Transcripts For CSPAN2 The Next Pandemic 20171113

And vote on this bill after things getting and popularity to combine their version with house version and hopes to get it to President Trump for christmas. Next up will take you alive to a forum on preparations for the next health pandemic, scientists and doctors are reviewing current influence the dangers and future challenges. Hosted by the Johns Hopkins school of Public Health it live coverage around hes been to. It is a combination of protection in their age group that has seen the related strain of [inaudible] but [inaudible] also now look at historical tenements from 1890 to 1918 to 1,962,009 and theyre all different. They share pictures and come at odd times and come in the summer and the effect more of the younger population but they are quite different and that means for the future we need to have systems to have Technology Information and what it looks like. David, in 1918 there were no pharmaceutical interventions available to help expand the pandemic. We now both antivirals and vaccines, though as tony mentioned, their efficacy is not as high as we like them to be. Could you talk about the influence of vaccine history and where i see the field going in the near future to try to improve the tools we had to deal with the pandemic. I think back in 1918 as jeff pointed out they were already working on vaccines. Mistakenly working on a vaccine for a bacteria and it wasnt until 1931 that it was dependably shown that influenza was caused by a virus, 1933 they were able to grow it in the laboratory in may 1945 there was the first license vaccine in the United States. There have been some improvements since 1945. There have been improvements in the manufacturing process. The 1945 vaccine was a [inaudible] vaccine for one influenza type a component and a type b component and we are now moving to for vaccines and in 1935 we used embryonated eggs to grow the virus and now we still use those to grow the virus for most of our vaccine but as the doctor pointed out some companies are moving to subculture to move the virus and some are largely bypassing the growth of the virus in the sense that theyre using technology to express the proteins from the surface of the virus to make the vaccine. We have improved vaccines for older adults by virtue of higher doses or by using [inaudible] and importantly were using the vaccines more since 2010 theres been a recommendation for universal use of the vaccine for all of us from six months of age and older to get each year but still, as the doctor pointed out our current vaccine needs some work and theres more we can do. They are different from other vaccines. First of all, the disease were trying to prevent is very prevalent, up to 20 of us will have an influenza infection during the course of the year. Secondly, the viruses keep changing. That is why we need a new vaccine each year. Also, the efficacy is lower than for other vaccines. On the doctor slide and show the different efficacy estimates for 2014 and 2015 and the efficacy was 19 but cdc tells us that year that vaccine presented 1. 6 million cases of influenza despite relatively low use of the vaccine and a low apathy. Increased use particularly in pregnant women we heard from john about pregnant women being in a particular susceptible group for disease and this all helps. Looking forward i think there is two ways we are moving to improve things. The doctor covered the idea of universal influenza vaccine and if we are successful they are then we have a vaccine for any influenza virus. Past, president or future, human, alien drives, we are set. This is a vaccine that who is looking for. Most influenza deaths occur in developing countries and very few vaccinations occur there. The second approach is to advance these Rapid Response platforms. Gs k has few such platforms and one of them, for example was used to make a vaccine for aged seven and nine virus. That took eight days to make that vaccine from the time the chinese posted the sequence information for the virus until it was injected into cell culture and into mice and talking to the scientist that did that work they tell me they could have done it in four days because they were too snail mail steps in the process. Once we have these platforms that are working it then becomes quality control, release a product, regulatory steps that are on the critical path. We need the time and resources to make it happen. I encourage anyone in the audience to ask questions and if you have a question raise a hand and try to get my attention. He will try to acknowledge it and get you involved in the discussion. While we are waiting for that a couple of followup questions and will start to start with jeff. Do you think influenza is most likely virus or are there other microorganisms out there that pose an equal or greater threat to the human population . Well, i think the future is always a good strong vet and their other viruses you think about other respiratory viruses an animals for one that led to stars and something concerning but the but can be concerned about and there are viruses that the insect borne virus like [inaudible] that are concerning but influenza is the way to bet something that is most concerning. You have enormous diversity of influenza virus in an incredible in birds and mammals and domestic birds and mammals and these viruses mutate like mad and can adapt and move between species. That is what i think gets us the greatest fear is that despite 100 years of studying the virus we really have no way to accurately predict what strains will emerge and how they will adapt from one animal to another and how serious they will be. That is a huge challenge. To be added to that the national vectors are such a different disease. It doesnt cause that much illness and these animals can be affected for long periods of time and go on migration patterns that take them hundreds if not thousands of miles away to introduce them to new reservoirs. The diversity out there and how those viruses move around the world is mindboggling. Cecile, you have been doing a lot of work in understanding and modeling how pathogens spread in human populations. This has been particularly fascinating to me as my center of working towards understanding seasonal influential more carefully. Could you speak to how modeling efforts can perhaps inform our Public Health responses to the next pandemic and help us come up with interventions or ways to at least minimize the spread of viruses. It is useful to look at scenarios and in the context of the closing schools when should you close schools and for how long and [inaudible] there was also a lot of questions about in the context of a pandemic and all of the models agree that it is no use to [inaudible] there is more and more effort to end the cdc context that has been done in 2009 since the evil outbreak and there has been modeling around typecasting and decades ahead of the web and putting effort into that. One i think the progress is quite exciting. David, you mentioned briefly in your answer to the first question, they started initiatives aimed at shortening the time to generate new vaccines to emerging pathogens including one for a Global Pandemic potential and its a relatively new facility opening up nearby here in rockville, maryland, devoted to those efforts and can you tell us about approaching this idea of making vaccines to pandemics or potential pandemic. Gs k has been working with the Us Government specifically the Biomedical Advanced Research and Development Authority since the inception in 2006 to develop and to produce preparedness products. In our case age five and one vaccine we had month so close antibodies for anthrax, for treatment for influenza and also a microbial resistance would be a great topic for another option symposium. Barta is working with other companies and they have 21 products in the Strategic National stock ready for use in this is great but its not really sustainable. We need more and more products and the products we have reached the end of their shelf life and need to be replaced. Dsk and others are interested to move more to the Rapid Response platforms. Dsk is partially motivated by the 2014 epidemic of ebola in west africa. We responded to that outbreak with our primary scientific partners at nih and went from the start of a phase i Clinical Trial to the start of the phase three Clinical Trial in five months rather than the usual five years or longer. But it was too late. We need to be able to act faster. Again, many other groups are working for these platforms. In the ideal we would have continued to have or improve our surveillance and we identify pandemic threats and it would be sequenced posted to the cloud, Research Laboratories would be downloaded and create a vaccine handling a computer identify the gene segments that are needed for that and loaded back up to the cloud and it would come down to different manufacturing facilities that are using a platform and using it every day for standard vaccines, say influenza in many parts of the world. Then when the pandemic threatens they interrupt their routine manufacturer and they start making pandemic vaccines within weeks and months or billions of doses and that is the ideal. I glossed considerably there but i think those are the sort of things we can hope to look forward to. Thats an excellent to make. Some of the work we have been doing using seasonal influence is the model system for setting up those realtime diagnostic efforts and identify the past and spread the word around and see what new variants are coming through. What you would want to do eventually in a pandemic its a great way to model social as ever to talk about it on the par away. At least organisms where we understand it well like influenza and we know what the target should be as the head of the [inaudible] trent. [inaudible] i repeat the question. John asked that we been talking about vaccines but what about progress on antivirals and their role in terms of the tool in countering pandemics. Well, there are antivirals against influenza that really only in two classes and the problem is that influenza viruses can very often develop mutations to make them resistant to these drugs and clearly more classes, newer classes of drugs need to be made in clearly there has been a lot of research governmentfunded research as well as industry to develop anti value and as far as i know i dont know how close those are two Life Insurance but we are still faced that for many strains the antivirals that are available for position to describe are often inadequate because viruses are already resistant. Nothing to add except the Silver Lining to the 2009 pandemic in the 2008 viruses were becoming resistant but the new h1 and one is susceptible. I think there is an added realization that developing one antiviral is great but having two or three as a administered as a cocktail is the ideal situation. Those are seen with hiv and hepatitis c virus when you have a group or a cocktail of antivirals the likelihood of resistance coming up really is decreased exponentially and i think that is something to keep an eye on in the future as terms of these moments. [inaudible] yes, i know there are few drugs in the pipeline and i know there has been one new antiviral license to japan but certainly i dont think there is as many antivirals in the pipeline of development that could be or should be. [inaudible] what about the immune response mechanism for protection against the influenza virus you mentioned the antibodies in gluten however i went to a session in the Political Center where it showed a better correlation where antibodies then in gluten with protection and a human study and i found that really interesting finding is fairly recent, years ago and wondering whether that has been pursued or what i was once told and all about ctls and theres always people that believe in ctls and i dont have a feeling for what how much is known at this point about what kind of immune response would confer better then, lets say, the maximum 60 which would not pass these days for approval of any vaccine. Thank you. Im sure i cannot completely answer that question. I dont know that much more than what you stated in your question. There remain a number of unknowns about that in the best way to prevent it. It is completed with having a series of infection that complicates so the history is important in terms of you as an individual respond to a vaccine and there are parts of the viruses that can be targeted through cellular responses and antibodies can protect and if there is enough for them but the current standard for better hemagglutinin antibodies which is acknowledged as perhaps meaningful by regulatory authorities would you like to add . I can speak to the fact that i spent the morning at the campus where universal flu vaccines are being discussed in the first thing that came up was set up studies to better understand immune responses, infection and vaccination outside of the typical anti back and get a stronger sense of what the natural course of it induces as protecting into my responses into no longer fit into the [inaudible] looking at the protein standard. Its a much broader thinking now that we need to go back and think about any antibodies and t cell responses and immune response in total to seasonal influenza and use that as a way to help us inform universal vaccine study going forward. It cant speak clear that because we had some success with seasonal flu vaccine that we were okay and there wasnt a lot of going back to the basics it its almost a little embarrassing that we have hemagglutination and that is what we use as the protection. We had not pursued normal [inaudible] and we havent pursued t cells as much is the shed and so forget to get to the universal vaccine that i was trying to we are almost in some respects going to have to go back to the basics and ask fundamental questions of what the true immunity in the scope of the its very interesting that in 2017 we really dont know as much as we probably should. That is the conclusion of that workshop you are at. Absolutely. With that im going to close this panel i want to thank my panelists for their wonderful discussion we had in thank you very much for your attention. [applause] good afternoon everyone. Im ball, director of the center for military health at Johns Hopkins Bloomberg School of Public Health. Were going to talk about. For the worst and is the world ready to respond. Im hoping he will get beyond the vaccine to other areas clearly there will not be a universal vaccine anytime soon and there will be a lot of people that are sick and how will the Healthcare System in Different Countries respond. We have two speakers and im going to introduce the first one, doctor daniel, Deputy Director and chief medical officer of the Public Health preparedness and response or php are at the center for Disease Control and prevention. In this role he is the lead science advisor it provides scientific representation for preparedness on behalf of php are in cdc. He served in the external partners for cdc and the sears strategy and Program Coordination for php are in the medical and Public Health preparedness response. Daniel, welcome. Thank you, paul. Its an honor to be here had to represent the cdc scientists and staff who are more than 60 years have worked to address this threat of influenza and ways the Public Health response to health crises. You have heard how the 1918 influenza pandemic was an unprecedented Public Health crisis and nearly 100 years later the world has made major advances in the science of influenza prevention and control. Influenza virus, however, continue to pose one of the worlds greatest Infectious Disease challenges and risk of pandemic influenza remains. Our vulnerability in a pandemic relate to the virus its susceptibility of our population and the environmental factors that favor the spread of disease. By definition a pandemic virus is one for which the population lacks immunity and is capable of transmission from person to person and to cause severe disease. In addition to our naive immune systems in a pandemic significant numbers of people today are more susceptible to Infectious Diseases because of disease is a have or therapies they take that compromise their immune system. The exponential growth of our populations around the world expanded International Travel and increase proximity to humans to animal reservoirs increase the risk that a pandemic influenza will emerge with extreme effects. In the absence of a vaccine that can illuminate influenza pandemics time will be of the essence and early recognition of persontoperson transmission of a pandemic virus can make all the difference to effective response. This is why ongoing Surveillance Networks around the world are so important. Many pathogens can cause similar symptoms to influenza so diagnostic tests that are rapid, accurate and feasible for widespread use are critical to rapid understanding of the pandemic conditions and for specific treatment plans. Nonpharmaceutical interventions such as personal protective equipment, respiratory etiquette, hand hygiene and social distancing can prevent disease transmission even with a specific medical intervention is not available. Vaccines will be an aborted part of response even today. Medical treatments for influenza in secondary infections can save lives available in the right hands at the right time. An effective pandemic also requires effective with the public. And with our help responders so that 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 of surveillance, much less a global surveillance effort. Viruses, as you heard, have not been discovered and there were no laboratory test. There was little personal Protection Equipment and no vaccines. No informatics to treat secondary bacterial infections and no in several drugs. No mechanical ventilation or sense of care units. We heard earlier about medication challenges in 1918 which are surely different today with respect to our understanding of Effective Communication and the variety of tools to share information. What is cdc do to lessen the impact of influenza . Cdc works with domestic and to monitor human and animal influenza virus is to know what and where viruses are spreading and what illnesses they are causing. Cdc supports more than 50 countries. They will find emerging influenza threats and to respond to them. Cdc studies more than 6000 human and animal influenza virus is in the laboratory each year to better understand the characteristics of these verses. Cdc develops and distributes tests and supplies materials to laboratories around the world so they can detect and characterize influenza viruses. Cdc works for state and local government, the World Health Organization and partner countries and pandemic planning efforts. Cdc evaluates the effectiveness of pharmaceutical and nonpharmaceutical interventions and updates recommendations. Cdc health and local experts choose which viruses to include and seasonal vaccines and guides prioritization of pandemic the moment. Cdc monitors influenza vaccine distribution. Cdc also manages the us Strategic National stockpile in support, Public Health departments across the country to ensure that critical medical supplies are available when and where they are needed. Cdc also informs Healthcare Providers and the public about influenza prevention and control measures. Cdc works at home and abroad to train staff and do Emergency Operations centers that improve the efficiency and interconnectedness of the Public Health response. Each emergence of a new virus such as the age seven, and nine virus essentially initiates a new Pandemic Response as our scientists and partners around the world work to characterize the virus, develop and distribute new diagnostic tests and investigate transmission patterns and disease severity. Since the 2000 h1n1 pandemic cdc has reviewed and updated tools for pandemic preparedness including the pandemic influenza preparedness and response framework which can be used as a pandemic planning guide. The influenza Risk Assessment tool which possesses potential pandemic risks posed by influenza viruses that currently circulate in animals but not in humans. A strain is scored on ten factors for the likelihood that it will change to impact people and for the potential severity if it does. The pandemic severity assessment framework guides Public Health officials to anticipate the severity of the pandemic once the novel virus is identified and responding in a sustained manner. So what progress have we made . Due to Global Investment in endemic investments theres a a global lens of surveillance and response is with mechanisms to share laboratory and surveillance information. Laboratory capacity has shown exponential improvement in recent years. We can sequence a full influence of virus genome and single day and they are great in protest to detect novel viruses and these are shared with more than 100 warty labs around the world. There is personal protective equipment to prevent transmission particularly in healthcare settings. There are Vaccines Available and selected vaccines for pandemic use. Vaccine manufacturing capacity has expanded in the past decade including development of new vaccine technologies. There are three recommended antiviral drugs to treat infection and there are many antibiotics to treat secondary bacterial infections. There are mechanical ventilators and intensive care units to care for patients in respiratory failure. Theres a one Health Initiative to increase interaction and cooperation between human and Animal Health authorities. We are now experienced in presenting pandemic information through a a variety of Media Channels to support lifesaving action. While tremendous advances have been made, there is still much to be done to improve pandemic preparedness. Only about onethird of the 196 countries that signed on to the International Health regulations in 2005 2005 early report havie ability to assess, detect and respond to Public Health emergencies. To approve we need to fill the surveillance gaps. There are geographic gaps and global stability including parts of africa in the southern hemisphere. We need better surveillance of influenza viruses circulating in birds and pigs. The ability to share physical virus specimens needs to be improved. Better diagnostics are needed including overthecounter and point of care test. Vaccines must be more effective, more broadly immunogenic and available more quickly. Global infrastructure to produce and distribute vaccines need to be improved, better personal protective equipment is needed and needed in large supply. Better less costly influenza treatments are needed, and there are large parts of the world that dont have the Critical Infrastructure and equipment to treat severely ill patients, and they must be supported. Even in this country we need creative approaches to manage the demand on healthcare. So 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, detect and respond. A number of novel viruses detected is increasing requiring ongoing laboratory and epidemiology work. And a weak link in global preparedness as a threat to all countries. So achieving Global Health security must remain a priority to lessen the threat of pandemics. Thank you. [applause] thank you, dan the next speaker is from the debut at joe, Health Organization World Health Organization. He began his career in peru working in general practice and i lens. And in 1987 he was appointed as regional director and later Deputy Director general of the National Institute of occupational health. He served as director general of the National Defense and Disaster Relief office in the ministry of health in peru. And he joined as a shortterm consultant in honduras where he also served as United Nations Disaster Task force core data for this country. He presently serves as a regional advisor for Emergency Preparedness and Disaster Relief in washington, d. C. [applause] hello. How are you doing . Very good. I am pleased to be her because i engaged by with the previous presentation on how is the world prepared for next pandemic. And the presentation i will give you is regarding the International Response to a potential pandemic. So one of the conclusions of the International Response is that it should be to improve the coordination with National Response we have to be complementarity to the National Capacity. So each nation who is able to early detect and share that information, and begin the response, meanwhile International Support is coming is crucial for that. So how the world is performing on that, it is related to International Region capacity. It was approved in 2005 and begun in 2004 and 2007, but see the countries are not there yet. Most of them have requested an extension to reach those capacities. The last extension was provided in 2014. So in the americas for example, only 13 of the 35 countries have reached that level on the Self Assessment aspect. They say they are there. But how are they performing in terms of those capacities . You see here have countries have been performing one year to another, and you see, for example, the first year is 2011 and then we go to 2016. Each of these areas, and we see the capacities are increasing in legislation, coordination and National Focal points, et cetera, so no advance or from 90 and you see a chemical capacity and emergencies are also increasing and, of course, for the first time more than 60 of the countries are unable to reach those capacities. Then we see the status of those capacities also in terms of which are the regions, the regions in the americas that are prepared can we see it still lagging a lot of that. So 12 of the 15, 80 of the countries have reported and we see the certain capacity like chemical events are very low. But we see also the central and south america are very high in terms of most of the Infectious Disease related capacities. How are they doing in terms of their contact with paho and w. H. O. . We test those contacts, and you see among the years the context in the connectivity past but you know, for example, is above 90 . And the first 24 hours. The connectivity by telephone. In the next hour, more than 90 . So we do have the connectivity with most of the member states, and they are reporting to the paho. And how are we doing on the points of entry . We are moving from 35 ports and airports two rounds of consultation with state parties, state parties are the ones who signed the international relations. And we have draft procedure, e final report is not there yet, but we have 64 ports in 31 of 35 states, or 35. 78 airports and 22 ground crossings and we moving around 500 authorized force in 27 States Parties in the region. So we are moving towards the points of entry. We are not there yet. We are moving towards that and most of the countries now are eager to do that. In a couple of weeks im going to chile for the third exercise in a row in terms of points of entry. They are not only in terms of airports and ports, but also in terms of those type of ports that you have entries through tourism, for example, like Easter Island and all this. And these are events being reported by who was reporting on that. You see the National Focal point is that yellow, dark yellow, or maybe orange. And use more or less 40 in 2017 are coming from the national, so its the official figures official from the government but you see there is a large amount of events that no report not reported by the governments. So how can we say that they do have an outbreak if the government or the National Focal point is not sharing that information . So we are seeing in terms also what is the type of events that are reported. Most of them are infectious, but it still, there are some issues on food safety, Animal Health and all this, and these are the differences between all the years how we are going through. This report is being officially up to 13 of july this year. And how is the system reporting going in other regions . We see here, for example, that the dark blue, euro, we see a huge difference in the reporting in the americas. Why . You know why. Because we work with the government, with the countries, and we are convincing them along with several partners in region that they do have to report. And they reporting. So overwhelmingly in 2016, for example, most of the reports come from the americas. And its not also in comparison with all the other regions, we see that afro, euro, the Southeast Asia and west pacific regions. So clearly the americas is overwhelmingly the best lets say prepared region in terms of alerting the events. Is that, as capacity and place . Lets see whats happening in the surveillance. You see all the countries are mixed surveillance and countries without surveillance. We have two countries that without surveillance, well, the countries that are not reporting actively, okay . It is as we saw previously the official reporting and unofficial reporting. How are we doing in terms of reporting on biological data . We see here that 75 of data reporting in several countries, but the light blue is more than, between 5074 and other countries important countries reporting less than that your biological data. So whether the differences for someone follett also tracking how many samples are being tested or sent to cdc for example, the original incentive for influenza. In 2014 we have up to six shipments, two or more shipments and you see 2016. So the tendency is going forward. We are doing much more reporting on that. And this is the number of samples tested by the national influential center. You see them in the tens of thousands, nearly 70,000 in 2016. Yes, we are moving on that. But is this enough . We do have tools, w. H. O. Surveillance tools. We have paho tools also being applied on top of the w. H. O. Tools and we have capacity to do with pandemic come once the pandemic influenza comes, we will most probably know, you and we, through the media. So it would be extremely difficult to see, sorry, to control the pandemic once it begins. Its happened in the case of mexico city. We have huge challenges to control there, and the biggest problem would be in security and Economic Impact. So it is a huge political thing. So what happens after 2009 pandemic influenza . The United Nations were important partner, coordination were useful but also u. N. Agencies not only [inaudible] use their participation but they became [inaudible] we have to provide support for the u. N. Agencies in the africa countries. And some board members, a global outbreak on Outbreak Network response maintained their institutional objections rather than the overall controls of the pandemic. So we do have issues there and still we have interagency work. We work about with all those partners in 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. [laughing] so its a difficult task to do that, so we need to political endorse the document, ensure coordination of more published organization but also establish procedures. Were working on that. 24 countries can send their delegates this year to paho to coordinate in this response to pandemic influenza. So we need also with those partners timeconsuming crisis meetings without operation on impact, yes. We have to [inaudible] we see that even inside the countries. This emphasis on visibility rather than we want to be in the photo. And convenience rather than and ambitions not supported. We drink a lot. We dont sleep enough. And the final goal we have National Capacity to respond to completing a Global Response capacity and a pretty the quality of external assistance. Thank you so much. [applause] thank you very much, ciro. Very, very enlightening. We will be taking some questions. I will start off a bit, and its hard to see with the lights here, body hope that you from the audience will have some questions to our colleagues. Man, i wanted to start with y, and you mentioned many of the key responses that would occur beyond just with an epidemic occurs be on just the vaccination. One question i have is if you could compare what happened, what did happen or did not happen in 1918, compared to what you believe would happen now from everything from ventilation to the antibiotics, but also talk about the capacity even your within the United States to be able to respond. Yeah, so i had a list of 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 transmissible the virus is obviously. There are limits to what even in the United States our Health Care Capacity is our ability to provide antiviral medications, ventilator, respiratory support, all those, have their limits. I dont have direct numbers, and perhaps you do, on modeling todays therapeutic interventions and Public Health interventions on the population then. But its clear even with our more moderate pandemics in the past few decades that we have much greater capacity to respond, and we would expect to respond more effectively to a 1918 like virus, but we could have one more transmissible and more severe. So thats what all this work across the spectrum, including universal vaccine or better vaccines are so critical. Thank you. And ciro, one question i have even within the americas we see the disparity amongst many countries in americas. Can you talk a little bit about the differences that you may see, lets say, in some of the more response countries . You dont have to name them, and the differences that may occur in terms of both prepare despite in particular in response, maybe you can use mexico is one example, but what the question really is to try to talk, try to get at the differences and the capabilities of his countries even within the americas, never my in africa or other areas i m more familiar with. Most important aspect of the countries capacity, to alert, teach information, is the National Focal point, or the National Offices of Health Officer that house to report they are empowered to do that. And most of the cases they have to filter the sharing of information to the political channels. And you know immediately when you reach that level it is the Economic Impact is facing. But even in pandemic in 2009, we saw that many countries that did have the capacity to lets say detect, they were not reported because Economic Impact would be huge. That some of the aspects they do have in the americas. Most of them are able to detect, not necessarily the specifics of it but they can report. Some countries we do have that delay. Not necessarily only the countries that we saw in the picture that they do not have surveillance, but most of them they like about. Mexico showed by example that theyre able to report almost immediately when they discovered that there was something new, different. And they declare emergency. The response happen most immediately. They welcomed many partners. I was there coordinating the response for the first two months, and we saw the capacity was there. But some of the officers that were in charge were moved out of their offices a couple of weeks ago, before that because of the reorganization. And because of political reasons they were not brought into that. That havent also in 2008 in the yellow fever outbreak in paraguay. It had to convince the minister of health to a point the person who knew more about yellow fever that was in position. So those of the political and economic aspects are the ones will make the difference, in my opinion. It is not security and safety. Interesting. Opening up for questions. Please raise your hand. Yes, we had one in the back, please. They are coming to you right now. Im from smithsonian magazine. A question for dr. Sosin please come and i would be if you could comment on the impact, if any, of the Current White House administration on the ability of the cdc to respond to future or near future influenza pandemic . Sure. [laughing] pretty much everything i talked about, the type of work we are 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 is really important work and by hook or by crook we will 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 those resources change we will figure out how to adjust into the best we can with the resources we do have. Are there any other questions from the audience . To questions. I will name one of the countries that was slow to report, and that was brazil. I know for a fact that there was a back channel feeding information from epidemiologists in brazil to the white house during 2009, at the white house was telling the source that they were getting information two weeks after from the government. But my question actually, i want to applaud you, you certainly did tell the truth. Appreciate your presentation. My question is 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 lavelle after that problem requested paho to do external evaluation of h1n1 2009 response. And we found that brazil recognized Community Transmission 12 weeks later than it actually happened. And it caused brazil to have the highest locality of h1n1 in the world. So they modify their procedures and up to the last three or four years they improved a lot, okay . Yes, mexico was punished but mexico was punished, paraguay was punished, haiti was punished, peru my country was punished after the cholera outbreak reported on time, the second day we were punished. What was the punishment . Punishment is economic punishment. Pandemic influenza in mexico, irrational, exactly, because of the fear. Fear causes all these decisions to be made in a fearless, i mean, extremely fear related efficient, closing borders, stopping all the importations of products that are not related with that. Stopping tourism and antenna, et cetera are just as a relation, mexico spent more or less 180 million to respond, the Health Response for pandemic influenza. The first wave of 2009 pandemic influenza mexico, 9 billion. You make the math. And who was coordinating the response to h1n1 . Prime minister of health. Its nonsense. So the preparedness, it is more [inaudible] it is the security sector, the tourism sector, the transportation sector, entertainment, other sectors that have to be there in order to respond. We have it on paper. But in reality a National Emergency management officer in mexico, sorry, i will say that because i was there, was not allowed to enter the coordination beatings. I have two never shake with the Health Research to let her get in. And that was the fema like director, so we see those types of things and then we see where the fear is coming from. So that thing is, yes, most of the countries are prepared not at the level of political willingness to control the Economic Impact of this. You see the Health Impact and use the Economic Impact, overwhelmingly large we are not touching this in terms of preparedness. Thank you. I will have one more question but i want to make sure that, we have a couple more minutes left, any other questions from the audience . Okay. My one point is exactly what ciro, what youre saying is the Health Response is a huge but one component of a much broader, and weve seen this consistently, you mentioned ebola, we have seen whats happened with ebola, the political response and economic response are essential. The other thing, john mentioned this is the Community Response. Although i know its an extremely different that will be sought in ebola we learn the Community Response was probably just as more important than others. Dan, you mention you have a Community Mitigation guidelines for cdc. Id like briefly, we have two minutes left but starting with the dan and then ciro, talk about the community either both your expenses but also how you think you can address the community to make sure that they are supported in a decent response as opposed to just fear. Well, i saw jim here from the association of state and territorial Health Officers, cdc works domestically to provide assistance, support, guidance to the Health Officials who have the authority to do this work at the state and community level. So these Community Mitigation guidance isnt the breadth of work that happened at a committee level. These are the nonpharmaceutical interventions that could delay or forestall certain aspects of the pandemic, prevent some disease and spread it out over time to lessen the burden on the Health Care System and the Public Health system. And we have more dated because of the 2009 pandemic. So there are, is more confidence in these measures and a little bit more information as to when they might be most effectively applied and to give guidance to the state and local Health Officials to take action in the appropriate time. I do believe very strongly in the message that john barry gave us about communication and Officials Committee can get we know a lot more about effective fumigation and health crisis, and working as best we can to get Political Leadership to follow those principles will be key. And lastly i just wanted to respond to the point that Health Leadership kept out the rest of the response Emergency Response leadership. In the United States we have been working for the past 15 years to get Public Health seat at the table, and its been an important and challenging journey to get there. I dont see us ever having the lead in National Response of this nature, but having the voice and letting scientists be at the table with the Political Leadership has been very important. The Community Participation is crucial, but the first thing to have a Community Participation is trusting authorities that are telling them what to do. If they dont trust the Health Officers or the government in an everyday basis, why would the trust in any crisis . So it is a very complicated aspect. We have to build that. Im just telling the truth is important but telling the truth all the time, not just in times of emergencies, you know . And those things happen, and also if we are able to convince persons from different perspectives telling the same message and during the cholera outbreak in peru we managed to have one of the lowest fertility of cholera because we convinced academia but also college and the media to help us. We began first with 12 or 24, between 12 and 24 recommendations, and then we came up to three recommendations. Knowing that. So doing risk will only work if we do crisis remediation pics of telling the people that were taking care of them but telling the truth, not expanding that come not diminishing the risk. And that will build the Community Participation. The communities are not able to respond to all emergencies. That will not happen. The dream may transform into a nightmare. So it is the right communication and trust in the government that will make the difference. Thank you. So you want authorities to tell the truth all the time. [laughing] utopia, a great journey. You are still a dream and you work for paho. Thats wonderful. [laughing] i what you think ciro and dan very much for the very insightful comments today, and lets [applause] a reminder if you missed any of the earlier part of this venue you can find it later unlighted cspan. Org just search pandemic. On the issue of health President Trump announcing a new hhs secretary nomination. Happy to announce he tweets im nominating alex to be the next hhs secretary. He will be a star for Better Health care and lower drug prices. The use senate gavels thing coming up at 4 p. M. Eastern for third consecutive week taking up executive nominations there will have live coverage on cspan2. In the meantime part of todays washington journal. Join us for a conversation on the state of u. S. Manufacturing, to guess were joined by scott paul, president of the alliance for american manufacturing, and vincent, producer and director of the American Made movie to both of you. Thanks for joining a us. A little a bit about your