Transcripts For CSPAN Ebola Epidemic In Western Africa 20141019

Into the conference center. Lunch will be served. The rest rooms are to your right. People look out for the yellow wall. All that is left for me is to thank our panelists. Please, join me in thanking them. [applause] on tuesday, the first debate was held for louisianas u. S. Senate seat. Louisiana has an open primary system in which all candidates in office run against each other with the majority votegetter getting the election. However, run off election will occur between the top two candidates in the clear winner cannot be determined. Here is a portion of the debate on the subject of Climate Change. I do believe our climate is changing and i do believe we contribute. We have to be very careful about the policy that we promote. I am a strong supporter of fossil fuels, natural gas particularly because it is a 50 cleaner fuel. We have 200 years of it. America could do itself a Great Service and Great Security by promoting more Domestic Energy exploration production. I have been a strong supporter. I will open up 8 million new acres in the gulf. I have secured expert that it permits on western land. I do not agree with president obama on his energy policy. I have now served with three president s and six governors. I have disagreements as well as support with some of their policies. We have to be careful about what we do but we can do a Strong Energy future with canada and mexico and the energy independence. Thanks. There might be Climate Change, but we have not seen that reflected in temperatures. Are losing the coastline but that is relative. That isi to our related to our river as well as other factors that caused the land to sink as much as water rises. In florida, they have hardly seen any rising of the water relative to the beach. If you want to preserve our coastline, i am not sure Climate Change is the issue as much as it is getting that sentiment at of the mississippi river, putting it into the marshes where he could rebuild, that is what is important. I will point out that the first vote was for senator harry reid. A bill toever allow come to the floor of the senate and she said that would be her first vote. Cspans Cameo Campaign 2014 coverage includes more than t200 debates. Stay in touch and like us on facebook. Com cspan. On newsmakers, the executive Vice President of the planned Parenthood Action Fund will talk about the role of planned parenthood in 2014 and now the issues are playing out this year. Newsmakers, today at 10 a. M. And 6 p. M. Eastern on cspan. Monday night on the communicators, technology and the 2014 campaign. The Digital Tools are largely thought of as email tools, the online contributions, the website. I think it has evolved. Our company also offers tools that a neighb enable the shoe leather side of the campaign. The canvassing, phone calling, direct mail. We are seeing many more marketing channels come online where there is now addressable tv ads, online ads. You can have interactions through social networks. I think now there is a pretty wide swath of things you could call digital. We have moved from the broadcast era. We are in the tail and of what weve known as the early 1960s that has dominated by broadcast. It is really moving into a relationship era. We have known in the commercial sector if you are going when you go branding. Andbody actually advocating influencing this fear, how is it we moved and just knowing than messages. We have known what the messages are to deliver to people. We need to know who the right message or is messenger is. Next, Johns Hopkins host a forum on ebola including Treatment Options and how to contain the outbreak in west africa. After that, texas officials discussed their plan on how to deal with undocumented minors. A call for changes in congressional ethics investigations after that. Johns Hopkins School of Public Health hosted an ebola conference in baltimore. Health experts participated in discussions about the various types of strains, symptoms, therapeutic and vaccine treatments, and how to effectively cam contain the outbreak in west africa. Good morning. I have the privilege of being the dean of the Bloomberg School of Public Health. I will like to welcome here. Our school was founded 99 years ago and since then, we have stood ready to confront the worlds most pressing Global Health challenges and ebola is no exception. Our school and the Johns Hopkins University School of medicine and school of insing has faculty and staff central and west africa who are working to reduce transmission prevent deaths and build trust with families and communities. The of all a virus is threatening the lives of People Living in west africa and creating uncertainty and fear in our country in other countries around the world. Time andlly a critical we have brought leaders connect bridge for multiple sectors to educate us on the ebola virus. Today, we will discuss the impact of the epidemic in west africa, current and future possible responses, the status of vaccines and possible their piece and recommendations on containment strategies that prevents the spread of disease. I will like to knowledge those that are working with Doctors Without Borders on the front lines of this crisis. Im pleased to recognize dr. Hankins. Dr. Hankins is the International Coordinator in his at the school for the 25th anniversary. Welcome to dr. Hankins and the 1998 class. [applause] i also welcome our speakers and went to thank them for being with us on short notice. I am grateful to the departments of microbiology and immunology who organized the program and to keep elliott and his team who provided the logistical and organizational support. Organizational support. Thank you both for your leadership. It was just about a week ago that the director of the Malaria Research institute are at the Bloomberg School contacted me to suggest that we invited speaker to discuss the epidemic. That idea grew into a symposium but it was her universities president , ron daniels, who talked about bringing this to as large an audience as possible. One is the 40th president of Johns Hopkins university. A former prowest at the university of pennsylvania he was professor of law at the university of toronto. Since his arrival since 2009, he has brought an appreciation of Global Impact with his programs in 120 countries while emphasizing the importance of Johns Hopkins as an institute in baltimore. He has articulated strategic goals for the university and lead and pushed us to become one university. He is a scholar at the intersection of law and governance and economic development. He is an elected fellow of the American Academy of arts and sciences and has received many awards and honors including an honorary doctorate from the university of toronto. Its my pleasure to welcome ron daniels to the podium. [applause] [applause] thank you so much, mike. And thank you for your great and inspired leadership. What a remarkable Louisburg School of Public Health. I want to thank the faculty and staff of the Bloomberg School will have worked to bring together the remarkable assembly of colleagues from across the nation to share their experiences and expertise. To speak with which this symposium came together is tough because of the debt and breadth of our capacity across the divisions from bluebird to the school of nursing to the school of medicine to our affiliated partners to Human Capital to help understand mounting Public Health crises and inform the response. This is, simply put, what are people do and india have always done. As a member of the Public Health service, Johns Hopkins professor compiled and analyzed data on the app epidemic of 1918 to 1919, providing the foundation for tracking still by the Public Agency today. The first step in controlling an epidemic is accurate diagnosis. Time and time again, Johns Hopkins individuals have identified from polio to fevers that are vulnerable on populations. The Bloomberg School mom and i led the who campaign to rid the world of smallpox and then returned to the school. In the early years of the aids crisis, playing pivotal roles in identifying the population in sponsoring the spread of disease in hospitals and clinics from baltimore to uganda. Now as the numbers of ebola cases and the death toll rises, as nations and communities across west africa struggle with basic Health Care Needs of populations in addition to managing acute care for patients, as we consider the daunting implications if this outbreak is not met with an International Response, we are acutely aware of the obligations with the intellectual and moral bounty is the community wrestles with this unpredictable epidemic. An epidemic that who director general yesterday declared a crisis for international security. And so with this across the african continent and our expertise including Public Health and International Public policy, we are wellpositioned to help ignite ideas around best practices and most importantly turn those ideas into actions, working in concert with our many partners. Building on our past work and efforts, they are as we said a few moments ago, well under way as across to aid in the response and to work with the ministries of health. These collaborative efforts range from implementing Training Programs that would put 1000 Health Workers in liberia to assist with care and academic management. They are developing a robust and realistic analytical model that will help those leading the fight make better Strategic Decisions and in the present. And to create a communication strategy to educate and empower workers and to put the most current information in the hands of the population. Of course as a Research University we play as evidenced here today another essential role, we are told convener of importance in these controversial conversations. In these conversations with todays speaker, Michael Osterholm has extolled us to do, we ask questions that the world is most afraid to ask. And we can create a scaffold to discipline an informed debate and we reckon with the answers no matter how daunting or complex or how unnerving they are. Once again, this is a moment where they must be present and for hopkins, this is more than a professional obligation and it demands that we continue to deploy personal courage and grit that defines us. So for all of these reasons to be here today, your president and your engagement inspires optimism and i know that this will be a productive day and i think each of you for being part of the important work that lies ahead. I hope and trust that we will be able to do more to lead the our experts and energy to the african continent. So now i would like to turn the program over to the associate professor of molecular your biology at the Bloomberg School of Public Health and research is focused on influenza but its emerging research has led to research on other viruses including the enterovirus d68 and ebola. Recognizing the discoveries can be an important part of communicating effectively with the media and the broader public. In addition to the instrumental invaluable role in organizing this symposium, he will be monitoring todays program. Andrew pekosz, thank you for your extraordinary efforts to bring us together. Take you both for being here today. [applause] [applause] thank you for the speakers web kindly agreed to be here and speak on tort notice. Welcome to the audience and for everyone who is reading this online as well. Putting together a broad wideranging and informative symposium that we are told every one can appreciate, we are into general sessions ominous warnings session will be five presentations on a variety of topics related to response preparedness dealing with the epidemic and we will take a short break and then we will have our featured speaker here giving his keynote address. Then we will convene a panel. At that point in time we really hope to engage the audience in terms of asking any range of questions that they have regarding challenges for the intervention Mitigation Strategy for the outbreak. We want to focus our questions here as its going on right now in west africa and honestly concerns about this outside are things that we touch on as well. And so without further ado, i would like to introduce the first speaker. Dave peters is a professor of the school of Public Health. His seminar is entitled be helpful, be hopeful despite ebola. [applause] [inaudible] identify my wife, or you can find her. [laughter] okay, lets start at the beginning. Okay, there we go. Enqueue very much. And i am pleased to be able to talk with you about the community they strategy to fight ebola. Its an operation that we are privileged to be involved in. I would like to first put it in a little bit of context. Of course we see the ebola disease being the center of this and this is a picture of the emerging epidemic in terms of the number of cases and as you can see although it started sometime in december, we are now in the expotential part of the curve and so it is increasing concern about this and i think that others are going to talk more specifically about the patterns. But its not just about the virus that started all of this. There are numbers of other types of epidemic that are going on in west africa as well. First of all most, after the virus of felt, a contagion of fear and distress. Only within the country but also internationally. This has led to another several patterns and its important to recognize what we are doing and why. So this has to do with a series of self reinforcing types of feedback situations that we to epidemic. One of them being with the Health System itself. It started off being a very with weak Health System and they had four strikes before the Ebola Outbreak because of the inability to pay off workers. And when the epidemic struck of course we had a tragedy with those dead in liberia alone. The clinics have been closed and this leads to the worsening of Health Conditions and Collateral Damage not just for ebola, but also being like malaria, diarrhea and pneumonia. So this type of reinforcement is part of it. But also in terms of the economy and livelihood and these people are not always been harvested. There are lots of trade and comes and of course feedback around this area. And then another one around social capital and institutions as the government has been unable to deliver services to the type of need with government institutions and a real damage to cohesiveness and culture that is reinforcing. Part of the way of getting these cycles is to break the leadership. I wanted to highlight to the assistant minister of health in liberia, he is the person for the outbreak in liberia. He is also a graduate of the school of Public Health and he has written how it is important to Pay International support in winning the Publics Trust to stop the outbreak. His statement is that we must be helpful and stay hopeful to his own staff and his own people. The slogan within liberia is to be effective stay safe and keep serving. So part of the rationale of moving to a communitybased strategy actually emerges from the area of liberia itself. And so it shows basically the cases over the months where monrovia, the capital is. But what you see is the one that started off in his axis turning to curtail off. This is one of the early counties where they have a problem with fear and a lot of distrust. What has happened is that communities are mobilizing in different ways organize them knows to try to address the epidemic. This has become the focus how the Community Care center is being managed out of these emerging properties in the county itself. There are other rationales and these are some pictures from those who have known to us in the Community Care center hospitals. What he is showing here is in liberia there is not a lot of Running Water and this is the kind of creativity that they are trying to do so that people can wash hands. Until actually trying to find ways to improve hygiene. So these are things that are sort of happening in the community themselves. A lot of innovation. Theres analysis but also backs up the notion of the Community Approach including those that we were collaborating with a took the models and updated them and try to model some of the strategies here in the u. S. Strategy of bringing of vets from hospitals. You can note the curve in the production in february. And its actually that you need a lot of extra will mobilization and a few add to this the ccc strategy you can come up with a lower projection. Theres some analytic support to this as well to support this kind of approach. And so the other rational comes from experiences self. This is another one of the eight leaders that i think that we should recognize in the outbreak or a minister of health from the congo. And they have experienced seven prior epidemics and are currently managing them. In discussions he is having with us and others, the describing that the control depends on a communitybased care strategy. The touring the city offered to say that we have 120,000 doctors and nurses in congo and we have the experience and we have offered to bring a thousand of them to west africa and that is where we get involved work with, who and the others involved including the world bank. So part of the test was to facilitate how this works and its useful to show his perspective how the outbreak is actually working. So this is from going back to these notions of vicious cycles. What you see is the source where the transmissions occurred when you have patience and you cant identify them, trying to transfer them. At the hospital level you do the screening and a new sword and then you have the patient care to the exposure is low and then funerals arent porton in every society, burials take ways in society and practice not just because of what happened but with dignity for the dead. But its also long funerals in the next of kin and wash the body, many times they will wash in a common pot and its a long funerals that can happen through all day and all night and its a critical part of working in the community together. And so what he has noticed here is that there is an epidemiological component in this context taking care of patients and contract. And its important as a Human Behavior component. What we are seeing is an approach that reinforces fear and stigmatizes survivors and reinforces the bad side of the control and care at all three levels. And so they are notion again of how it has worked successfully is basically by combining the Human Behavioral and epidemiologic aspects as all of the cool aspects where they try to reinforce ownership and integrate survivals and provide high quality of care and of course this is sort of the notion that is trying to be reinforce. What they have done with lots of experience with, one of this knowledge is passive knowledge and a lot of the roles that we have laid is to formalize that in a way can be reinforced in a way that we can actually get it implemented further in west africa. So part of this notion was around putting together but the concept is, the Community Care Center Concept is. So this is a Multidisciplinary Team working to define and all three levels of communities, it depends on trained and paid workers and then a whole series of Standard Operating Procedures that we are working with trying to operationalize as well as protect Health Workers and providing the separate areas as well as having Outreach Services and logistics. So the package that has to come together and this is basically trying to codify the response in congo. So the concept has been evolving in liberia and they were originally having this that would later transport this and have this as is a place where you can take your patience and its also planning to use Committee Members and volunteers and caregivers and they have transformed that into having paid Health Workers and the systematic in terms of how they come in. This also health care for those who dont have ebola and basically starting to team up for what looks like. So just to give you an idea that the drc will have for their team, they have coordination, management and a treatment under with clinicians and biologists and the Community Outrage side and about half of the clinicians are nurses that are involved. On the Liberian Team its about 60 people that will rely largely on Community Leaders and volunteers were care assistance and education in various types of management. And of course we will need with early translation although we are trying to get as many English Speakers as possible into the program. So that is basically an idea of what the team looks like. I want to highlight some of our First Responders if we can call them that. We are in the same day of finding out about this and we had three people that came over to work in congo and develop the concept together. So i want to know particularly these three, nancy. Ansi and to understand what the conflict is which is really part of standardized support to do this. Trish perl who was currently able to jump across and work on developing the clinical and Infection Control. And also leadership there. And angela was a recent graduate from the school of Public Health and she was able to help the mobilization aspects. So we have an ongoing team and i just want to show you about the 30 or so people that are currently involved across the school of Public Health and just in terms of who you should Pay Attention to in particular. Trisha is the point person and tom quinn relies on other people to provide assistance. Der cummings is taking the lead on the data that will be needed for the daytoday management and trying to merge the protocols of management. And we have a large team that. We have about a dozen people who are already volunteering either to go to congo or liberia initially and so i wanted to able to talk about it. Theres many people and we welcome more support on outside. So what this is here is basically why we are involved and how we can work together. And so one thing is that we are an honest broker and can negotiate with the different agencies, some of which have lots of experiences. Including alumni and other networks and thats important to be able to draw upon. We initially got involved with the analytic support and we will hear more about bad. But its also a multidisciplinary type of support and implementation research. We are able to provide training and Technical Support although its a real challenge to match up our responsibilities here with Clinical Teaching and the otherwise that we are somehow managing and of course a large area that is needed and we actually need to rely upon our good name to stand behind the protocols because a lot of these will not be the evidence to support them and theres a lot of other agencies that will be able to stand behind them and its really about making the most of what we have. So again, i want to and with a statement that had been given to his own staff and his own population, but i think its just as important here. And the message is that we are neighbors and Community Leaders and global Citizens United for the common good and witty we can accomplish even more. Thank you very much. [applause] thank you very much. At this time we are going to focus and move on to this presentation our next presentation here. Its my great pleasure to introduce trish perl who is a professor of medicine at Johns Hopkins school of medicine in her presentation is entitled rethinking care, lessons from the current and previous Ebola Outbreaks. [inaudible conversations] [inaudible conversations] thank you, and welcome everyone. I want to thank the organizer for this as well as president daniels. I am actually charged with talking a little bit about some of the epidemiologic background and the medical aspects of this particular disease. Trying to tied into what the doctor discussed in making the argument that by improving care we can also improve engagements in the community. So just remind everybody that this is one of the viral hemorrhagic fevers of which there are many. This is a virus coming from the french word [inaudible] and there are two viruses in this particular family, both ebola and of marburg. The ebola name actually came from the ebola river, which is in the republic of congo that was first discovered in 1970. There are five species of this virus and all of them reside in africa except for the one that is found in the philippines. That is the one that does not infect humans as far as we know. The strain is certainly one of the most feared with very high mortality. The outbreak primarily began in Central Africa and this includes the outbreaks that have been reported worldwide and have been garnered. It is actually relatively recently that this has emerged in west. And in fact this actually started around the area and this includes where siberia and liberia intersect. In an embossed the case of a 2yearold boy and this includes moving into sierra leone and liberia. And so nice chain of events, if you will, with transmission moving from very remote areas into urban areas. And that is one of the most notable features of this particular outbreak. And they are found to be over 8000 suspect cases and half are little but more than confirmed. The country that has been most affected by this has been liberia and also significant cases in sierra leone and guinea as you all know. What is most important is that most of these cases have occurred in last three to four weeks and the burden of this particular outbreak is increasing. So in the democratic republic of congo, the outbreak is actually a separate outbreak and begin in the province were some of the original optics occurred with a pregnant woman that budget is animal that was killed and given to her by her husband. Since then they have had 71 cases and it appears that the outbreak is slowing down and they have had 43 deaths. What i would like to talk about now is the clinical presentation of this because the disease presents very acutely, usually six to 10 days after exposure but up to 21 days and very nonspecific symptoms with fever and weakness and diarrhea and vomiting, severe headache. It sounds like influenza and that is one of the big challenges. It sounds not only like influenza but larry at and typhoid fever and a lot of things that you see on this part of the world. And its really not as dramatic as in the movie outbreak. What you see is even a rash that looks like this, hemorrhaging is actually pretty rare. Even in many situations of less than 15 of the cases. So its not really this that is bleeding to death in these patients. This is a cartoon of how the disease progresses with the nonspecifics and the symptoms that occur early on and then you move to the more hemorrhagic phase to reemphasize it can be minimal. Between six and 16 days is when people declare them elves and they can progress into a bigger form of the disease or they can move into a phase where they have clinical improvement, which is actually thought to be partly associated with an immune response. So id like to argue that we need to move away from isolating patients and i would like to show you some data about basic medical care and make the argument that this is like hiv where we argued that we can take an hiv drug into africa and improve the outcomes. So i think that we can take the bold medical care and improve outcomes. So this is data and there is an outbreak of this hemorrhagic fever with extremely high cases of fatalities of around 87 or 88 in africa. The use of electrolytes without being able to measure electrolytes so we are just giving people electrolyte supplements and therapy that the case fidelity rate where they have tried this or the etu via bullet Treatment Centers has dramatically decreased. They are investigational therapies that the talk about in the western world, im not going to dwell on these because someone later in the symposium will be giving a much more area dight discussion than i can give. But just to note that these have not been used in africa. They have been primarily used here. Now the second component of this is hardly against transmission and i fully believe, you will never get anybody who works in Infection Control telling you we must not do Infection Control and i believe isolation welcome need to do is use to break infection. Through breaks of the skin mucus membrane exposure and exposure with needles. Initially as i mentioned you can get infection from me eating bush made or infected animal but the transmission from humantohuman is really the contact in the direct contact with the secretions whether its sweat or blood etc. There is no evidence really of airborne transmission with this particular virus. It can be aerosolized by some of our medical treatments but at this point we dont think at least the zaire strain is. So the risk of transmission, what do we know about this . As i said there have are been 26 prior outbreaks. All of these have actually been terminated with Pretty Simple barrier precautions. A lot of what you are currently seeing has not been needed to determine these outbreaks. It requires a very assiduous attention to making sure your tpp is appropriate but it doesnt need to be super complicated. Now what do we know about these . One of the outbreaks were we have the best data, 16 of household contact developed a bola. 29 who had direct contact with cases their fluids became infected but no household members who had no direct contact became infected. So i think thats one of the messages we can dispel is that if you dont have contact you are not going to become infected. Interacting in this outbreak 80 of this outbreak 80 of the cases so 80 out of the 315 were Health Care Workers and the epidemic was arrested by the institution a simple barrier precaution in intensive training. This is an active epidemic curve from pickwick pickwick and heres where the implemented barrier precautions. You can see that there were cases for about a week after the implementation that would fit with the fact that these people were incubating. There was one isolated case and by the way the black bars are Health Care Workers. Whether there was transmission and this particular Health Care Worker admitted to rubbing her eyes. In terms of uganda what have we learned . 26 Laboratory Confirmed cases and the specimens were tested using rg tcr. They actually found a confined virus in many of the bodily secretions. You can see blood in the stool. Seaman can continue for up to 90 days after you get better from the infection. What i found most interesting about the study and the reason i present it is among the environmental isolate none of the isolates were positive for nonbloody specimens. This is truly the bloody specimen where you can isolate this in the environment. And then finally there is the very similar case from a johannesburg hospital, an unrecognized ebola case became an recovered recovered. The patient had upper and lower endoscopies during their care and in anesthesia assistant put in a central line. He had many procedures they would see commonly in the hospital. Hemodialysis and wasnt debated and ultimately died. Despite this they had no secondary transmission. So what about spain and alice . People say trish what happened there are . What i can tell you is there is a very dangerous moment when you undress and this is not a Health Care Worker issue. This is really a systems issue. When you get out of these isolation units you are tired. You take off your protective gear. You are sweating and remember its about 115 degrees in these foods especially if you are in africa. You take off your glasses or you just touch her face like that. It can be something as simple as that there can be almost devastating and its very unforgiving to see. So what do we do . We want to identify cases as david peters mentioned. We want to triage these cases. We certainly want to put in place Infection Control and we want to train people about doing it. Im not going to dwell much on these. I think david covered this well but just really wanted to point out that this outbreak has been complicated by a lot of human factored distrust not only at the government but of medical care providers. By improving outcomes i think we can improve that distress. The other human factor in terms of medical infrastructure, these are rudimentary overcrowded hospitals. I dont know how many of you heard the piece on npr this morning about the initial case in liberia and the challenges with isolation. Theres a lack of personal protective equipment. Sometimes it is reused and not appropriately cleaned. Sometimes its even makeshift. Just to give you a sense of this, here is from a mmwr last week where they talked about challenges with supplies of nonsterile gloves, obstetrical gloves that were depleted are absent. There are not many handwashing statements. The handwashing station consists of water jugs and even sometimes those are scarce. Their supplies of soap legion alcohol or depleted and you have as i mentioned rudimentary isolation facilities. David really dealt with some of the challenges with the Cultural Habits that have complicated this. Let me just summarize by saying this is an acute viral illness that from our perspective what is remarkable about this this mers cokie h. Seven and nine is one that is impacted Health Care Providers who are just doing their jobs. I think that all of these are examples of failure of Infection Control. This is something that is not. Its just about doing it right. Its about learning how to drive. We have to really start thinking about paying attention to how can we drive down this road a little bit better . To read garner the kind of respect, not respect but the kind of trust we need and the medical care i think we have to change the paradigm of care look at the data about hydration and integrate those into the Public Health response and Start Talking about not only decreasing transmission by isolation and prevention but also by increasing mortality so thank you. [applause] we are going to move on to her next speakers. Josh michaud associate director of Global Health policy at the Kaiser Family foundation and professorial lecturer at the International Development department at john Hopkins Schools for international studies. His talk is entitled financing and governing the Global Response to ebola. Are we where we need to be . I think we are ready to go. Its a pleasure to be here and thank you to the organizers for putting this Wonderful Program together. Some honor for me to join the rest of the speakers to talk about this very pressing issue. My talk today is going to be focused on three main things. I wanted to cover the economic, social and some of the political impacts of ebola in west africa. I wanted to talk about the response the u. S. Government response date and the International Community responds as well as the financing thats been provided to support the Ebola Response in west africa. Then i would like to take a step back and look at the broader implications of this outbreak for the governance of responses to Public Health events of International Concern. So i think the cases have been mentioned already. We are up to over 4000 deaths in west africa from this virus across, five countries that have had cases that the three most effective countries and what i wanted to focus on the first was the broader economic and social impacts. The world bank put out a study initially in september and they updated it last week discussing what they saw as the Economic Impact of the opal epidemic in the three most affected west african countries. This is just one of the charge from it. There are many different ways that they have slice and dice the data but they have looked at several scenarios Going Forward one were ebola is wellcontrolled which they call low if poland one where the epidemic is not controlled and by the end of 2015 you have on the order of 200,000 cases which is a very high estimate. But should that occur the economic implications are very dire. In 2013 both sierra leone and liberia were among the countries that experienced the highest rates of growth in the world. Sierra leone was second and liberia was sixth actually but the Ebola Outbreak has already caused the economies in these countries to shrink and that trend will only continue. Wrapped up in this Economic Data is whats going on, the major sectors that are drivers of the economy in these countries, the Agriculture Sector which makes up 50 of the economy in my area, the Mining Sector which makes up a great portion of the economies in the country are severely impacted by the controls on movement and the decisions made by individuals and firms and businesses to not engage in productive economic behavior. The fiscal implications and the tax revenues for these governments at the time they need to be spending more on responding to the epidemic have been shrinking. Tax and tariff revenues are down and will continue to do so. But most of the cost from the Economic Contraction is due to this aversion behavior with the economists are causing calling the version behavior basically the fear and distrust demonstrated by the virus. While we dont have good data on the impact of that particular behavior in west africa right now the world bank did a study on the sars epidemic and found a big billions of dollars lost during that epidemic in 2002 and 2003, 80 to 90 of the economic losses could be explained by this aversion behavior not the direct cost of patient care but not the indirect cost of lost productivity. So this is obviously a very important for the government and the liberian government itself has said this raises the specter of this becoming a failed state. As the government representatives themselves. They were meant to have a National Election today but were unable to hold it and had to postpone it due to the emergency from ebola. Turning now to the u. S. Government response there are multiple u. S. Government agencies that have responded to the outbreak in west africa. I want to talk about all of these. Some of these agencies are focused on Vaccine Development and we have other speakers to cover that topic but i will talk about usaid, cdc and the department of defense. Usaid is the lead Government Agency in charge of coordinating all the different u. S. Government agencies involved in responding with africa. They have a Disaster Assistance Response Team which has been on the ground since early august. 20 to 30 people and they coordinate all of the resources provided by the others. That includes the cdc which has on the order of 120 or 130 station across west africa right now the largest deployment of their staff for an International Health response. Its the first time the u. S. Government through the office of foreign Disaster Assistance has declared a disaster that is a Public Health disaster so there are a lot of first involved in the response to this. As you likely have heard the military is becoming involved in the Ebola Response. President obama made a statement about a month ago now saying that the department of defense would become increasingly involved. At the time he stated that would mean 3000 troops would be sent over to assist in response. That has now been bumped up to 4000 troops. Not all of those are in the process of scaling that up somewhere in the order of 200 to 300 troops are there right now but their responsibilities is to help build the ebola ebola treatment unit and liberia. 17 hundred units is going to set up a Training Program for up to 500 Health Care Workers a week to help staff those ebola treatment units. They also support logistics and transportation by a created an air bridge for moving personnel and equipment and also are involved in laboratory testin t. There has been a bright line that has been drawn by the leaders in the department of defense and no military medical personnel will be involved in direct patient care. At least thats the thinking right now. So the funding piece of this, this chart shows you on the line as the cases have increased over time the commitments by the u. S. Government have also increased. There was an early response back when the first cases were reported out of any cdc involved in the early response but that led up a little bit in august is the first teams were sent out and then of course last month we dramatically scaled up. The pledge for the Us Government for september was 750 million would be provided to support Ebola Response. This has now increased in october to 1. 25 billion dollars, 1 billion of which is made up of the department of Defense Budget to be reprogrammed for the funds meant for supplemental funding for the war effort in iraq and afghanistan now provided for for this he did humanitarian effort. Clearly the largest expenditure in the humanitarian effort into your ts history. But that money is not ready to go. The Congress Asked the administration the leaders of the department of defense to provide a detailed plan about how that money will be spent and in which ways they plan on doing that. By the end of this week is a matter of fact. Turning to the International Response what has been the International Donors support for the Ebola Response. This data comes from the u. N. , the office of the coordinators for humanitarian affairs. They have a financial transit tracking service which tries to keep tabs on all of the money being provided by all the different players not just donor governments by private actors as well that are being funneled towards the support for the west africa response. I just pulled out some of this information. You can see at the top there are two categories of financing. There are contributions and commitments which are considered to be firm either money in the bank or commitments made on a legal basis as pledges of support. Its important to keep in mind what is a commitment to what is the pledge and you can see together they total 818 million. I pulled out from that data the commitment in the bar chart by various donors and actors. You can see the United States has provided the most in terms of financing to date but there are other very important supporters such as the world bank and the African Development bank. Even the Gates Foundation pledged 50 million and have provided 14 of that as far as the data showed yesterday. Other governments have provided much less of course and there has been some pressure on other wealthy countries to provide more support. This is what is then provided and what is the estimate of what is needed. The u. N. Has done an estimate of that and released a report in the middle of september. Basically outlining what they see as all of the financing needs that would be required to mount a full and complete response to ebola in west africa. I wont go through all of these categories here but you can see there are fairly comprehensive in that they not only consider the cost for treatment of individuals and in ebola treatment units and tracing from a publichealth standpoint but also Food Security and providing nutrition making sure that there are transport and fuel for cars and vehicles and also community engagement. If you add up their assessment of all the things that are needed to get to basically a billion dollars for the next six months for the Ebola Response. We think back to the previous slide in terms of Firm Commitments we have half a billion dollars or 50 of this need estimated by the u. N. If you add in the pledged amount we are about 83 of this total. So thats the financing piece but of course if you are going to build 17 ebola treatment you will need to staff them. One of the most striking figures at least to me from a recent World Health Organization situation report from last week was this chart showing the bed capacity and requirements for patient for a bowl in the three countries most affected. You can see in the case of liberia and sierra leone that only 20 to 26 of the cases that need to be isolated in beds are currently in demand so its much higher than the current capacity as far as estimated by the w. H. O. These data come from the ministries of health of the relevant countries. So another bottleneck here is not just financing but where will all of the Health Care Workers put all of these beds and clinics come from . There is work being done to train us Health Care Workers but that remains a lot more to be done. The president of sierra leone said he believes up to 3000 people will be required in this country alone. So just to close i would like to step back a bit and talk about the governance and the financing response to emerging Infectious Diseases in general. The theme that have been emerging over the past several months in relation to ebola have been the International Community has done too little too late and has been poorly coordinated as it has approached this. It might seem ironic that its less than 10 years ago that the International Community came together to basically reinvents the framework by which they come together and mobilize against emerging Infectious Diseases. That framework is the International Health regulations which which were a vice in 2005 and came it into an effect 2007. Now that framework when it was revised expanded w. H. O. s mandate in the context of these Public Health offense of International Concern and a set minimum requirements for countries to build the capacity to prepare for it to detect and respond to emerging events of International Concern within their borders. And so in theory that the framework was there but clearly in reality the investments have not been made over the seven or eight years since that document was signed. The weakness had been all along that these countries that are very poor are unable to invest in their core capacity. There is no mechanism or no requirement for International Assistance to help in this regard to build up the health capacities. Everyone was on their own. Even though it wasnt in the best interest of all to make sure that the capacities did exist. So right now and even earlier this year there have been an effort to bolster that effort. The u. S. Led effort to make the International Health regulations vision a reality is called the Global Health security agenda and this was launched in february. You may not have heard about them but you may have heard about it now. It was announced on the day that the u. S. Government was closed due to a snowstorm. They didnt gather the kind of attention that it is now because the ebola crisis represents the exact thing that this agenda is trying to address. Recently a few weeks ago they had a meeting to bring together leaders of the u. S. Government and there was very highlevel representation. Including president obama as well as the organizations and 30 other partner countries which made pledges toward building capacity in their own countries with assistance from United States. As of now theres no additional money associated with this agenda. Its really meant to be a mobilizing force to get the Different Actors to work towards a common goal of building Public Health capacity. Another idea has been quoted last week by the president of the World Bank Jim Kim saying he thinks there needs to be a Global Pandemic emergency facility basically prepositioned money and access including personnel who are experts in responding to emerging diseases. That can be rapidly mobilize in the case of an epidemic. This is an idea at this point and its unclear how it would work out but its clear from these efforts that the framework encapsulated by the International Health regulations hasnt done the job it was intended to. Either by working on all string those or going around World Health Organizations and another sensitive as Global Pandemic emergency facility. There are attempts to try and tweak the system and make it work better for the next time. In closing i would just say the lessons that i can see from this epidemic so far in the broader landscape of governance and Health Emergencies are that there is no substitute for making sure that every country has the basic capacity to detect and respond to emerging Infectious Diseases because they can and do arrive and spread without warning. Therefore any country without that capacity becomes a weak link for its neighbors and perhaps for the entire globe. Finally under funding global institutions needs to underwhelming results in a time of need. Thank you. [applause] thank you for that. We have incorporated time for questions at this symposium because we feel its important to have people not to speak to the audience that set up a conversation between the audience and the people have gathered here here. There are two microphones on the side here. Right now this is a natural breaking point and i would encourage anyone who has a question to walk right up and we will call on you. If i can ask the three speakers from this morning symposium to come up and field some of these questions. This is a natural breakpoint in her presentation. We have heard about the Ebola Outbreak in some of the responses. Please use the microphone. We will field some questions about this part of the presentation before we move onto the second second part of our symposium. If the mics are active we can start. [inaudible] some of them are older in 2015 and some of them are couple hundred thousand. I saw one projecting 15,000. What assumptions go into those numbers and how many cases will we have by 2015 and which one do you see as closer to reality . I am happy to answer that. Josh epstein will be talking a bit more about this because its part of his talk. I dont think any of the numbers can be believed in terms of what the projections are. Some of the highend projections are over 4 million but the problem is the assumptions that go into it are very unclear and the types of models we have are rather outdated. So for example the model we see from cbc assumes there is 2. 5 times as many people that are identified. They have assumptions about full mixing of the population and assumptions that basically look at what happens at the hospital and the community and burial and they have these contained areas where different transmission rates but they dont account for changes in behavior and changes in implementation. They are really kind of rigid in terms of what they can do. I would look at the model not so much in terms of the exact numbers are of what protection because none of them have a way of changing the exponential curve until it saturated and that is clearly not the case in reality. You can use the model is an indicator of relative impact of different strategies at this time. I think that this is an area of importance of developing a different class of models that can be more responsive and put in place in the future. I think josh will talk more about this specifically. Good morning and thank you. I am from library and i have been here for three months. I was at cdc attending the training course. My concern here is we figured out at that time most of the International Organizations the ngos and nongovernmental organizations are now going to cdc to get trained. Its an intense course for three days. Before they can go to any of the west african countries. A simple calculation, some of them were researchers and people who would not be working in the clinical aspect. If the cdc is is Johns Hopkins thinking of also developing a site for training volunteers or others who want to go to these countries . We asked the question at cdc because there are many nurses and Health Care Workers in minnesota. We asked them is their problem they dont have enough instructions so i was wondering if would be better these training are set up in different institutions . I dont know. I think its a good question terms of what we can do in the hospital. I think its one of the reasons why we got involved in, because it was being able to do the training they are. Partly its also a question of being able to adapt to their resources that you have so that kind of protective equipment we have here in the hospital is going to be different from what we are going to be able to get in liberia and sierra leone and guinea. Its a good point whether that can be more in the u. S. I think its important. We found an opportunity to do something practical and get Health Workers in these coherent units together and hopefully we can build from that experience. We have dave kelen who can also comment. W. H. O. Is doing training so there are multiple