And alnerabilities pandemic relate to a virus, the susceptibility of our population, and the environmental factors that favor the spread of disease. By definition, a pandemic virus is one by which the population lacks immunity and is capable of transmission from person to person to cause severe disease. In addition to our naive immune people and a pandemic, today are more susceptible to Infectious Diseases because of diseases they have or therapies they have that therapies they take that compromise their immune system. Populations around the world and increased proximity to humans and animal reservoirs have increased the risk that a pandemic will emerge with extremely fax. N the at extreme effects time will be of the essence and early recognition of persontoperson transmission of a pandemic virus can make all the difference to an effective response. This is why ongoing Surveillance Networks around the world are so important. Many pathogens can cause similar symptoms to influenza. Diagnostic tests that are rapid and feasible for widespread use our critical are critical to understanding the pandemic. Pharmaceutical interventions such as respiratory etiquette, hygiene, social distancing can prevent disease transmission specific medical intervention is not available. Vaccines will be an important part of the response. Medical treatments for influenza and secondary infections can save lives if available. Effective Pandemic Response also requires Effective Communication with the public. Respondersr health so there is confidence in our recommendations and motivation to follow them. In 1918, we were sorely lacking in these capabilities. There was no national system. Viruses have not been discovered and there were no laboratory tests. There was limited personal protective equipment. Antibiotics to treat secondary bacterial infections and no antiviral drugs. There was no mechanical ventilation or intensive care units. In 1918, it was surely different today with respect to the variety of tools to share information. What is cbc due to lessen the threat of influenza . Cdc works with domestic and Global Health partners to monitor both human and animal influenza viruses to know what and where viruses are spreading, and what kind of illness they are causing. Cdc supports more than 50 countries and builds Laboratory Capacity to respond to them. Cdc studies more than 6000 human viruses ininfluenza the laboratory each year to better understand the characteristics of these viruses. Cbc develops and distributes tests and supplies materials to laboratories around the world so they can detect and characterize influenza. Cbc works with state and local government, the world health organization, and countries. Effectivenessthe of pharmaceutical and nonpharmaceutical interventions. Cdc helps global and domestic experts choose and guides Pandemic Development pandemic Vaccine Development. Cdc monitors influenza vaccine distribution. The u. S. Manages Strategic National stockpile and support Public Health departments across the country to ensure their medical supplies are available when and where they are needed. Cc cdc also informs the public about influenza control measures. Cbc works at home and abroad to improve theto efficiency and interconnectedness of the Public Health response. Each emergence of a new virus 7n9 buyers in china virus in china, they work to characterize the virus and investigate transmission patterns and severity. Since the 2000 9h1n1 pandemic, cdc has reviewed and updated 2000 9h1n1 pandemic, pandemic,2009 h1n1 cbc has reviewed and updated specific tools. A strain is scored on 10 factors for the likelihood that it will change to infect people and for the potential severity if it does. Frameworkic severity isonce a nighovel buyers identified novel virus is identified. Guidelinesitigation provide the latest Scientific Evidence available on non pharmaceutical evidence to slow the pandemic virus. Made . Ogress have we do the global investments, there is a global influenza response system with mechanisms to quickly share laboratory information. Laboratory capacity has shown next has grown exponentially in recent years. There are greatly improved tests there is personal protective equipment to prevent transmission particularly in health care. Vaccines are stockpiled for pandemic use. It has expanded in the last decade. Are three recommended antiviral drugs to treat infection and the many antibiotics to treat secondary bacterial infections. There are mechanical ventilators to care for patients. There is a one Health Initiative to increase interaction. We are now experienced in presenting information through a variety of media channels. While tremendous advances have been made, there is still much to be done to improve pandemic preparedness. The 96out one third of countries that signed on to the International Health regulations in 2005 currently report having the ability to assess, detect, and was on the Public Health emergencies. To improve, we need to fulfill the surveillance gaps. We need better surveillance of influenza viruses circulating in birds and cakes. The ability to share physical specimens needs to be improved. Vaccines must be more effective, mores broadly more broadly, and available more quickly. Better personal protective equipment is needed and needed an large supply. Better, less costly influenza treatments are needed. There are large parts of the world that do not have the medical infrastructure and equipment to treat severely ill patients and they must be supported. We need to manage the demand on health care. In conclusion, much progress has been made, but we remain vulnerable to an extreme pandemic. Influenza viruses are constantly changing requiring sustained efforts to anticipate the response. The number of novel viruses detected is increasing. A weak link in global preparedness is a threat to all countries. Achieving Global Health security must remain a priority to lessen the threat of pandemics. Thank you. [applause] thank you. Dr. Cirospeaker is ugarte. Perugan his career in working in general practice and in 1987, he was appointed as regional director and later Deputy Director general of the National Institute of occupational health. He served as the director general of the National Defense and Relief Office in the ministry of health in peru. Ugarte guard take dr. Also serves as the United Nations task force toward nader for this country. As theently serves regional advisor for Emergency Preparedness in washington dc. [applause] hello. How are you doing . Very good. I am pleased to be here because thegage very well with previous presentation on how the world is prepared for the next pandemic. The presentation that i will give you is regarding the International Response to a potential pandemic. One of the conclusions of International Response is that it should be to improve the coordination with National Response you have to be, mentoring to a national you have to become elementary you plementary to a National Response. Support istional crucial. How the world is performing on that it is related to the it International Regulations capacity. It was improved in 2005 and began in 2000 four and 2007 in 2007. The countries are not there yet. Most of them have requested an expansion to reach those capacities. The last extension was provided in 2014. In america, only 13 of the 35 countries have reached that level on a selfassessment aspect. They say they are there. How are they performing in terms of those capacities . You see here how the country stopped performing one year to another and you see for example and then year is 2011 we go to 2016. We see the capacities are increasing and legislation and National Focal point so in order to come you see that a chemical capacity and biological emergencies are also increasing and for the first time, more than 60 of the countries are now able to reach those capacities. We see that the study of those capacities in terms of which of , we see that the caribbean region is still lagging on that. 80 of the countries have reported and we see that in certain capacities are very low. We see also that central and south america are very high in terms of most of the Infectious Diseases related capacities. How are they doing in terms of their contact . We test those contacts. Years that thehe conductivity test like email for example is about 90 . The first 24 hours of that. The connectivity test by telephone, by the next hour of , is by telephone. They are reporting. How are we doing . On the points of entry . How are we doing on the points of entry . Parties. Ving on state we have the final report, it is not there yet, but we have 64 ports in 31 of 35 states. 78 airports. 22 ground crossings. We are moving around 500 authorized ports. We are moving towards the points of entry. We are not there yet, but we are moving towards that. In a couple of weeks im going to do the third exercise and a road in terms of points of entry. Those types of reports that do have entries like easter islands in all this. These are the events that are being reported by who is reporting on that. The National Focal point is the dark yellow or orange. You see more or less 40 in 2017, so it is sufficient but you see that there is a large amount of events not reported by the governments. So how can we say that they dont have an outbreak of the government or the National Focal point is not sharing that information . What is the type of events 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 year. . How is the system reporting going in other regions of the we see here. For example, we see the huge difference in the reporting in americas because we work with the government and the country and convincing them along with several others in the region, so overwhelmingly most of the reports come from the americas. In comparison with all of the other regions, we see that in the South East Asia and west pacific region, so clearly the americas are overwhelmingly the best prepared in terms of alerting. Lets see what is happening in surveillance. All the countries without surveillance and with surveillance. They are not reporting actively. We saw official reporting an unofficial reporting. How are we doing in terms of reporting on the biographical biological data . The light blue is more than between 50 and 74 and all the countries are still important that our reporting less than that. What are the differences from those falling into tracking how many samples are being tested . Had six shipments of two or more shipments in 2016. Forward, wees going are doing much more reporting on that. This is the number of samples tested by the National Influenza center. The number of tests are in the tens of thousands. Nearly 70,000 in 2016. Is this enough . We do have the surveillance tools that are being applied on top of the tools. The biggest on top of the tools. Once the pandemic influenza,s, we will must we most likely know through the media. It would be extremely difficult control the pandemic once it begins. It happened in the case of mexico city. We had huge challenges to control their and the biggest problem would be so it is a huge political thing. What happened in the 2009 influence are you . . United nations were important partners. Lso u. N. Agencies not only reduced their participation but they became victims. We have to provide support to the u. N. Agencies in the affected country and some goarn members. The global outbreak and Response Network maintained their institution objectives rather than the overall control of the etch demic. So we do have issues there and still we have interagency work. We work a lot with all those partners on the global outbreak but the problem is that each of those institutions have their own mandates, their own interests and then when we come, the biggest challenge is the coordination, why . Because everybody wants to coordinate but nobody wants to be coordinated. Its a difficulties task to do that so we need to politically endorse the documents, ensure coordination among established organizations but also establish rganizational coordinational procedures. Were working on. That 24 nations are sending delegates this week to ordinate the response to endemics. We have to on productive duplication competition, we have that. We see that even inside the in ries and we want to be the and convenience rather han and the so we dream a lot. We dont sleep enough. And the final goal, to enhance national and International Capacity to respond. Complete interglobal response and capacity and improving the quality of federal assistance. Thank you so much. Thank you very much, ciro. Senior, senior enlightening. We will be taking some questions. I will start off a bit and its hard to see with the lights here but i hope that you from the audience be have some questions to our colleagues. Dan, i wanted to start with you and youve mentioned many of the key responses that would occur beyond just when an epidemic occurs beyond just the vaccination. One question i had is if you could compare what did happen or did not happen in 1918 compared to what you believe would happen now from everything from ventilation, from the antibiotics, but also talk about the capacity even here within the United States to be able to respond. Yeah, so i had a list of a variety of capabilities that we have today that we didnt have in 1918 and a lot depends on how severe the virus is and how transmisable the virus is, obviously. There are limits to what even in the United States, our Health Care Capacity is and our ability to provide antiviral medications, ventilator, respiratory support, all those have their lifts. So i dont have direct numbers and programs, doctor, you do, on modeling todays therapeutic and Public Health interventions on the population then but its clear, even with our more modern pandemics in the past few decades that we have much greater capacity to respond and we would expect to respond more effectively to a 1918like virus but we could have one more transmissable and more severe so thats why all this work across the sprect rum, including universal vaccines or better vaccines is so critical. Thank you. And ciro, even within the americas we see the disparity amongst many countries in the americas. Can you talk about the differences you may say in some of the more responsive countries, you dont have to name them, and the differences that may occur in terms of both preparedness but in particular in response. And maybe you could use mexico as one example. The question is to try to get at the differences in the exavelts of varlse countries even within the americas never mind in africa or other areas im more familiar with. The most important aspects of the countrys capacity to alerts and share information is that the National Focal point or the National Health offices that have to report that theyre empowered to do. That in most of the cases they have to filter the sharing of the information through the political channels and you know immediate limb when they reach that level, it is economic million it is facing. So nevin pandemic influenza in 2009, we saw that many countries that did have the capacity to, lets say detect, they were not reporting because the Economic Impact would be huge, and thats some of the aspects that do happen the in the americas. Motives of them are able to detect. Not necessarily the specifics of it, but they can report and in some countries, we do have that delay. Not necessarily only the countries that we saw in the picture of those that dont have a swainls capacity but most of them, they lag on. That mexico showed by example that they were able to report almost immediately when they discovered that there was something new, different. And they declared emergency, the response happened almost immediately. They welcomed many partners. Itches there coordinating response for the first two months and we sauna the capacity was there but some of the officers that were in charge of pandemic influenza were moved out of their offices a couple of weeks before that because of anywhere reorganization and because of political reasons they were not brought into that. It happened also in 2008 in the yellow fever outbreak in paraguay. I had to convince the minister of health to appoint the person who knew more about yellow fever , that was an added position. The political officials whoa are the ones who will make the difference in my opinion. Not necessarily the health aspects. Interesting. Opening up for questions. Please raise your hand. Yes, we have one at the back. Theyre coming to you right now and please introduce yourself. Im terry from Smithsonian Magazine. A question for the doctor and that would be if you could comment on the impact, if any, of the Current White House strachingse on the ability of the c. D. C. To respond to future near future influenza pandemic. Sure. Pretty much everything i talked about, the type of work were doing continues to be supported. There are many potential changes coming in the future which i cant predict myself, much less a pandemic so i feel that the kind of work, the areas of work that we are working on continue 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 by hook or by crook were going to figure out how to keep doing it. I cant speak to political changes which may come in future budgets. I just hope and pray that we get the resources we need to continue to do the work we do and if nose resources change well figure out how to change and do the best we can with the resources we do have. Are there any other questions from the audience before john . Please. Two questions. Ill name one of the countries that was slow to report and that was brazil. I know for a fact that there was a back channel fielding information from epidemiologists in brazil to the white house during 2009 and the white house was telling the source that they were getting information two weeks faster than from the government. But my question actually, and i want to applaud you for you certainly did tell the truth. I really appreciate your presentation. It seemed to me that mexico also told the truth and got punished for it internationally and im wondering if, from your perspective, things have improved at all. Thank you for those two questions. Very important questions. Brazil, though, after that problem, requested to do extensive evaluation of h1 h 2001 response. Brazil had communication 12 weeks later than it actually happened and it caused the Southern States of brazil to have the highest fatality of h 1 n 1 2009 in the world so they modified anywhere procedures and up to the last three or four years they improved a lot on those things. Ok . Yes, mexico was punished. Paraguay was punished. Haiti was punished. Peru, my country, was punished after a coal reoutbreak we reported on time, the second day, and we were punished. What was the punishment . Economic punishment. Pandemic in mexico. Irrational because of the fear. Fear causes all these decisions in extremely fear related decisions. Closing borders. Stop all the importation of products not relateed that with that stopping counter rich, events. Just the relations. 180 spent more or less million on the Health Response to pandemic influenza. Overall cost just on the first wave of the pandemic in mexico was 9 billion. You make the math. And who else was coordinating the response to h 1 n 1 in the mini City Ministry of health. So the preparedness is the security sector, the tourism sector, the entertainment all the other sectors have to be there in order to respond. We have that on paper but in reality the National Emergency management officer in mexico sorry, i will say that because i was there was not allowed to enter to the coordinate nation meetings. I had to negotiate with the health of research to let her get in and that was the femalike director. The chief of femalike. We see those types of things and then we see where the fear is coming from. Yes, most of the countries are prepared but not at the level of political willingness, to control the Economic Impact of this. For example, you see the Health Impact and you see the Economic Impact, its overwhelming large. So were not touching the proper bottom there in terms of preparedness. Excellent. Thank you. I will have one more question but i want to make sure that because we have a couple more minutes left. Any other questions from the audience . Ok, what point is exactly what you were saying is that the Health Response is a huge but one component of a much broader and weve seen this consistent lip. You mentioned ebola. Weve seen whats happened in polio. The political response and the economic response are special but essential but the other thing and jon barry mentioned this, is the community response. I know its extremely different but what we saw in ebola, we learned that the community. Response was just as important if not more than others. Dan, you mentioned the communication guidelines for c. D. C. We have two minutes left but starting with dan and si ciro, talk a little bit about the community, either about your experiences but also how you think you can address the communities to make sure theyre supported . A decent response as oeasy toed oppose told just fear. I jew same jim here from the association of state and Territorial Health officers. C. D. C. Works to provide assistance support guidance to officials who have the authority to do this work at the state and communities level. This isnt the breadth of work that happens in a communities level. These are the nonpharmaceutical interventions that could delay or stall certain aspects of the pandemic. Prevent some diseases and spread it out over time to lessen the burdenen on the Health System and the Public Health system and we have more data because of the 2009 pandemic so there is more confidence in these measures and a little bit more information as to when they might be most effectively applied to give givense to those state and local Health Officials to take action at an appropriate time. I do believe very strongly in the message that jon barry gave us about communication and officials communal indicating. We know a lot more about Effective Communication in Health Crisis and working as best we can to get middle leadership to follow those pretties will be key here and and lastly, i want to respond to the point that the Health Leadership kept out the rest of the Emergency Response leadership. In the United States weve been working for the past 15 years to get Public Health at the table. Its been an important and challenging journey to get there. I dont see us ever having the lead in a National Response of this name but having a voice and letting scientists be at the table with the Political Leadership has been very important. Community participation is crucial but the first thing to have a Community Participation is their trapped in the authorities that were telling them what they do and if they dont trust the Health Officials or the government in an everyday basis, why will they trust them in a crisis . So it is a very complicated aprotect. We have to build that just telling the truth is important but telling the truth all the time. Not just in time for emergencies. Those things happen, and also if we are able to convince persons from different perspectives telling the same message and during the coal reoutbreak in per cholera noub peru, we managed to have one of the lowest outbreaks because we convinced act damea and also the college of surgeons and the media to help us. We began with between 12 and 24 recommendations and then we came up to three recommendations knowing that. Communication will only work if we do crisis communication so telling the people that we are talking taking care of them but telling the truth. Not expanding, that not diminishing the risk and that will build the community. Participation. Communities are not able to respond to all emergencies. Thats a dream. That will not happen. That dream may transform into a nightmare, no . So it is the risk crisis communication and also the trupt in the government thattle make the difference. Thank you, so i want enormous to tell the truth all the time. Utopia. Youre still a dreamer and you work for thats wmple. I want to thank ciro and dan very mucher for their very insightful comments today. [captions Copyright National cable satellite corp. 2017] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] hello. I am tom and i am the director of the centers for Health Security at the Johns Hopkins block bergs school of Public Health and our centers mission is to study epidemic risks and to work to diminish the consequences of nose. And it is my failure to introduce dr. Sally phillips, the Deputy Assistant secretary for policy at the office of the assistant secretary for preparedness and response at h. H. S. Sally is responsible for policy development, strategy and overwhelm coordinate nation of activities that were talking about today within that office, which is one of the most important offices of governments alongside f. D. A. And others in the federal family working on neets issues. Before sally was in this role, she worked at the department of homeland security, at the agency for health, quality, and research and on the hill prior to that for a number of years. I think its fair to say that if youre working on pan gemic preparedness in washington, you know sally and sally knows you. Were very fortunate to have you, sally. Come on up. Sally can you now relax. There are no power points. Dr. Bob is our assistant. Secretary for preparedness and response and was hoping to be here with you today but he sends his regrets and im delighted that hes not here because i am. But i did wants to share a little bit of his view since many of you havent had an opportunity yet to react with him and hear some of his proposals for possibly changes. In this everchanging threat land same, his view of preparedness and pandemic preparedness particularly articulates a strategy where strategy implementation and the should ben of process based on a threat land same. We mean any threat to the health of the american people. These may be naturally occurring, such as diseases, extreme weather. Accidental. Service bio safeties incidents and labs or deliberate. Cyberattacks on the Health Care System. We recognize that no no order to have a effective response, the systems we put into place must be adaptsed to whenever threats were faced with. We develop strategies that focus and hone in on federal resources and supports to state, local, transcribe terrell stakeholders as they develop strategies. He asmse to do this through four key priority areas. First, to provide strong leadership, including clear policy directions, improve threat and situation awareness and secured a quality resources. Second, to seek the creation of a National Disaster Health Care System. By better leveraging and august menting existing Programs Service the Hospital Preparedness Program and the National Medical system to comp a more coharnltse, henceive system. Third, support the steanlment of robust and reliable Public Health capabilities, includesing an improved capabilities to detect and diagnosis Infectious Diseases and other flements as well as the capabilities to rapidly dispense medical Counter Measures and fourth, to capitalize on advance Bio Technology and science to develop and maintain a ro bulls stock pipe of safer vaccines, medicines and supplies to respond to emerging outbreaks, pan dem exand chemical and nuclear emdemic and attack. R goal is to save lives, protect america from threats. They released an update in june on the plan. It was developed with our partners and expands on concepts outlined in the original 2009 plan. Acknowledge the advances made in science and research and our outdoorlines for continued improvement across key domains. Kneels across swainls, community. Mitigation measures, development of medical Counter Measures. Health care systems and infrastructure preparedness. Domestic and International Response policy. In 2007, weve made progress in addressing many needs and were better prepared now than we were in 2005. Specific fully, supported state ask local partners of development of their own plans. Weve worked with partners to expand the definition of who can vaccinate and when in what settings. For example, 10 years ago you had to go to the doctor or to the hospital to be vaccinated for seasonal flu. Now you can go to your local pharmacies. Allow for wilder distribution of medical Counter Measures. The Research Development Development Partner has developed and licensed new cellbased vaccines for seasonal and pandemic influenza. It was create told bridge the valley of depth with. Flexible, nimble norlts and multiyear funding to have partnerships with cutsing edge super tiles. Theyve developed 34 f. D. A. Licensed products. 14 products of the Strategic National stockpile are ready for energy use and significant lip expanded pan delic influenza domestic advantage seals advantage seen capability. Weve expanded from 6730 million to 600 impact over the last decade thanks to significant United States investments in both egg and cellbailsed vaccine manufacture rerg infrastructure. Barta has also slerpted the antibiotic product development. With respect to the Health Care Systems preparedness, the Hospital Preparedness Program in the past year released new guidance, documents for its awareness and health care coalitions. The funding opportunity nouncements for 2007 through 2022 corps active agreements was reels and would outlines program equirements for c. B. C. And others. The preparedness response exainlts represent the ideal statement of readyness for the Nations Health care system. Ese build and improve upon h. P. P. s capabilities. These new prablets comment the Critical Role during pandemics and other emergencies, focusing on operation a. M. Health care coalitions for effective response. For example, to achieve the refined medical research capabilities, timely and officiates care must be delivered to patients when demand exceeds available supply. It also requiring Health Care Organizations and colations do litigations to take specific sticks stems towards advancing therrian preparedness. They also emphasize the importance for planning for standards of care, which may play an important care during man dem. When the lake system is difficult, its critical to have inclusive planning process, including health care departments, hospitals, e. M. S. , clinician, legal and experts to name a few. The National Training centers were created after the 2007 2014 ebola pandemic. They established the National Ebola training and Education Center through a joint agreement that began in 2015 and will end in 2020. Its facilities that successfully treated a confirmed patient with ebola in the u. S. During the 2014. Outbreak. The technician is to increase the competency, to improve the exablingt of Health Care Facilities to deliver safe, first quarter, and effective care to patients with ebowla and other path again path generals. Theyve developed methods to measure meth Health Care Readiness to care for parents with hype Infectious Disease. Theyve contained over 3,000 and completed over 3,000 site and readyness assessments. Created a suite of Educational Resources related to exercises in training and established a phone line for federal partners to provide emergency consultation with Health Care Facilities requiring snoivens with potential cases of Infectious Disease and lastly they launched a specific Pathogens Research network in 2016 to create a special platform for the study of special path generals. 2018 marks the 100year anniversary of the 1918 influenza pandemic. Its important to realize realizing and celebrate the significant advancements made. However, key challenges rainfall. We will continues to develop better ways to respond to and recover from pandemic outbreaks and also those of other emergencying Infectious Diseases and release of agents whether accidental or intentional. Thank you. Just have time for, i think, a couple of questions and you talked a little bit about the Health Care Program that asper is managing in federal government. Could you say more about government, what did we all learn in the experience of ebola when we tried to take care of highly contagious parents . Thing some ways it caught us a little off guard. We deal with infectious parents every day in the hospitals. We Infection Control nurses, we have systems in place to monitor and track Infectious Diseases one our hospitals situations but bringing something guard as unique as this put a challenge on to how it is transfers official and what are the other levels of care which when we dont really know the cause and something we have dealt with. Has put a call on to revisit. When i was a nurse we happened Continuous Education classes almost on a weekly basis. A lot of those programs hadnt been placed in hospitals where we were bringing people back together and reindependent grate their knowledge base. Ebowl avel gave us a wakeup call that we need to put an else on Infectious Disease and not just the things we were used to coing and the knost commonly there was fear involved in the Health Care System. Providers trying to get ready. It placed a new challenge on education and training. For people who are how did the federal government interact with hospitals in america . The ability of communities is informed and enhanced by the Health Care Provider communities. It is a reception to the Hospital Preparedness Program. It is a communitybased focused. We are trying to build a coalition of people within the region so that when a pandemic thes up, we can share resources of the community. Related to the program that stands emergency workers to hurricanes and responses to disaster . That is a separate program. That is shortterm employees, physicians, nurses, from all over the country who volunteer to be temporary employees with us during National Disasters. We have teams activated during a response and go in for two weeks and provide care. They do a rotating system. The last three hurricanes challenged our ability. People did more than one tour to meet the health care needs. Support the and medical care needs during those events. One last question. Firstrd a lot from the panel about Vaccine Development. What is the rule of barter in your office to how it relates to the cdc and nih . Barta takes the work of nih and fda and role it into advance Research Development. In the last stage they are a partner along the chain. Processed e artats the process and b takes it up during the end. Thank you, sally. We appreciate it. [applause] let me invite the next panel up. I am very happy to be moderating this panel and i am here with two widely respected people to talk about these issues. On my right is marissa, the deputy. She directs programs, operations, strategy for the departments Emergency Preparedness and response work, including oversight as it relates to the Health Care System. She is basically responsible for directing pandemic preparedness for new york city. To her right is the Program Officer for bio security at the open philanthropy project, they are dedicated to making grants in this area. Leader for the last 18 months where she has been getting grants around the world to diminish pandemic risks. Prior to her work there she worked at the department of defense and on the Global Health security agenda at hhs. I will turn to them in a moment with questions. Im going to start with a few observations. To place the pandemic in a local context, it is worth looking back at what happened in 1918 in baltimore. Here were 600,000 residents over the course of one month, one in four people became ill with influenza. 2 died. In one month more than 3000 people in baltimore died of influenza. Every sector of the workforce in the city was affected. Impaired. Ion was trade with other parts of the country were impaired. Ethnic groups or scapegoated. It was devastating. Event in the life of baltimore. Attempting to think of today we would be able to escape that , ael from our sensor pandemic the scale of 1918 would require seven times the number of ventilators that we have on hand in terms of the number who would require medical care. My last point before we turn to questions is that no matter how you slice it, how the people on the frontlines lines respond to a pandemic will have enormous consequences. We have to talk about the global and federal issues. We have to also focus on the doctors and nurses in Public Health agencies that are doing so much work to prepare our country. With that we have someone who has been focusing so much on that to start our discussion. Marissa,nt to ask maybe you could take us through the pandemic efforts and a high level in new york city. How is the city preparing . It is worth starting to say in the past we have conducted an analysis and pandemic flu ranked number two. This is a threat we take very certaintyand we feel this is something we will see in our lifetime. The point was made earlier about the Health Department taking the lead. That is definitely the case in new york city but it is a collaborative effort. We cannot respond alone. The lead ine driving planning, it is very much in partnership with the fire and Police Departments and the Health Care System. They are critical. We planned for both mild to moderate and also severe scenarios. Our goal is to limit impact and spread. We do not assume we will prevent this from entering new york city. This is about how to we limit the spread. We break it down into objectives. Surveillance, antiviral distribution, health care ,upport, Mental Health communication and outreach. The other two point is that it is a living document. Events, from previous we started writing the initial plan in 2006. A lot has changed since then. We learned a lot from h1n1 and also a bola. And also ebola. We also did an exercise in 2013 that informs our planning. On publicry dependent health Emergency Preparedness funding. Without the funding we would not have the dedicated resources to focus on this type of planning. Great. Lets turn to jamie. You have spent the last 18 months wandering the country looking for the most impactful ways to prepare. Youve talked to universities, laboratories, governments. Whathave you learned and do you think might be the most appreciated part . Me excepth surprises for one thing. We find ourselves in a cycle of panic. Means is while there is an acute response in reaction , as soonics like h1n1 as the acute phase passes, it does not continue to be a priority at the highest levels of leadership. So this thing that is surprising to me is how quickly that happened after the acute of cola crisis acute ebola crisis fadeaway. We saw a full outbreak in 2014. I would consider this a warning shots. It is incumbent upon us at the federal level to maintain sustained attention. When i talked with my colleagues in the field, a number of them said we are in the neglect stage. It is surprising to me that we find ourselves in this place. This is not the first time we have gone around this merrygoround. We were also focus on the biological threat after the 2001 anthrax attack. There was a lot of funding. But as time went on, attention diminished and funding diminished. We are repeating that. I am hoping we can learn from these warning shots. In terms of what is least appreciated, it is productive to have a lot of conversations about the direct impact of the disease on Public Health. It is also important to remember there will be secondary effects. Especially in dealing with an extreme pandemic. It is going to strain our Hospital Systems and other systems like food and water and power. It could lead potentially to conflict. I think it would be useful to draw lessons from the past on how these effects play out. What are the critical vulnerabilities and how can we be resilient to the disease and critical a infrastructure perspective. What would you consider new york citys greatest challenge in pandemic preparedness . And in terms of plans to get medassets people, in terms of plans to get medicine to people, what is most likely to go wrong . As new york city, for us, the population size and density that comes into play. Also being a port of entry. We anticipate this is something that would hit as early and have dramatic spreads. As one of the major strategies being social distancing, i think that will be very challenging, especially with a public so dependent on mass transit. 5 Million People ride the subway every day. Is other big challenge resources. The fhp award has been cut. 37 in new york city. Concerning because this is the funding we depend on to get the planning done. It is not just about planning, it is training and exercises. Health department alone. It is bringing together colleagues. A lot of what we invest is in personnel. When funding gets cut, that is what gets jeopardized. Of a general challenge, something we have been looking equity and issues of health disparity. Something you see day today. When you Start Talking about how would thees, resources be allocated when chunks of the population will not have daytoday access. That is what we worry about. In terms of how we plan to get medication to the people, it is a multi pronged strategy. We have relationships with city agencies that have medical divisions so we can take care of our first responders. We have relationships with providers to get medication to schools. During h1n1 we did a Massive School vaccination. We were excited to see the culmination of a decade of planning. The other thing we are very proud of is we have built robust relationships with pharmacies. Of the pharmacies are mom and pop pharmacies. We have really been thinking through how we can utilize them. Not just in the pandemic but in other scenarios as well. In terms of challenges, it is whenchallenging to staff it is a vaccination scenario. Not everyone can vaccinate. That limits our personnel. Found largescale vaccination can be challenging. Truste issue of how to the government and have people do a we need them to do. You need to have relationships built in advance. Jamie, what do you think are the biggest unmet challenges with the organizations you have been working with . The number one thing i would point to in what they are doing well is the Global Health issue. Was an international there was an International Initiative launched during the Obama Administration and it is continuing. Reducing risksn globally. There are a number of things that are exciting. What is it was a focused effort to develop a shared set of goals across countries and different threats. O respond to actionable steps were highlighted and funding was committed by the governments to take on those tasks. The intention has always been to constitute measurable progress where governments can be held accountable for results. Aspect that has been productive is it recognized that the ability to detect outbreaks and to respond to them is largely the same whether it is natural, deliberate, or accidental. They brought together the Public Health community and the National Security community to Work Together to identify and share. Those were really productive initiatives. See theretening to has been a renewed commitment to this initiative. The question now is whether or not the resources will continue to be there in the next five years. Marissa, on the Health Care City how do you think any could respond to an event of magnitude . What kind of respiratory capacity to be have on hand for pandemics in new york city . I think as is true in all the jurisdictions, our Emergency Support system is the linchpin of coordination. Using our hpv funding to build up the system. Are used to bring all the sectors together to address systemwide gaps and build coalitions and also to provide support to facilities. We work directly with Nursing Homes and provide support to the primary care sector. Pandemic flu is one of the scenarios we work with the sectors on. In 2013 we didnt exercise to test medical surge and rapid discharge. We just we tested with all 55 hospitals. All of them were able to discharge up to one third of their patients. We feel this has applicability to a pan flu scenario. In terms of ventilator capacity, we have 22,000 licensed hospital bed. Ventilators bedside that could be used for adults. We have an ongoing contingency contract and we have set up a nurse triage line. The ebola money, we have been doing intensive work with the Health Care System on Infection Control including doing mystery patient drills in every hospital. We bring them in and we document what the reaction is. At a high level we are finding that Infection Control levels can be strengthened especially around hand hygiene. Infection control needs to become more routinized with more testing of staff to make sure it is part of the way the hospital is doing their business and to maintain vigilance. Jamie, in terms of the work you are doing, can you give us a sense of the opportunities for improvement . Where you see greatest opportunities for foundations like yours, and maybe focusing on technology in particular. Which technologies are worth investing in . Ice i see opportunities to get stronger in all areas. On prevention, in particular because i am thinking about deliberate risks, there is an opportunity to get stronger. We have made a lot of progress in terms of advancing policies but we have a long way to go. , we have an opportunity to improve our systems for Early Detection of outbreaks, in particular the technology that is rapidly emerging that could be useful is the next generation frequency technology. We can integrate that to a clinical setting to identify unanticipated outbreaks earlier and potentially apply technology to environmental monitoring. That could be another way to detect outbreaks early. In terms of medical countermeasures, i think something we need to think about is we are not sure where the next pandemic will come from. We should be prepared to be adaptable. The kind of technology i think are most useful in the space are ones that use diagnostics. Antivirals are not only against flu but against other hazards that could emerge. Also platform technologies we heard about from other speakers that can rapidly develop new medical countermeasures to threats we had not anticipated. These are all opportunities to get stronger. Marissa, how do you think other cities are doing . We always care about new york city because it is always a high performer. Sense interacting with the rest of america . Dear think other cities are doing as well as you described other do you think cities are doing as well as you described today . I started at the beginning and something i have learned theg the way is that process is what is important with planning. Not the document. It is about the process. Something we have learned through pan flu planning, there are a lot of policy issues that come up, many of which you can work out in advance. It requires resources. It has been challenging. There was dedicated pan flu planning way back when. Sometimes with different scenarios you have a focus on a particular scenario and then it goes away. About building all hazard capabilities. It is about Building Systems you can leverage for many types of events. That requires continued investments. For the capabilities we have built, they have to be maintained. For the gaps that we have identified, that needs investments to address the gaps. That has been very challenging for all jurisdictions. Trex city has more resources than a lot of other places. City has moreork resources than a lot of places. They are struggling to deliver on the baseline capabilities. You ask what we need from the federal government. Just continuing to try to preserve the funding which is so critical. That is at the top of the list. And better defining the roles of different federal agencies in these types of scenarios. This is not going to be daytoday business. Understanding with the roles are and communicate it and communicating it. We had our federal and state and local proctors together in a room and talked about what had gone well and what we could improve with a specific focus on communication. That is important to do. In these types of scenarios, guidance is coming fast. To this state that local can be consulted at advance, but at the time, we found with ebola and h1n1, some of the guidance that came out would not be in sync with urban settings. It created problems for us. Jamie, beyond pandemic influenza, you have an interest in preparing for the broader range of series biological threats in the world. . Hat else are you worried about in addition to pan flu, we think a lot about manmade pathogens that could emerge in the coming decades where they could be engineered to be more resistant. Pose a severeould risk. It is highly relevant to our interest. Thank you both so much for being with us. I appreciate it. Ok. Ok. Good afternoon. Schulz, and irina am a curator at the National Museum of Natural History where you are where we have the wonderful mission of understanding the Natural World as a place of humans with in its. One of the great privileges of being a scientist in this museum is our connection, our service to the public. Ourhe smithsonian, it is mandate not only to increase knowledge but to infuse it. We reach millions of people a year. Curator on an exhibit. This serves a critical function of public communication about pandemic risks and threats. It is called outbreak. Epidemics and connected world. Opens in may next year. Influenza ands zika,viruses, ebola, and hiv in any ecological complex. We represent human and animal and Environmental Health as one health. We show how pandemics can result from a failure to recognize and respect that connectedness. We do this with stories that demonstrate the principles of one health. Worry human impacts on animal or where impacts on animal or Environmental Health can impact humans. We explain the human drivers, the activities that spread disease, such as Global Travel and trade. Cause anhey can outbreak anywhere and threaten the health of people everywhere. Show the effects of a pandemic on human health and society and the kinds of efforts scienceo fight back by and activism and health care and policy. Importance ofthe the community in breaking the curve of an epidemic and the cultural factors that will always be part of that effort. We explaint least, to her visitors the fundamental role of research and vaccines and preparing us for the next pandemic. Is a new kind of exhibit for us. Health iscause public a new space for us as a museum. A place for us to be. Asis part of our work stewards of Natural History and a curator of collections like motivating this in most cases. While it is true that our collections to have value for research as we show in the back room, that is not the only strength that we are actually using in this situation. Convening power at this museum, which i think is demonstrated by this event today. Manys also shown by the free public events. Awareness we want to motivate behavior change and we want to catalyze conversation about pandemic risks in the public. Because pandemics are global a Global Health threat, we are trying to convene a global audience outside the walls of this museum and the city. Outbreak will not only be a new subject for our exhibits, but it will be a new model. That is because we designed a second version of the exhibit that will be able to popup up in a community anywhere in the world. This is using free resources we will provide digitally, including a guide to develop Educational Programming and public files to customize exhibits. That is the important part, allowing communities vulnerable to epidemics to have those rules and communicate and reach those visitors, audiences, population in ways we cannot with the most effective messages in the most appropriate way. These are messages about epidemics in a connective world. Possiblewould not be without the generous support of so many partners. We have just been really, really fortunate. Our donor partners are listed here. Just a few of our content are shown in that photo and some of our partners are here today. I want to say thank you so much to them and to all the rest of you for the good work that you do. We tried to communicate and we will hopefully and successfully bring this to our audiences and thank you for your attention. , i would going to introduce our final speaker of this program. Dr. Ellen mckenzie. She is the dean of the John Hopkins Bloomberg school of Public Health and a bloomberg distinguish professor in the department of biostatistics and the school of medicine departments. Addition to hundreds of publications and numerous cdcrs, she was named by the of one of the 20 liters of an effectwho has had on violence and injury prevention in the past 20 years. [applause] thank you very much. On behalf of the Bloomberg School of Public Health, i would like to extend my thanks to our panelists and speakers and collaborators, the Smithsonian Magazine and the museum of Natural History. I got your little early today and i took the opportunity to wonder around the museum and was reminded how wonderful a place it is. Brought back a lot of great childhood memories and memories of taking my son here. You are juste taking it the next level and it is fantastic. It is really wonderful to see. I would also like to thank our sponsors for this event, the bill and Melinda Gates foundation and the wellcome trust. And a special thanks for you all for being here in this room and those of you watching online over the internet. Public healthday, scientists have made remarkable andress for identifying characterizing influenza virus strains that could potentially cause a pandemic. These efforts can also help identify other emerging viruses that pose a pandemic threat that are still of great concern as we have heard. Our methods of surveillance and detection have also improved as have our capacity to manufacture and distribute vaccines. Speakers are reminded of other advances also point to the disparities across countries and regions within countries for our ability to prepare, response, and recover from a pandemic. Clearly, more is needed to safeguard the population against another catastrophic pandemic. We heard loud and clear in the very beginning that the push to develop a universal influenza vaccine that protects against a wide range of virus strains must be at the top of our priority list, especially given the current seasonal vaccines have limited efficacy. We also heard that we may need to go back to the very basics of we understanding immunity if are to get closer to that ultimate goal of creating a universal vaccine. Other areas for concern, the need for global surveillance in both human and animal populations, a decrease in the time for vaccine productions. On antiviral drugs, including new classes of drugs and cocktails of drugs. And rapid exciting technology. Finally, the improvement for capacity and readiness of our Health Care Systems around the world to respond to a pandemic. Localg improvement of our Public Health infrastructure within emphasis on forging multisectorial links is critical as we heard for the level of our preparedness. We also heard loud and clear that Effective Communication is critical. Health officials at all levels need to communicate Health Threats to the community in a matter that can be understood and acted on in a reasonable way. Our officials must always tell the truth all the time. They must get out front in state out front. That is a broad summary of what we heard today. I thought i would like to end this symposium today as we began it with some history. Although i will not pretend to be as great a historian as john berry is, but i would like to reflect on the ways that influencedandemic our own school of Public Health. As a new dean, i am only six or seven weeks into the job. I am particularly interested in our history and i would be remiss if i did not think knowledge the input from our own historian karen thomas and reminding me of this rich history, especially as it relates to pandemics. 1918, was then known as the school of hygiene and Public Health, it held its first classes as the great pandemic again to intensify. The school made the pandemic the urgent launch point for its work. Influenza jumpstarted the schools growth for training in epidemic disease. The first chair of the john hopkins was already an expert when the pandemic hits. At that time, data were extremely difficult to collect, much less interprets. As head of the Public Health services office, frost work with worked with colleagues to conduct surveys nationwide. These revealed a defining characteristic of the 1918 outbreak we heard about today. That is that the highest mortality was among rich adults under the age of 40. Frost then published a chronology, which became the model for all subsequent efforts to track global pandemics. Today, frost methods are still used to predict a measure epidemics. Under frosts influence, the school would pioneer the tactic of teaching students she leather etymology. House, from house to block to block to confirm all cases of the disease in a particularly defined area. For students. Pai the schools leadership intensified after alumnus founded the Epidemic Intelligence Service at the centers for Disease Control. Many Bloomberg School graduates have gone on to become the i. S. Officers, and many eis officers in turn have since joined the faculty of the school. Of those eis officers he then came to the school as its eighth dean. Henderson, like his mentor, was his advocacy of by a Security Preparedness amount to establish the center for Health Security. This is now approaching its 20th anniversary. Alfred sommer and henry moseley, officers,notable eis were sent to assess the 1970s cyclone that decimated east bengal, now part of bangladesh. They conducted the first survey following a National Disaster. Their goal was to guide longterm relief and recovery planning. Their experience as epidemic springboard for Outstanding Achievement and Research Training and administration at the Bloomberg School. Dr. Sommer became our ninth dean, and dr. Moseley chaired the department a department for over 20 years. The schools experience and fighting influence of both the foundation for its rise to International Prominence and Vaccine Development evaluation. The faculty has and continued to work to implement testing and policy for acting against influenza, hiv, and other devastating diseases. They have established the power of micronutrients to prevent nutritional deficiencies and Infectious Diseases. Using the Public Health tools of laboratory investigation, andtatistics, epidemiology, policy, the school has emerged in the 21st century as a thought leader, convener, and firstline collaborator for tackling epidemics. During our century, existence aircraft to have broadened the scope of Public Health, strengthened its Scientific Evidencebased, and trained a Global Network of Public Health leaders. If together in this room we are unrelenting in our pursuit of and not neglect the lessons we have learned, we will one day hopefully measure death from Infectious Diseases as a one in million occurrence. Extend my me as