全球衛生安全的變化。埃博拉的教訓 (Shifts in Global Health Security: Lessons from Ebola)

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>>> GOOD AFTERNOON AND WELCOME. ON BEHALF OF CDC, I'D LIKE TO
WELCOME YOU TO PUBLIC HEALTH GRAND ROUNDS.
CONTINUING EDUCATION CREDITS FOR PUBLIC HEALTH GRAND ROUNDS ARE
AVAILABLE FOR PHYSICIANS, NURSES, PHARMACISTS, HEALTH
EDUCATORS, AND OTHER HEALTH PROFESSIONALS.
PLEASE SEE MORE AT THE GRAND ROUNDS WEBSITE.
GRAND ROUNDS IS AVAILABLE ON ALL OF YOUR FAVORITE WEB AND SOCIAL
MEDIA SITES. FOR TODAY'S SPECIAL SESSION, WE
WILL ONLY BE TAKING QUESTIONS BY E-MAIL AND SOCIAL MEDIA, AND
WE'RE ALSO LIVE TWEETING TODAY. HERE'S A PREVIEW OF UPCOMING
GRAND ROUNDS SESSIONS. PLEASE JOIN US LIVE OR ON THE
WEB AT YOUR CONVENIENCE. I'D LIKE TO THANK TODAY'S
FEATURED SPEAKERS AND THE MANY PEOPLE LISTED HERE WHO HELPED TO
MAKE THIS SESSION POSSIBLE. WE HAVE A FEATURED VIDEO SEGMENT
ON YOUTUBE AND OUR WEBSITE CALLED BEYOND THE DATA, WHICH IS
POSTED SHORTLY AFTER THE SESSION.
THIS MONTH'S SEGMENT FEATURES MY INTERVIEW WITH
DR. JORDAN TAPPERO. WE'VE ALSO PARTNERED WITH THE
CDC PUBLIC HEALTH LIBRARY TO FEATURE ARTICLING RELEVANT TO
THIS SESSION. IT'S NOW MY PLEASURE TO
INTRODUCE THE CDC DIRECTOR, DR. TOM FRIEDEN.
[ APPLAUSE ] >> THANK YOU ALL, VERY MUCH FOR
BEING HERE, AND THANKS TO THE SPEAKERS AND THOSE WHO
CONTRIBUTED TO THE TALKS THAT WE'LL HEAR.
EBOLA WAS AN UNPRECEDENTED EPIDEMIC WITH AN UNPRECEDENTED
RESPONSE. WE'VE NOT YET GOTTEN TO ZERO,
ALTHOUGH WE'RE TANTALIZINGLY CLOSE, BUT WE'RE OPTIMISTIC THAT
WE WILL. THE PROGRESS HAS BEEN ENORMOUS.
IT'S BEEN THE RESULT OF ENORMOUS ACTIVITY AND EFFORT ON REALLY
ALL PARTS OF CDC AND A LARGE NUMBER OF OUR NATIONAL AND
INTERNATIONAL PARTNERS AND THE COUNTRIES AND COMMUNITIES IN
WEST AFRICA. WE STILL HAVE 150 PEOPLE IN WEST
AFRICA IN THE THREE AFFECTED COUNTRIES, AND WE STILL NEED
PEOPLE TO GO. SO IF YOU'RE WILLING, BARB IS IN
THE FRONT OF THE ROOM. WE'LL ALSO TAKE E-MAILS WITH
VOLUNTEERS. I THINK THERE ARE REALLY THREE
KEY LESSONS FROM EBOLA. THE FIRST IS THAT EVERY SINGLE
COUNTRY NEEDS STRONG CAPACITY TO FIND, STOP, AND PREVENT HEALTH
THREATS WHEN THEY EMERGE. THAT'S WHAT GLOBAL HEALTH
SECURITY AGENDA IS ALL ABOUT, AND THIS IS A GOLDEN OPPORTUNITY
FOR THE WORLD, INCLUDING THE CDC, TO ACCELERATE PROGRESS AND
LABORATORY SYSTEMS, SURVEILLANCE SYSTEM, EMERGENCY RESPONSE,
VACCINATION, AND OTHER PROGRAMS IN THE COUNTRIES AROUND THE
WORLD THAT NEED IT MOST AND HAVE IT LEAST.
THE SECOND KEY LESSON I BELIEVE IS THAT WHEN COUNTRY CAPACITIES
ARE OVERWHELMED, THE WORLD NEEDS TO BE ABLE TO SURGE IN MORE
RAPIDLY TO SUPPORT PROGRESS. THAT MEANS AT CDC, WE'VE CREATED
THE GLOBAL RAPID RESPONSE TEAM, ABLE TO PUT 50 PEOPLE VIRTUALLY
ANYWHERE IN THE WORLD WITHIN JUST A COUPLE DAYS.
WE'RE WORKING TO SUPPORT AND STRENGTHEN THE WORLD HEALTH
ORGANIZATION, THE AFRICAN UNION CDC, AND OTHER ORGANIZATIONS SO
THAT THE WORLD CAN MOVE RAPIDLY WHEN SOMETHING IS TOO MUCH FOR
AN INDIVIDUAL COUNTRY. AND THE THIRD IS THE ENORMOUS
IMPORTANCE OF INFECTION CONTROL. HEALTH CARE WORKERS ARE ON THE
FRONT LINE. THEY'RE POTENTIALLY AT RISK.
THEY'RE ALSO CRITICALLY IMPORTANT IN REPORTING DISEASES
AND OUTBREAKS, AND HEALTH CARE FACILITIES CAN BE BOTH
AMPLIFIERS OF DISEASE AND CONTROLLERS OF OUTBREAKS.
AND WE NEED TO MAKE SURE THAT THEY'RE SAFE FOR HEALTH CARE
WORKERS, SAFE FOR PATIENTS, GOOD INFORMATION SOURCES FOR PUBLIC
HEALTH, AND PART OF THE SOLUTION IN TERMS OF STOPPING OUTBREAKS.
AS WE MOVE FORWARD, WE HAVE A UNIQUE OPPORTUNITY TO MAKE SURE
THAT WE DON'T GO BACK TO THE WORLD THAT EXISTED BEFORE EBOLA,
A WORLD IN WHICH THERE WAS NO ACCOUNTABILITY FOR WHETHER
COUNTRIES WERE READY, ON THE ONE HAND, AND INADEQUATE ASSISTANCE
FROM THE WORLD TO SUPPORT COUNTRIES TO BECOME READY ON THE
OTHER. EBOLA PROVIDES US WITH REALLY A
UNIQUE OPPORTUNITY TO IMPROVE PREPAREDNESS IN COUNTRIES AROUND
THE WORLD, AND IT'S UP TO US TO SEIZE THAT OPPORTUNITY AND MAKE
SURE WE MAKE AS MUCH PROGRESS AS RAPIDLY AS POSSIBLE.
SO I'M VERY MUCH LOOKING FORWARD TO THE PRESENTATIONS AND THANK
THE SPEAKERS FOR BEING HERE. [ APPLAUSE ]
>> THANK YOU VERY MUCH, DR. FRIEDEN.
OUR NEXT SPEAKER IS JENNIFER NUZZO.
>> THANK YOU SO MUCH. I'M VERY GLAD TO BE HERE TO TALK
ABOUT WHAT'S CLEARLY ONE OF THE MOST PRESSING HEALTH SECURITY
CHALLENGES IN A VERY LONG TIME. THE EBOLA CRISIS STARTED IN WEST
AFRICA AND SICKENED MORE THAN 28,000 PEOPLE.
IT'S CAUSED UPWARDS OF 11,000 DEATHS.
IT'S BEEN DEVASTATING TO THE ECONOMIES THAT HAVE BEEN
AFFECTED. PRESIDENT OBAMA AND DIRECTOR
FRIEDEN BOTH RIGHTLY DESCRIBE IT AS A THREAT TO OUR NATIONAL
SECURITY. I COMPLETELY AGREE.
THE CHALLENGES THAT HAVE ARISEN DURING THIS CRISIS REALLY ARE
ENORMOUS, BUT WE CAN AND SHOULD LEARN FROM THEM SO WE UNDERSTAND
HOW WE CAN RESPOND BETTER IN THE FUTURE.
AND HOPEFULLY PREVENT SUCH A CRISIS FROM HAPPENING AGAIN.
THAT'S WHAT I WANT TO TALK ABOUT TODAY, SOME OF THESE LESSONS.
BEFORE I GET INTO THE CHALLENGES, I WANT TO TALK A
LITTLE BIT ABOUT WHAT I THINK WORKED WELL BECAUSE THERE HAVE
BEEN A LOT OF BAD NEWS STORIES THAT HAVE DOMINATED, AND I WANT
TO RIGHTLY SORT OF CELEBRATE RESPONSES THAT WENT WELL.
FIRST, THERE'S ABSOLUTELY NO DOUBT THAT THE EBOLA CRISIS
WOULD HAVE BEEN MUCH, MUCH WORSE IF IT WEREN'T FOR THE HEALTH
CARE AND PUBLIC HEALTH PROFESSIONALS WHO ARE ON THE
FRONT LINES TACKLING THIS CRISIS.
THE BRAVERY, SACRIFICE, AND IMPACT OF THESE INDIVIDUALS IS
REALLY ENORMOUS. THEY WERE RIGHTLY RECOGNIZED AS
"TIME" MAGAZINE'S PERSON OF THE YEAR.
I CONSIDER THAT TO BE AN ENORMOUS SUCCESS.
I'M ALSO INCREDIBLY PROUD OF U.S. LEADERSHIP DURING THIS
CRISIS. THIS GRAPH HERE SHOWS SOME OF
THE U.S. COMMITMENTS. IT DOESN'T INCLUDE THE EBOLA
SUPPLEMENTAL THAT CONGRESS PASSED.
QUITE ENORMOUS, ESPECIALLY TO OTHER COUNTRIES.
AND IT'S NOT JUST THE U.S. ALSO NGOs AND VOLUNTEERS WENT
OVER, POTENTIALLY PUTTING THEIR LIVES AT RISK.
I KNOW THAT CDC STAFF PLAYED A PIVOTAL ROLE IN ALL OF THIS, AND
REALLY, YOU DESERVE OUR NATION'S THANKS FOR ALL OF YOUR HARD WORK
AND EFFORTS. I KNOW THAT THE WORK CONTINUES,
AND WE SHOULD CONTINUE TO OFFER THANKS ON THAT FRONT.
IT'S NOT JUST ME WHO THINKS THIS IS IMPORTANT.
THE AMERICAN PUBLIC REALLY DOES TOO, AND IT'S REALLY HARD TO
TELL IN THE MEDIA REPORTS, BUT IF YOU LOOK AT THIS POLLING DATA
FROM THE KAISER FAMILY FOUNDATION, THE MAJORITY OF
AMERICANS THINK THAT WORKING OVERSEAS, YOU KNOW, TO MAKE
INVESTMENTS IN DEVELOPING COUNTRIES HELPS PROTECT
AMERICANS HERE, LIKE IT HELPS TO PREVENT BY SPREADING -- HELPS
THE PREVENTION OF SPREADING DISEASES.
AND NEARLY SIX IN TEN THINK THIS IS IMPORTANT TO DO NOT JUST FOR
OUR OWN PUBLIC HEALTH BUT ALSO TO ENHANCE PROTECTION ABROAD.
THERE'S ALSO GOOD SUPPORT FOR WHAT WE'VE DONE AT HOME TO
TACKLE EBOLA CASES THAT HAVE RISEN IN THE U.S.
THIS SURVEY SHOWS THAT THERE'S A HIGH LEVEL OF CONFIDENCE IN BOTH
CDC, PUBLIC HEALTH AGENCIES, AND LOCAL HOSPITALS TO BE ABLE TO
RESPOND -- RESPONDENTS WERE ASKED IF EBOLA WAS DIAGNOSED IN
YOUR AREA, HOW CONFIDENT WERE THEY THAT THE AREA WOULD BE ABLE
TO RESPOND. THERE WAS A DIP IN CONFIDENCE
FOR SURE AFTER THE TEXAS EBOLA DEATH, BUT IF YOU LOOK AT THE
NUMBERS, THEY'RE STILL PRETTY HIGH AND CERTAINLY WELL ABOVE
WHAT YOU TYPICALLY SEE FOR MEMBERS OF CONGRESS.
I KNOW, DON'T SET THE BAR TOO HIGH.
I THINK ANOTHER KEY SUCCESS IS THE RAPID EXPANSION OF
DIAGNOSTIC CAPABILITIES WITHIN THE REGION.
IT'S IMPORTANT TO REMEMBER THAT, YOU KNOW, ALTHOUGH WE THINK THAT
THE FIRST EBOLA CASES PROBABLY HAPPENED SOMETIME IN MAYBE
DECEMBER 2013, THE FIRST CASE THAT WAS CONFIRMED WAS CONFIRMED
IN MARCH 2014 WHEN A SPECIMEN WAS SENT TO FRANCE FOR
LABORATORY TESTING. THAT WASN'T GOING TO BE
SUSTAINABLE TO SEND SPECIMENS OUT, SO THERE WAS MUCH EFFORT IN
ENHANCING THE DIAGNOSTIC CAPABILITIES LOCALLY.
I KNOW CDC STAFF WERE PARTICULARLY INVOLVED IN SETTING
UP THESE LABORATORY NETWORKS THAT EMERGES REALLY WITHIN A
MATTER OF MONTHS. THAT'S A GREAT SUCCESS AS WELL.
THIS WASN'T THE FIRST TIME THE U.S. GOVERNMENT THOUGHT ABOUT
EBOLA. THANKS TO SOME ADVANCED
INVESTMENTS ON BEHALF OF THE U.S. GOVERNMENT, RAPID RESPONSE
FROM THE PRIVATE SECTOR, AND FLEXIBLE REGULATORY MECHANISMS
LIKE EMERGENCY USE. WE ALSO SAW THE DEVELOPMENT OF
ADDITIONAL DIAGNOSTIC TOOLS FOR EBOLA.
SINCE AUGUST 2014, TEN DIAGNOSTIC TOOLS HAVE NOW BEEN
DEVELOPED THAT CAN BE POTENTIALLY USED UNDER EMERGENCY
CONDITIONS. SO THAT IS BY FAR NOT A
COMPREHENSIVE LIST OF ALL THE SUCCESSES.
I JUST WANTED TO REALLY HIGHLIGHT WHAT I THINK IS
PARTICULARLY HELPFUL. BUT I REALLY DO WANT TO TURN
ATTENTION NOW TO WHAT ARE SOME OF THE CHALLENGES THAT WE NOT
ONLY EXPERIENCE DURING EBOLA BUT WHAT WE'RE LIKELY TO EXPERIENCE,
YOU KNOW, MOVING FORWARD FOR FUTURE HEALTH SECURITY THREATS.
THERE HAVE BEEN A LOT OF AFTER-ACTION REPORTS, EXPOSES OF
ALL THE THINGS THAT WENT WRONG. I'M NOT GOING TO TRY TO GIVE A
COMPREHENSIVE LIST OF EVERYTHING THAT I THINK DIDN'T WORK, BUT
WHAT I DO WANT TO FOCUS ON IS WHAT I THINK ARE THE KEY ISSUES
THAT WE NEED TO ADDRESS GOING FORWARD BECAUSE WITHOUT
ADDRESSING THESE ISSUES, WE'RE GOING TO HAVE SIMILARLY
DIFFICULT PROBLEMS IN FUTURE HEALTH SECURITY THREATS.
SO ONE OF THE PROBLEMS IS ON SURVEILLANCE.
NOW, WHEN THE WORLD AWOKE TO THE CRISIS THAT WAS UNFOLDING IN
WEST AFRICA, THERE WERE A LOT OF PEOPLE, INCLUDING ESTEEMED
PUBLIC HEALTH FOLKS, WHO CALLED THIS CRISIS A SURPRISE.
YOU KNOW, THEY EXPLAINED IN THE PREVIOUS OUTBREAKS THERE WEREN'T
NEARLY AS MANY PEOPLE INVOLVED. THEY WERE IN RURAL AREAS AND
TYPICALLY CONTAINED. BUT I GUESS WE HAVE TO EXAMINE
WHETHER OR NOT IT REALLY SHOULD HAVE BEEN A SURPRISE.
THIS MAP HERE SHOWS THE RANGE OF FACTS THAT HAVE BEEN KNOWN TO
HARBOR THE EBOLA VIRUS. WHEN YOU ASK THE QUESTION, WAS
EBOLA IN WEST AFRICA A SURPRISE, THE ANSWER FROM THE HEALTH
COMMUNITY PERSPECTIVE IS NO. THIS IS SOMETHING THAT I WANT TO
TALK ABOUT A LITTLE BIT BECAUSE THOSE WHO ALSO WORK IN
PREPAREDNESS, THIS IS THE CHALLENGE.
DEFEATING THE MENTALITY OF IT HASN'T HAPPENED, THEREFORE IT
ISN'T GOING TO HAPPEN. WE HAVE TO FIGURE OUT HOW TO GET
AROUND THAT. I THINK IT'S SOMETHING THE
BIPARTISAN 9/11 COMMISSION CALLED A FAILURE OF IMAGINATION.
WE HAVE TO BETTER ANTICIPATE WHAT THREATS ARE GOING TO BE.
BUT EARLY DETECTION IS HARD. I DON'T THINK IT SHOULD BE OUR
SOLE FOCUS. WHAT I THINK IS ALSO PROBABLY
PERHAPS AN EVEN GREATER PRIORITY IS MAKING SURE WHEN WE DO
RECOGNIZE THERE'S A CRISIS THAT WE HAVE THE RIGHT INFORMATION AT
OUR HANDS TO BE ABLE TO RESPOND EFFECTIVELY.
CLEARLY WHAT HAPPENED IN TEXAS WAS A SHORTCOMING OF
SURVEILLANCE. IT TOOK DAYS AND MULTIPLE VISITS
TO A HOSPITAL FOR THAT PATIENT TO BE DIAGNOSED WITH EBOLA.
WE NOW KNOW THERE ARE VARIOUS REASONS FOR WHY THAT IS, BUT WE
NEED TO FIX THAT TO MAKE SURE THAT DOESN'T HAPPEN AGAIN.
THERE'S ALSO PROBLEMS ON THE GLOBAL GOVERNANCE FRONT.
AFTER SARS IN 2003, A LOT OF EFFORT WAS PUT INTO TRYING TO
FIX SOME OF THE PROBLEMS WE SAW WITH GLOBAL GOVERNANCE.
A LOT OF EFFORT WAS PUT ON TO UPDATING THE INTERNATIONAL
HEALTH REGULATIONS AND FOLLOWING THEM OUT AND PUTTING THEM INTO
FORCE. AND THERE'S ENORMOUS POTENTIAL
IN THE REVISED INTERNATIONAL HEALTH REGULATIONS, BUT
UNFORTUNATELY WHAT WE SAW IN EBOLA IS THEY DON'T COMPLETELY
SOLVE THE PROBLEM. IN FACT, I DON'T THINK ANYBODY
THINKS THAT IT'S A GOOD THING THAT EBOLA WASN'T DECLARED A
PUBLIC HEALTH EVENT OF INTERNATIONAL CONCERN UNTIL
AUGUST WHEN THERE WERE ALREADY FOUR COUNTRIES REPORTING CASES,
YOU KNOW, OVER 1700 CASES AND A THOUSAND DEATHS, WHICH WAS FOUR
TIMES AS MANY CASES AS WE HAD SEEN IN ANY PRIOR EBOLA
OUTBREAK. SO WE NEED TO FIGURE OUT BETTER
MECHANISMS FOR HOW WE MOTIVATE GLOBAL ACTION IN RESPONDING TO
CRISES. I THINK IF YOU LOOKED AT EARLIER
SLIDE OF U.S. CONTRIBUTIONS TO THE EBOLA CRISIS, I MEAN, THERE
WAS AN ENORMOUS, REALLY UNPRECEDENTED LEVELS OF
COMMITMENT TO RESPONDING. WE DID A LOT OF REALLY IMPORTANT
THINGS ON THE GROUND. ONE THING THAT WE DIDN'T DO WAS
ASSESS ORGANIZATIONS WHO WERE ON THE FRONT LINES WHICH KEPT
ASKING FOR TEAMS OF CLINICIANS WHO COULD TREAT SICK EBOLA
PATIENTS. THIS WAS SOMETHING THAT WAS
ABSOLUTELY NECESSARY, NOT JUST BECAUSE, OF COURSE, WE WANT TO
PROTECT PEOPLE, TAKE CARE OF PEOPLE WHO ARE SICK, BUT BECAUSE
WE FOUND THAT IT'S VERY HARD TO GET POPULATIONS TO ACCEPT OUR
PUBLIC HEALTH MESSAGES IF WE CAN'T GIVE THEM SOME ASSURANCES
THAT WE'RE GOING TO TAKE CARE OF THEIR LOVED ONES IF THEY GET
SICK. AND IT'S ALSO IMPORTANT THAT WE
HAVE EFFECTIVE MEDICAL RESPONSES TO INFECTIOUS DISEASE
EMERGENCIES. HEALTH CARE FACILITIES CAN
BECOME ULTIMATELY SOURCES OF INFECTIONS FOR THE REST OF THE
COMMUNITY IF WE DON'T FIGURE OUT HOW WE CARE FOR THE SICK AND
PROTECT THE WELL WITHIN THE FACILITIES AS WELL.
POLITICS WAS ANOTHER PROBLEM. IT'S ALWAYS A PROBLEM.
I'M GOING TO SHOW YOU AN EXCERPT FROM AN AFTER-ACTION REPORT.
THIS EXCERPT, JUST SOME OF THE THEMES THAT EMERGE ARE TENSIONS
BETWEEN FEDERAL AND STATE AUTHORITIES, DISAGREEMENTS OVER
WHAT LEVEL OF ACTION, WHETHER OR NOT WE SHOULD CLOSE BORDERS,
IMPLEMENT QUARANTINES. IT SOUNDS VERY FAMILIAR, RIGHT?
SOUNDS LIKE THE STORY OF EBOLA. IT'S ACTUALLY AN EXCERPT FROM A
TABLE TOP EXERCISE THAT OUR CENTER CONDUCTED IN 2001 CALLED
"DARK WINTER." IT WAS A FICTIONAL SMALLPOX
RESPONSE. BASED ON "DARK WINTER," REALLY
THREE OTHER EMERGING INFECTIOUS DISEASES SINCE 2001 SHOULD HAVE
BEEN COMPLETELY -- I MEAN, YOU COULD TELL THAT WITHIN
SHORT-ORDER, PUBLIC HEALTH OFFICIALS WERE GOING TO HAVE TO
DIVERT THEIR ATTENTION FROM RESPONDING TO THE CRISIS TO
TRYING TO MANAGE THE POLITICAL FALLOUT FROM LEADERS TRYING TO
DO THINGS LIKE SHUT DOWN BORDERS, CANCEL TRAVEL, ALL
THINGS THAT OUR BEST EVIDENCE SAY LIKELY WILL NOT WORK AND
WOULD ULTIMATELY EXACERBATE THE TOLL OF THE CRISIS.
THIS IS A STATE RESPONSE, A STATE EBOLA RESPONSE PLAN.
YOU CAN SEE THAT THE PUBLIC HEALTH OFFICIALS THAT DRAFTED
THIS PLAN WERE CLEARLY AWARE OF THIS PROBLEM.
THEY TALKED ABOUT THE CONSEQUENCES OF, YOU KNOW,
QUARANTINING A-SYMPTOMATIC INDIVIDUALS, THAT THERE'S NO
SCIENTIFIC RATIONALE FOR THIS. UNFORTUNATELY, THIS PLAN WAS
ULTIMATELY SCRAPPED BY THE POLITICAL LEADERS IN THAT STATE
WHO BASICALLY DECIDED TO IMPLEMENT POLICIES THAT WERE NOT
CONSISTENT WITH CDC GUIDANCE. AND THIS IS REALLY UNFORTUNATE.
ONE THING I THINK THAT'S PARTICULARLY DIFFICULT, AND I
WANT TO POINT IT OUT IN THIS SLIDE, YOU CAN SEE THERE'S A
TERM OF ABUNDANCE OF CAUTION. WE HAVE TO PUT THIS TERM TO BED.
WHAT IT MEANS IS BASED ON NO EVIDENCE WHATSOEVER.
AND IT'S DANGEROUS BECAUSE WHEN WE SAY OUT OF ABUNDANCE OF
CAUTION, IT GIVES THE PERCEPTION THAT THERE IS EVIDENCE
SOMEWHERE, AND IT BASICALLY REINFORCES PEOPLE'S FEARS THAT
THEY'RE GOING TO GET SICK. AND IT'S DANGEROUS.
IT CREATES AN INCONSISTENCY IN OUR MESSAGE.
WE CAN'T SAY THERE'S NO THREAT, BUT OUT OF AN ABUNDANCE OF
CAUTION, WE'RE GOING TO SCRUB DOWN EVERY SINGLE PLACE THIS
INDIVIDUAL WENT BEFORE THEY BECAME SICK.
I KNOW THAT WHEN THE DOCTOR GOT SICK IN NEW YORK, I GOT LOTS OF
CALLS FROM THE MEDIA ASKING, WE
WELL, IF THEY SAY HE LIKELY DIDN'T INFECT PEOPLE BEFORE HE
BECAME SICK, WHY ARE THEY SCRUBBING THE BOWLING ALLEY?
WHY ARE THEY CLOSING DOWN THE MEATBALL SHOP?
WHAT'S UNDERLINING THOSE QUESTIONS THAT THE MEDIA WAS
ASKING IS, ARE THEY LYING TO US? THAT'S A REALLY BAD PLACE FOR
PUBLIC HEALTH TO BE. SO WE HAVE TO BE VERY AWARE OF
THE CONSISTENCY OF OUR MESSAGE. AND THESE WEREN'T LIKE CRAZY,
OUT THERE MEDIA OUTLETS ASKING THESE QUESTIONS.
IN FACT, MANY OF THEM CAME FROM NPR, WHICH YOU CONSIDER TO BE
GENERALLY BALANCED ON THE ISSUES.
SO MOVING FORWARD, HOW DO WE MOVE BEYOND THESE CHALLENGES?
DOES EVERYBODY KNOW WHO THIS IS? OKAY, GOOD.
I'LL JUST LEAVE IT THERE. SO WE HAVE TO FIX SURVEILLANCE.
THIS PICTURE SHOWS SOME OF THE CHANGES THAT WERE MADE TO THE
ELECTRONIC HEALTH RECORD AT THE HOSPITALS AFTER THE EBOLA CASE
IN DALLAS. ESSENTIALLY WHAT IT DID WAS TRY
TO ASK SOME OF THE QUESTIONS LIKE TRAVEL HISTORY.
I THINK THESE APPROACHES ARE REALLY IMPORTANT, AND I THINK WE
SHOULD CONTINUE TO SUPPORT THEM AND MAKE SURE THEY EXIST
ELSEWHERE BECAUSE I KNOW THAT I'VE TALKED TO PUBLIC HEALTH
DEPARTMENTS THAT EXPRESS FRUSTRATIONS WHEN THEY GET
QUESTIONS FROM THEIR HOSPITALS LIKE, WHEN CAN WE STOP ASKING
TRAVEL HISTORY? IN THIS DAY AND AGE, WE CAN'T.
WE HAVE TO TRY TO CREATE A CULTURE AROUND THIS.
THE OTHER THING WE ABSOLUTELY NEED TO FIGURE OUT IS HOW WE ARE
GOING TO MEDICALLY MANAGE PATIENTS IN ACUTE INFECTIOUS
DISEASE EMERGENCIES. THE ABSENCE OF A CLINICAL
RESPONSE IS ONE OF THE GREATEST CHALLENGES FACED DURING EBOLA.
I COMPLETELY AGREE AND THINK WE HAVE TO FIGURE OUT HOW TO DO
THIS. WHEN THE U.S. -- I MEAN, IF WE
ARE SERIOUS ABOUT THIS BEING A NATIONAL SECURITY CRISIS, AND I
COMPLETELY AGREE THAT IT IS, THINK ABOUT WHAT THAT MEANS.
WE DON'T GO TO WAR BY JUST ISSUING A GENERAL CALL TO
VOLUNTEERS AND SEE WHO SHOWS UP, RIGHT.
WE RECRUIT INDIVIDUALS, WE MAKE SURE WE HAVE APPROPRIATE SKILL
SETS. WE TRAIN THEM FOR THE MISSION.
WE MAKE SURE THAT THEY KNOW WHAT THE MISSION IS AND WE GIVE THEM
ALL THE PROTECTION THAT WE CAN TO MAKE SURE THEY COME BACK
SAFELY. AND WE PAY THEM FOR THEIR JOB.
AT THE VERY LEAST, WE MAKE SURE THAT THEY'RE NOT FIRED WHEN THEY
RETURN TO THEIR DAY JOBS. BUT WHEN WE'RE THINKING ABOUT
MEDICAL RESPONSE, WE ALSO HAVE TO EXAMINE THE GENERALIZED
ABILITY AND SCALEABILITY. NOW, I THINK THE TIERED RESPONSE
FOR U.S. HOSPITALS FOR EBOLA DEVELOPED IS IMPORTANT WORK, AND
IT MAKES SENSE IN THE CONTEXT OF THE CURRENT EBOLA CRISIS.
BUT WE ALSO NEED TO THINK ABOUT WHETHER OR NOT WE CAN APPLY THIS
MODEL TO OTHER INFECTIOUS DISEASE THREATS.
AND I THINK THE ANSWER MAY BE NO.
BECAUSE IF YOU CONSIDER WHAT WE'RE DOING WITH THESE TIERED
HOSPITALS, THE TOTAL CAPACITY IS PROBABLY VERY LOW.
WE KNOW IT REQUIRES VERY INTENSE COMMITMENT OF STAFF.
WERE THERE TO BE MORE CASES, IT WOULD BE DIFFICULT FOR HOSPITALS
TO MAINTAIN FOR A LONG TIME. UNFORTUNATELY FOR THE POLITICAL
LEADERSHIP, THERE IS A TENDENCY TO WANT TO CHECK THE BOX.
WE'VE SOLVED ALL THE PROBLEMS. I KNOW FOLKS IN PUBLIC HEALTH
DEPARTMENTS WHO ARE GETTING QUESTIONS LIKE, WHAT'S THE MERS
HOSPITAL? WE HAVE TO EXAMINE WHETHER OR
NOT THIS IS A MODEL WE WANT TO ROLL OUT FOR ALL INFECTIOUS
DISEASE. THE NEXT THING WE HAVE TO DO IS
REALLY WORK ON PROMOTING EVIDENCE-BASED POLICIES.
THAT MEANS THINKING IN ADVANCE OF THE NEXT CRISIS WHAT MEASURES
WE'RE GOING TO TAKE AND WHAT EVIDENCE SUPPORTS THEM AND
SOCIALIZING THESE PLANS, NOT JUST WITH POLITICAL LEADERSHIP,
BUT ALSO WITH THE PUBLIC. THIS IS SOMETHING THAT IS COMING
FROM THE THINK TANK WORLD AND WE TAKE REALLY SERIOUSLY.
WE WERE HORRIFIED BY THE POLITICAL DEBATES OVER TRAVEL
RESTRICTIONS DURING EBOLA. WE TRIED TO DO OUR PART BY
TALKING TO THE MEDIA AND BRIEFING POLICYMAKERS AND
WRITING PIECES TO TRY TO COUNTERACT THOSE, I WOULD CALL,
REFLEXES. BUT WE CAN'T JUST, YOU KNOW,
FOCUS ON POLITICAL LEADERSHIP. WE ALSO HAVE TO REACH MEMBERS OF
THE PUBLIC AND FIGURE OUT WHETHER OR NOT THE PLANS WE HAVE
FOR THEM ARE CONSISTENT WITH WHAT WE WOULD EXPECT AND BE
WILLING TO DO IN AN EMERGENCY. A GOOD EXAMPLE OF THIS IS SOME
COLLEAGUES OF MINE HAVE BEEN WORKING WITH THE STATE OF
MARYLAND TO DO SOME ALLOCATION. BASICALLY ASKING OPPOSING
QUESTIONS TO THE PUBLIC. IF THERE WASN'T ENOUGH TO GO
AROUND, WHO SHOULD WE ALLOCATE THE CARE TO?
YOU KNOW, WHOSE LIVES SHOULD WE PREFERENTIALLY TRY TO SAVE?
APPARENTLY THE RESULTS OF THOSE FOCUS GROUPS HAVE BEEN
COMPLETELY EYE OPENING AND VERY USEFUL FOR STATE PLANNING
EFFORTS. WE NEED TO DO MORE THINGS LIKE
THAT TO MAKE SURE WE ARE APPROPRIATELY CAPTURING THE
VALUES OF THE PUBLIC IN OUR RESPONSE PLANS.
THE GOAL HERE IS THAT WHEN WE ACTUALLY ROLL OUT THE PLANS,
IT'S DONE SO IN PARTNERSHIP WITH THE PUBLIC, THE POLITICAL
LEADERSHIP, AND PUBLIC HEALTH. THIS IS SOMETHING THAT HAD TO
HAPPEN AFTER THE LEADERSHIP IN NEW YORK CITY HAD TO GO EAT
MEATBALLS AS A SHOW OF CONFIDENCE THAT THE GENERAL
PUBLIC WAS NOT PUT AT RISK. ONE THING THAT I'M REALLY
WORRIED ABOUT WHEN WE'RE TALKING ABOUT PUBLIC HEALTH PLANS IS
WHAT THE POLITICAL LEGACY OF SOME OF THE MEASURES THAT WE HAD
TO TAKE DURING EBOLA. ONE I'M QUITE WORRIED ABOUT IS
THE MONITORING OF TRAVELERS FROM WEST AFRICA.
I UNDERSTAND WHY WE DID THIS. POLITICALLY, IT WAS FAR
PREFERABLE THAN RESTRICTING TRAVEL TO AND FROM THOSE AREAS.
BUT WHAT WE'RE ALREADY SEEING IS -- I WORRY THAT WE'VE CREATED
EXPECTATIONS OF THE POLITICAL LEADERSHIP THAT THIS IS
SOMETHING THAT WE CAN AND SHOULD DO IN FUTURE CRISES THAT
ORIGINATE ABROAD. WE NEED TO EXAMINE WHETHER OR
NOT THIS IS SOMETHING THAT WE WANT TO ROLL OUT, AND IF NOT, WE
MAY NEED TO RESET POLITICAL EXPECTATIONS AROUND THIS.
AS DIRECTOR FRIEDEN SAID, I THINK WE HAVE ENORMOUS
OPPORTUNITY IN FRONT OF US TO, YOU KNOW, BUILD ON SOME OF THE
LESSONS OF EBOLA, PARTICULARLY USING THE GLOBAL HEALTH SECURITY
AGENDA AS A MECHANISM TO DO SO. I'VE HEARD A LOT OF CRITICISMS
OF THE GHSA FROM PEOPLE, OR SKEPTICISM.
THIS IS TOO AMERICAN, TOO WESTERN CENTRIC.
THEY DON'T REALLY CARE ABOUT HEALTH SECURITY.
I THINK EBOLA KIND OF PROVES THE FALLACY OF THAT THINKING.
ALSO, IF WE'RE GOING TO DO HEALTH SECURITY RIGHT, WE'RE
GOING TO DO IT BY BUILDING CORE PUBLIC HEALTH CAPACITY.
I SAY THIS BECAUSE DURING THE EBOLA CRISIS, I GOT A CALL FROM
"THE NEW YORK TIMES" SAYING THE THING THEY'RE DOING IN TEXAS,
CONTACT TRACING, IS THIS SOMETHING THE PUBLIC HEALTH CAN
DO? I SAID, YES, AND I WAS ABLE TO
CONNECT THEM TO MY COLLEAGUES IN TB CONTROL, WHO TOLD THEM A LOT
ABOUT CONTACT TRACING. LOTS OF HEALTH SECURITY LESSONS
EXIST IN THE PUBLIC HEALTH BATTLES THAT HAVE COME BEFORE
EBOLA. HIV, TB, EVEN H1N1 HAS LESSONS.
AND JUST AS AN EXAMPLE, I TRIED TO KIND OF CROSS WORK TB
CONTROL. YOU CAN PROBABLY CIRCLE ALL OF
ACTION PACKAGES UNDER THE GHSA AS BEING RELEVANT TO CONTROL.
WHAT I HAVE TO SAY IS THAT IF YOU DON'T THINK THAT THE GLOBAL
HEALTH SECURITY AGENDA IS RIGHT FOR YOU, CALL IT WHATEVER YOU
WANT. IF YOU WANT TO STRENGTHEN YOUR
CAPACITY IN THE NAME OF TB CONTROL, THAT'S TYPE.
WE JUST CAN'T HAVE ANOTHER EBOLA CRISIS.
CLEARLY IT SHOWED US IN MANY PLACES, INCLUDING HERE, THERE'S
A LONG WAY TO GO. SO THANK YOU.
WITH THAT, I'LL END WITH A REQUEST.
OUR JOURNAL HEALTH SECURITY, WE'RE GOING TO BE PUBLISHING A
SPECIAL ISSUE. I'M THE EDITOR OF THAT.
I'D LOVE TO HEAR FROM ANYONE WHO'S LISTENING TO THIS IN TERMS
OF WHAT YOU'RE LEARNING ABOUT SURVEILLANCE.
SO PLEASE CONSIDER SUBMITTING A MANUSCRIPT.
THANK YOU SO MUCH. [ APPLAUSE ]
AND NOW I'M GOING TO TURN IT OVER TO OUR NEXT SPEAKER, DAVE
BLAZES. >> GOOD AFTERNOON.
THANK YOU, ALSO, FOR INVITING ME TO BE A PART OF THIS REALLY
IMPORTANT PANEL. JOHN ASKED ME TO TALK ABOUT
SURVEILLANCE, DISEASE SURVEILLANCE AND HOW IT RELATES
TO GLOBAL HEALTH SECURITY. UNFORTUNATELY, I STILL THINK IS
LARGELY ASPIRATIONAL IN MANY PARTS OF THE GLOBE.
YOU MENTIONED WE HAD TROUBLE IN OUR OWN COUNTRY DOING
SURVEILLANCE FOR THIS, BUT YOU CAN IMAGINE THE SITUATION IN
MANY PARTS OF THE WORLD. MY STANDARD DISCLAIMERS.
I UNFORTUNATELY DON'T HAVE ANY CONFLICT OF INTERESTS.
OKAY. SO SURVEILLANCE.
I THINK WE ALL AGREE THAT SURVEILLANCE IS REALLY A KEY
COMPONENT OF GLOBAL HEALTH SECURITY.
I DO THINK, THOUGH, THAT SURVEILLANCE DOESN'T EXIST IN A
VACUUM AT ALL. IT REALLY EXISTS ACROSS THIS
SPECTRUM OF SCIENCE, IF YOU WILL.
I THINK HISTORICALLY, THE DEPARTMENT OF DEFENSE HAS MAINLY
DONE LABORATORY-BASE RESEARCH AS WELL AS CLINICAL TRIAL
DEVELOPMENT OF VACCINES AND OTHER PRODUCTS FOR HEALTH
PROTECTION REASONS. SO SURVEILLANCE IS SOMEWHAT NEW
TO OUR PORTFOLIO. THIS REALLY CHANGED TWO DECADES
AGO WHEN PRESIDENT CLINTON ISSUED THIS PRESIDENTIAL
DECISION DIRECTIVE NSTC-7. THIS PUT IN MOTION THE CREATION
OF SEVERAL ENTITIES, ONE OF WHICH WAS THE GLOBAL EMERGING
INFECTION SURVEILLANCE SYSTEM, GEIS.
THIS ORGANIZATION WAS TASKED WITH STRENGTHENING GLOBAL
DISEASE REDUCTION EFFORTS, DISEASE SURVEILLANCE, REALLY
TRYING TO ADDRESS ANY EMERGING INFECTIOUS DISEASE THAT MAY
OCCUR. THE GEIS PROGRAM, AS MANY OF
YOU HAVE PROBABLY HEARD ALREADY, IS NOW ALMOST TWO DECADES OLD.
YOU CAN SEE THAT IT'S ONE OF DOD'S RESPONSES.
THE SCOPE AND MANDATE HAS REALLY ONLY INCREASED SINCE THOSE TWO
DECADES AGO WHEN PRESIDENT CLINTON ISSUED THIS DIRECTIVE.
I THINK NOW IT INCLUDES MANY OTHER DOD PROGRAMS SUCH AS
DEFENSE THREAT REDUCTION AGENCY AND OTHER ORGANIZATIONS WHO ARE
INVOLVED IN DISEASE SURVEILLANCE AND MITIGATION.
IF YOU LOOK AT THE DISEASES LISTED HERE, RESPIRATORY
INFECTIONS, VECTOR BORN INVEXS, SEXUALLY TRANSMITTED INFECTIONS,
THEY REALLY HAVE A STAYING POWER.
THESE WERE IDENTIFIED 20 YEARS AGO AS IMPORTANT, AND THEY
REMAIN IMPORTANT TODAY. SO THAT REALLY HAS REMAINED
LARGELY UNCHANGED IN OUR EFFORTS.
LIKE ANY GOVERNMENT AGENCY, WE NEED POLICY TO PROVIDE US
GUIDANCE ON WHAT WE DO. CERTAINLY THE DOD, WE HAVE A LOT
OF POLICY. THIS IS JUST SOME OF IT.
I WOULDN'T ASK YOU TO READ ALL OF THIS BY ANY MEANS, BUT SOME
OF IT APPLIES TO HHS AND OTHERS. SO WE IN DOD MOSTLY IN DISEASE
SURVEILLANCE AND THINGS RELATED TO HEALTH PLAY A COLLABORATIVE
ROLE AND ARE VERY MUCH SUPPORTIVE OF HHS' AND OTHER'S
MISSIONS, DEPENDING ON WHETHER IT'S DOMESTIC OR ABROAD.
I THINK WE'VE BEEN DIRECTED TO DO DISEASE SURVEILLANCE IN
SUPPORT OF GLOBAL HEALTH SECURITY, BUT IT'S OBVIOUSLY WE
CAN'T DO SURVEILLANCE EVERYWHERE.
SO WHERE DO WE FOCUS OUR EFFORTS IS A REALLY BIG QUESTION.
I REALLY LIKE THIS GRAPH. IT'S PRETTY OLD, MORE THAN A
DECADE OLD FROM AN IOM REPORT, BUT I THINK IT'S REALLY AT
PLACES WHERE MANY OF THESE FACTORS CONVERGE THAT WE SHOULD
BE FOCUSING OUR EFFORTS. I THINK THE HIGHEST YIELD FOR
DISEASES LIKE SARS AND MERS AND EBOLA ARE GOING TO BE WHERE
MICROBES CHANGE, WHERE WE INTERACT WITH MICROBES IN A
CONCENTRATED FASHION, WHERE THERE'S AN ENVIRONMENTAL
DEGRADATION IN POVERTY. SO WHERE THAT SWEET SPOT IS, IS
TOUGH TO FIND. IN MANY PLACES IT EXISTS IN
DEVELOPING SETTINGS WHERE IT'S DIFFICULT TO GO, BUT
INCREASINGLY, WE SHOULD REALLY FOCUS OUR EFFORTS IN THOSE HOT
ZONES OR SWEET SPOTS. I THINK INCREASINGLY, WE'RE
GOING TO BE BRANCHING OUT FROM THAT ONE HOT ZONE OR SWEET SPOT
WHERE ALL THESE FACTORS CONVERGE TO MORE ALONG THE PARALLEL LINES
THAT ARE DRAWN HERE BETWEEN FACTORS.
AS WE INCREASE OUR SURVEILLANCE PORTFOLIO AROUND THE WORLD AS A
GLOBAL HEALTH COMMUNITY, I THINK WE CAN GET TO MORE OF THESE
AREAS. SWITCHING A LITTLE BIT TO THE
DOD NOW IN A LITTLE MORE DETAIL, THE DOD'S TROPICAL DISEASE
RESEARCH LABS HAVE PROVIDED AN IDEAL PLATFORM FROM WHICH WE CAN
CONDUCT SURVEILLANCE. AGAIN, THESE LABS HAVE EXISTED
FOR DECADES, AS YOU CAN SEE HERE.
THE LAB IN CAIRO WAS CREATED MORE THAN 50 YEARS AGO.
I SEE SEVERAL PEOPLE HERE IN THE AUDIENCE WHO WERE STATIONED
THERE, WHO WORKED THERE. SO THE TRADITION GOES BACK A
LONG WAY IN MANY OF THESE LABS. THEY'RE OBVIOUSLY LOCATED IN
SOME OF THESE HOT ZONES THAT I'VE ALREADY TALKED ABOUT.
THAT'S NOT BY MISTAKE. THEY'RE THERE TO DO RESEARCH ON
TROPICAL DISEASE THAT AFFECT MILITARIES AS THEY'RE STATIONED
AROUND THE WORLD AND EXIST IN PLACES WHERE THOSE DISEASES
EXIST. SO THEY ARE STRATEGICALLY
POSITIONED. I THINK IT MAKES SENSE TO BUILD
SURVEILLANCE CAPACITY AROUND THEM.
THEY'VE REALLY BEEN KNOWN FOR MORE SCIENCE THROUGHOUT THE
YEARS, THOUGH, SO THEY'VE BEEN INVOLVED IN MANY MALARIA
DIAGNOSTICS, VACCINES, BOTH DEVELOPMENT AND TESTING, AND
EVEN THE DEVELOPMENT OF ORAL REHYDRATION SOLUTION.
I'LL FOCUS A LITTLE ON THE LAB IN CAIRO, EGYPT.
OBVIOUSLY THIS LAB IS THE OLDEST ONE IN OUR NETWORK, AND IT WAS
FORMED IN THE '40s. IT WAS ORIGINALLY RESPONSIBLE
FOR RESPONDING TO A TYPHUS OUTBREAK.
YOU CAN SEE THAT THEIR FOOTPRINT AND WHERE THEY WORK IS LARGER
THAN JUST IN EGYPT. THEY WORK IN THE MIDDLE EAST, IN
SOUTHERN EUROPE, AND INCREASINGLY IN WEST AFRICA.
THERE'S A DETACHMENT THAT EXISTS IN GHANA AND IS INCREASINGLY
WORKING IN THE NEIGHBORING COUNTRIES THERE, BOTH ON SCIENCE
AND DISEASE SURVEILLANCE. YOU CAN SEE THE TYPES OF
PROJECTS THEY WORK ON ARE PRETTY BROAD AND ARE CONSISTENT WITH
THE GEIS MISSION OF THOSE DISEASES.
EACH OF THESE LABS OBVIOUSLY HAS A CHAIN OF COMMAND.
IN THE CENTER, THE ONLY SOLID LINES THERE ARE FROM OUR BUREAU
OF MEDICINE. THAT'S OUR HEADQUARTERS OF NAVY
MEDICINE, IF YOU WILL. NAVAL MEDICAL RESEARCH CENTER IS
THE PARENT COMMAND OF OUR OVERSEAS LABORATORIES.
SO EACH OF THOSE FALL UNDER -- EACH OF THOSE LABORATORIES FALL
UNDER NMRC. THEY OBVIOUSLY HAVE A MISSION
RELATED TO FOREST HEALTH PROTECTION.
SO DEVELOPING A MALARIA VACCINE, FOR INSTANCE.
OBVIOUSLY GLOBAL HEALTH AND DISEASE SURVEILLANCE ARE DONE IN
COLLABORATION WITH MANY PEOPLE. THIS IS CERTAINLY NOT DONE IN
ISOLATION, AND WE'RE NOT DOING IT ALONE, BY ANY MEANS.
OBVIOUSLY THE MOST IMPORTANT COLLABORATOR IS THE HOST
COUNTRY. IF WE DON'T HAVE THEIR
PARTICIPATION, DISEASE SURVEILLANCE REALLY DOESN'T
HAPPEN. BUT ON A GLOBAL STAGE, REALLY,
THERE'S CLOSE COLLABORATIONS WITH THE REGIONAL W.H.O. OFFICES
AND OFTEN WITH THE CDC OVERSEAS, ASSIGNEES OR WHERE THEY'RE
CO-LOCATED WITH GDD SITES. I THINK DISEASE SURVEILLANCE IS
OBVIOUSLY A CONTINUOUS PROCESS AND ONE THAT INVOLVES DETECTION,
INTERPRETATION, RESPONSE, AND PREVENTION.
IT'S CERTAINLY NOT A ONE-TIME EVENT.
WE HAVE TO PREPARE FOR THIS CONTINUOUS PROCESS.
I TOOK AS AN EXAMPLE, BECAUSE WE WERE TALKING ABOUT EBOLA, THE
AREA WHERE EBOLA WOULD FALL UNDER IN TERMS OF OUR
SURVEILLANCE PARADIGMS. SO IT WOULD FALL UNDER INVECTOR
BORN INFECTIONS. THE GOAL IS TO STUDY ANY
INFECTION RELATED TO THIS. IT'S PRETTY BROAD.
OBVIOUSLY IT WOULD INCLUDE THINGS LIKE DENGUE, MALARIA, AND
EBOLA. WHAT WE TRY TO DO IS SUPPORT
SURVEILLANCE SYSTEMS THAT WOULD DETECT NOT ONLY HUMAN DISEASE
BUT RELATED DISEASES IN ANIMALS, IN VECTORS, AS WELL AS
ENVIRONMENTAL FACTORS THAT MAY CONTRIBUTE TO THIS.
SO WE REALLY DO TRY TO RESPECT THE EPIDEMIOLOGIC TRIAD AND
PERFORM HOLISTIC SURVEILLANCE, NOT JUST LOOKING AT HUMANS WHERE
THE END RESULT MAY BE DISEASE BUT TRYING TO UNDERSTAND WHERE
THOSE DISEASES COME FROM AND HOW WE MIGHT INTERVENE BEFORE IT
GETS TO HUMANS. OBVIOUSLY WE NEED ROBUST AND
ACCURATE DIAGNOSTICS AND CORRECT INTERPRETATION OF RESULTS.
SO IT'S REALLY NOT JUST FINDING A CLUSTER OF CASES.
THAT'S ALMOST THE EASY PART. BUT MAKING SURE YOU HAVE THE
RIGHT DIAGNOSTICS IN PLACE AND THE ABILITY TO INTERPRET THOSE
DIAGNOSTICS IS REALLY IMPORTANT. THIS CAN BE EXTREMELY
CHALLENGING IN DEVELOPING SETTINGS, AS MANY OF YOU WHO
HAVE WORKED OVERSEAS UNDERSTAND. ESPECIALLY WHEN YOU'RE DEALING
WITH A DANGEROUS PATHOGEN SUCH AS EBOLA.
I THINK WE'VE ALL HEARD OF LABORATORY ACQUIRED AND HOSPITAL
ACQUIRED INFECTIONS AND CERTAINLY DOING SURVEILLANCE IS
NOT AN EASY TASK IN THESE SETTINGS.
KIND OF ALONG THOSE LINES, IN TERMS OF A DIAGNOSIS, I'LL
MENTION A FEW OF OUR EFFORTS THAT THE NAVY CONDUCTED IN
COLLABORATION WITH MANY OTHERS DURING OPERATION UNITED
ASSISTANCE AS WE'VE TERMED IT. THE NAVY MEDICAL RESEARCH CENTER
LABORATORY ACTUALLY WAS DEPLOYED FOR ABOUT NINE MONTHS AND DID
MANY OF THE INITIAL TESTINGS OF EBOLA PATIENT THERE IS.
THEY HAD TWO UNITS SET UP AT THE ISLAND CLINIC IN MONROVIA AND
ALSO A UNIVERSITY. YOU CAN SEE THE DATES HERE.
IT'S REALLY IMPORTANT THAT THESE LABS WERE ABLE TO PROVIDE
SUPPORT ON A PRETTY RAPID BASIS. THEY WERE ABLE TO DEPLOY WITHIN
A COUPLE WEEKS AND PROVIDE EXCELLENT DIAGNOSTIC SUPPORT AS
WELL AS ONGOING TRAINING FOR LABORATORIES THAT HAVE REPLACED
THEM. I GOT THESE NUMBERS FROM
COMMANDER BILLY WHO WORKED CLOSELY WITH THE CDC IN HELPING
TO DEVELOP THESE DIAGNOSTICS. I THINK HE MENTIONED TO ME THAT
THE INITIAL DIAGNOSTICS WERE ACTUALLY PREPARED BACK IN 2002.
SO THEY WERE, YOU KNOW, QUICKLY REIGNITED AND SHARED WITH CDC.
OBVIOUSLY THE PCR WAS AN IMPORTANT CONTRIBUTION THAT WE
WORKED WITH YOU ALL ON, BUT ALSO THE DEVELOPMENT OF LATERAL FLOW
ESSAYS THAT SHOULD MAKE DIAGNOSIS FOR RAPID AND FACILE
IN DEVELOPING SETTINGS. I KNOW THERE ARE A NUMBER OF
DIFFERENT PLATFORMS BEING TESTED AT THIS STAGE AND HOPEFULLY
WE'LL GET TO ONE PRETTY SOON THAT CAN BE DEPLOYED IN A RAPID
FASHION OVERSEAS. SO AGAIN, I'M NOT GOING TO SPEND
MUCH TIME ON THE RESPONSE PART OF THIS.
I THINK DR. NUZZO AND I KNOW DR. TAPPERO ARE GOING TO DESCRIBE
MORE ABOUT THE EBOLA RESPONSE EFFORT THAT WE ALL HAVE HEARD
ABOUT. I WILL SAY THAT THE DOD
RESPONDED MAINLY WITH DIAGNOSTICS, WITH LOGISTICS, AND
WITH TRAINING. IT WAS INTERESTING TO TALK TO
DR. TAPPERO EARLIER TODAY IN THAT HE REALLY FELT THE DOD
CONTRIBUTION KIND OF STIMULATED A LOT OF INTEREST AND
REASSURANCE FOR OTHER PARTNERS WHO AT THAT POINT GOT ENGAGED IN
THE WHOLE RESPONSE. SO WE DIDN'T HAVE ANY DIRECT
PATIENT CARE BUT DID PROVIDE A LOT OF LOGISTICS AND TRAINING.
KIND OF ALONG THOSE SAME LINES OF THAT CONTINUOUS SPECTRUM OF
SURVEILLANCE, OBVIOUSLY PREVENTION IS KEY WHEN WE'RE
DEALING WITH PUBLIC HEALTH. SO I WOULD LIKE TO FINISH BY
HIGHLIGHTING SOME OF THE EFFORTS THAT OUR PARTNERS IN THE ARMY
ARE WORKING ON. COLONEL STEVEN THOMAS PROVIDED
THIS SLIDE TO ME. OBVIOUSLY IF WE CAN PREVENT
DISEASE, THEN WE MAY NOT HAVE TO RESPOND AS MUCH TO IT.
OBVIOUSLY THE WALTER REED ARMY INSTITUTE OF RESEARCH WORKED
VERY HARD ON TESTING ONE OF THE FIRST EBOLA VACCINES THAT WAS
PUBLISHED IN APRIL OF 2015 IN "THE NEW ENGLAND JOURNAL."
THEY HAVE ONGOING PROJECTS IN UGANDA AS WELL AS IN NIGERIA TO
TEST FURTHER VACCINES. SO PHASE TWO AND PHASE THREE
STUDIES ARE PLANNED. THE GREAT THING THERE IS
LEVERAGING SOME OF THE ASSETS THE DOD HAS INVESTED IN OVER
TIME. THE HIV VACCINE EFFORT THAT
NELSON MICHAEL AND OTHERS RUN AT THE MILITARY HIV RESEARCH
PROGRAM HAS INVESTED MANY, MANY YEARS IN SITES IN UGANDA AS WELL
AS IN NIGERIA. THEY'RE BEING LEVERAGED TO TEST
SOME OF THESE NEWER VACCINES. FINALLY, LET'S LOOK TO THE
FUTURE. I THINK HOPEFULLY WE CAN RELY ON
EXISTING TECHNOLOGIES THAT ARE OUT THERE TO OPTIMIZE DISEASE
SURVEILLANCE IN DEVELOPING SETTINGS.
INITIALLY, DARPA AND THEN GEIS AND NOW HOPEFULLY OTHERS ARE
SUPPORTING THIS. THIS WAS A PROJECT THE JOHNS
HOPKINS APPLIED PHYSICS LAB WORKED ON.
MANY OF YOU KNOW ABOUT THEIR ESSENCE WORK.
THIS WAS ESSENTIALLY BASED ON THE ESSENCE PLATFORM AND IS AN
OPEN SOURCE SURVEILLANCE SYSTEM THAT COLLECTS DATA THROUGH CELL
PHONES OR OTHER MEDIA. THE KEY HERE IS REALLY THAT THE
DATA CAN BE COLLATED ON A NEAR REAL-TIME BASIS.
IN THIS COUNTRY AND IN ASIA, IT'S NOT REALLY EXPECTED THERE'S
GOING TO BE A PEAK OF DENGUE DURING THE RAINY SEASON, BUT
WHAT IS NICE AND REALLY WHERE THE VALUE OF THIS IS, IS THAT
THOSE REPORTS CAN BE GEO REFERENCED BASED ON YOUR CELL
PHONE SIGNATURE. THIS HAS OBVIOUS BENEFITS TO
PUBLIC HEALTH PROVIDERS WHO WORK IN RESOURCE LIMITED SETTINGS
LIKE MANY OF THE PLACES WE ALL KNOW.
SO HOPEFULLY THIS TYPE OF TECHNOLOGY, WHILE IN ITS INFANCY
NOW, CAN REALLY BE SPREAD TO MANY PARTS OF THE WORLD SO THAT
WE CAN ACHIEVE GLOBAL HEALTH SECURITY.
AND THEN MY FINAL SLIDE IS INTERESTING.
SO THIS IS A PUBLIC HEALTH NETWORK IN PERU.
I WAS STATIONED THERE FOR FOUR YEARS.
THIS IS A PERUVIAN JOURNAL ARTICLE THAT JUST DESCRIBED A
PUBLIC HEALTH RESEARCH NETWORK. THE ORANGE DOTS ARE ACTUALLY
PERUVIAN ORGANIZATIONS. THE GREEN ARE FOREIGN RESEARCH
OR PUBLIC HEALTH INSTITUTIONS. AND THE CONNECTIONS OBVIOUSLY
ARE PROJECTS OR PAPERS. ONE OF THE THINGS I'LL POINT OUT
IS THAT THE NAVY LAB IS NOTED THERE IN ORANGE.
WE WERE VERY PROUD OF THIS. WE DIDN'T WRITE THIS ARTICLE,
ALTHOUGH WE PROBABLY SHOULD HAVE.
BUT THEY CALLED US A PROVEN ORGANIZATION.
THIS IS REALLY THE GOAL, I THINK, OF DISEASE SURVEILLANCE
AND CAPACITY BUILDING AND GLOBAL HEALTH SECURITY.
EACH COUNTRY REALLY NEEDS TO DEVELOP THIS CAPACITY.
NOW, WE ARE OBVIOUSLY SUPPORTING DISEASE SURVEILLANCE IN THESE
COUNTRIES AND SCIENCE. BUT THIS IS MAKES SENSE FROM
MANY DIFFERENT STANDPOINTS. THE ORGANIZATIONS, THEY'RE MORE
THAN 90% PERUVIAN. SO SCIENTISTS, TECHNICIANS,
EPIDEMIOLOGISTS. SO IT REALLY SHOULD BE AN ORANGE
DOT ON THE MAP. SO I THINK BUILDING CAPACITY
LIKE THIS WHERE IT'S MEANINGFUL AND SUSTAINED OVER TIME, I
THINK, REALLY HAS THE BEST CHANCE OF SUCCESS.
OBVIOUSLY DISEASE SURVEILLANCE IS JUST ONE COMPONENT OF GLOBAL
HEALTH SECURITY, BUT I THINK IF WE DO IT RIGHT, WE CAN BUILD
THESE NETWORKS THAT WILL MAKE OUR WORLD A SAFER PLACE.
SO THANK YOU FOR YOUR TIME. [ APPLAUSE ]
>> OUR NEXT SPEAKER IS CAPTAIN JORDAN TAPPERO.
>> THANK YOU. I THINK WE'RE A LITTLE BIT
BEHIND SCHEDULE, SO HANG ON TO YOUR SEATS.
I'M GOING TO BE TALKING TO YOU ABOUT THE ORIGINS OF THE GLOBAL
HEALTH SECURITY AGENDA AND THE IMPACT OF THE WEST AFRICAN EBOLA
EPIDEMIC ON MOVING IT FORWARD. NEW VIRAL AND BACTERIAL PAT JENS
WILL CONTINUE TO EMERGE. TODAY'S WORLD OF INCREASING
INTERCONNECTIVITY AND MOBILITY ACCELERATES THIS SHARED GLOBAL
RISK. GLOBAL TRANSPORTATION AND
COMMERCIAL AIR TRAVEL LINKS EMERGING MARKETS TO THE REST OF
THE WORLD MORE SEAMLESSLY THAN EVER.
THE NEXT EPIDEMIC MAY VERY WELL BE JUST A PLANE RIDE AWAY.
AS EARLY AS THE 14th CENTURY, PEOPLE USED QUARANTINE TO KEEP
DISEASES LIKE THE PLAGUE FROM SPREADING ACROSS BORDERS.
IN MORE RECENT TIMES, THERE HAVE BEEN A SERIES OF AGREEMENTS
BETWEEN COUNTRIES TO ADDRESS POTENTIAL SPREAD OF DISEASE,
BEGINNING WITH THE INTERNATIONAL SANITARY CONVENTION, AND LATER
THE INTERNATIONAL HEALTH REGULATIONS IN 1969.
BECAUSE OF THE MANY WAYS IN WHICH WE ARE CONNECTED, NO
COUNTRY CAN PROTECT ITSELF BY ITSELF.
THE LESSON BECAME INCREASINGLY CLEAR DURING THE SEVERE ACUTE
RESPIRATORY SYNDROME, OR SARS, OUTBREAK IN 2003.
AN OUTBREAK THAT SPREAD TO 37 COUNTRIES ACROSS THREE
CONTINENTS. TO ADDRESS THE SHORTCOMINGS OF
THE GLOBAL RESPONSE TO SARS, W.H.O. REVISED THE INTERNATIONAL
HEALTH REGULATIONS IN 2005 TO BETTER CONTROL PUBLIC HEALTH
THREATS WHILE AVOIDING UNNECESSARY INTERFERENCE WITH
INTERNATIONAL TRAVEL AND TRADE. AS THE WORLD HEALTH ASSEMBLY IN
2005, ALL 195 MEMBER STATES COMMITTED TO ACHIEVING THE GOALS
OF THE REVISED INTERNATIONAL HEALTH REGULATIONS OVER THE NEXT
FIVE YEARS. NOW, THE IHR REQUIRED THAT ALL
COUNTRIES HAVE THE ABILITY TO ENSURE THAT THEIR SURVEILLANCE
SYSTEMS AND LABORATORIES CAN DETECT POTENTIAL THREATS, WORK
TOGETHER WITH OTHER COUNTRIES TO MAKE DECISIONS IN PUBLIC HEALTH
EMERGENCIES, REPORT TRANSPARENTLY THROUGH
PARTICIPATION IN A NETWORK OF NATIONAL FOE CALL POINTS, AND
RESPOND TO PUBLIC HEALTH EVENTS. W.H.O. HAS THE AUTHORITY AND
RESPONSIBILITY TO DECLARE THE HIGHEST LEVEL OF HEALTH THREATS
CALLED PUBLIC HEALTH EMERGENCIES OF INTERNATIONAL CONCERNS.
WE HAVE SEEN OVER TIME THAT GLOBAL HEALTH RISKS HAVE
INCREASED THROUGH THE EMERGENCE OF NEW ORGANISMS, DRUG
RESISTANCE, AND INTENTIONAL EVENTS.
HIV RAGED UNDETECTED FOR OVER A DECADE BEFORE ITS DISCOVERY.
DRUG RESISTANT ORGANISMS ARE A GROWING PUBLIC HEALTH THREAT.
TARGETED MAILS OF ANTHRAX SPORES DREW THE WORLD'S ATTENTION TO
THE REALITY OF INTENTIONAL RELEASE OF DANGEROUS PATHOGENS.
AND THE RECENT EMERGENCE OF MERS AND EBOLA HAVE KEPT THE WORLD ON
HIGH ALERT. THE IHR COVERS ALL EVENTS THAT
MIGHT POTENTIALLY BECOME A PUBLIC HEALTH EMERGENCY OF
INTERNATIONAL CONCERN. SINCE 2005, W.H.O. HAS DECLARED
THREE OF THESE EMERGENCIES. THE H1N1 PANDEMIC IN 2009, THE
REEMERGENCE OF WILD POLIO VIRUS IN 2014, AND THE WEST AFRICAN
EBOLA EPIDEMIC. THE FIVE-YEAR CLOCK FOR IHR
COMPLIANCE STARTED IN 2007, BUT BY 2012, THE DEADLINE, FEWER
THAN ONE IN FIVE COUNTRIES HAD ATTAINED COMPLIANCE BY
SELF-REPORT. A TWO-YEAR EXTENSION TO 2014
INCREASED THE NUMBER OF FULLY COMPLIANT COUNTRIES BY ONLY AN
ADDITIONAL 10%. SO WHY SHOULD WE CARE ABOUT THE
GLOBAL HEALTH SECURITY AGENDA? AS WE'VE SEEN, MOST OF THE WORLD
IS NOT PREPARED TO ADDRESS PUBLIC HEALTH EMERGENCIES, WHICH
INCREASE THE LIKELIHOOD THAT INFECTIOUS DISEASE THREATS WILL
SPREAD WITHIN COUNTRIES AND ACROSS BORDERS.
THE HUMAN AND ECONOMIC COSTS OF EPIDEMICS ARE DEAR.
A.I.D.S. HAS KILLED OVER 40 MILLION, AND ANOTHER 40 MILLION
PEOPLE ARE LIVING WITH HIV AND IN NEED OF LIFE-SAVING
TREATMENT. SARS KILLED NEARLY 800 PEOPLE
AND COST AN ESTIMATED $40 BILLION.
AND EBOLA HAS KILLED OVER 11,000 PEOPLE AND TIME COSTS HAVE YET
TO BE TALLIED. THE 2009 H1N1 PANDEMIC SHOWED US
THE WORLD IS NOT PREPARED FOR A GLOBAL RESPONSE.
PRESIDENT OBAMA DURING THE SEPTEMBER 2011 SPEECH AT THE
UNITED NATIONS GENERAL ASSEMBLY SAID WE MUST COME TOGETHER TO
PREVENT, DETECT, AND FIGHT EVERY KIND OF BIOLOGICAL DANGER,
WHETHER IT IS A PANDEMIC, H1N1, A TERRORIST THREAT, OR A
TREATABLE DISEASE. THE TRUTH IS, WE NEED PRACTICAL
STEPS THAT WE CAN TAKE TO ASSIST ALL COUNTRIES TO REACH THE IHR
GOALS, WHICH BRINGS US TO THE GLOBAL HEALTH SECURITY AGENDA, A
UNIFYING FRAMEWORK TO IMPROVE OUR GLOBAL RESPONSE TO
INFECTIOUS DISEASE THREATS. ON FEBRUARY 13th, 2014, LEADERS
FROM 28 MINISTRIES OF HEALTH, THE WORLD HEALTH ORGANIZATION,
THE FOOD AND AGRICULTURAL ORGANIZATION, OR FAO, AND THE
WORLD ORGANIZATION FOR ANIMAL HEALTH, OR OIE, CAME TOGETHER TO
LAUNCH THIS UNIFYING FRAMEWORK CALLED THE GLOBAL HEALTH
SECURITY AGENDA. THE VISION OF THE AGENDA IS TO
REALIZE A WORLD SAFE AND SECURE FROM GLOBAL HEALTH THREATS POSED
BY INFECTIOUS DISEASES. NOW, AT THE TIME OF THE LAUNCH,
EBOLA WAS SPREADING UNDETECTED FROM GUINEA TO NEIGHBORING
LIBERIA AND SIERRA LEONE. EBOLA HAD GALVANIZED THE
INTERNATIONAL COMMUNITY AROUND THE AGENDA.
AT THE FIRST GLOBAL HEALTH SECURITY AGENDA MINISTERIAL IN
SEPTEMBER, WHICH CONVENED IN WASHINGTON AND WAS ATTENDED BY
PRESIDENT OBAMA, 44 COUNTRIES JOINED THE AGENDA.
NINE MONTHS LATER, THE SEVEN NATIONS OF THE WORLD'S LARGEST
ECONOMIES, THE G-7, PLEDGED TO HELP UP TO 60 COUNTRIES ACHIEVE
THESE GLOBAL HEALTH SECURITY AGENDA TARGETS.
I JUST RETURNED FROM SEOUL, THE SECOND GLOBAL HEALTH SECURITY
MINISTERIAL MEETING, WHICH WAS HELD IN SEOUL, KOREA.
IN SEOUL, 51 COUNTRIES MADE FIRM COMMITMENTS TO IMPLEMENT THE
AGENDA. AT THE CLOSE OF THE MEETING,
COUNTRY LEADERS SIGNED THE SEOUL DECLARATION, REAFFIRMING THEIR
COMMITMENT TO IT AND ACKNOWLEDGING THAT GLOBAL HEALTH
SECURITY SHOULD BE UNDERSTOOD AS A SHARED, MULTISECTORIAL
RESPONSIBILITY, THAT NO SINGLE COUNTRY CAN ACHIEVE ALONE.
THE GLOBAL HEALTH SECURITY AGENDA GOES FURTHER THAN ANY
PRIOR GLOBAL COORDINATION AROUND MULTIPLE DISEASES AND
CONDITIONS. GHSA IS NOT ANOTHER SINGLE
DISEASE INITIATIVE. IT DRIVES A SET OF CONCRETE AND
ACHIEVABLE ACTIONS TO ACTUALIZE THE INTERNATIONAL HEALTH
REGULATIONS. AND IT'S HELPED US REACH PUBLIC
HEALTH GOALS THROUGH A PREVENT, DETECT, AND RESPOND MODEL.
THERE ARE 11 MEASURABLE TARGETS, ALSO KNOWN AS ACTION PACKAGES,
THAT COMPRISE THE BACKBONE OF GLOBAL HEALTH SECURITY AGENDA.
WHILE THEY MAY SEEM LIKE DISCREET ACTIVITIES, THEY ARE
OVERLAPPING AND INTERRELATED. TIME DOES NOT ALLOW ME TO WALK
THROUGH EACH AND EVERY TARGET, BUT ALL WORK TOGETHER.
FOR EXAMPLE, THESE TARGETS INCLUDE A NATIONWIDE LABORATORY
NETWORK WITH A SPECIMEN REFERRAL SYSTEM REACHING AT LEAST 80% OF
ITS POPULATION AND WITH EFFECTIVE MODERN DIAGNOSTICS IN
PLACE TO DETECT EPIDEMIC-PRONE INFECTIONS.
IT ALSO INCLUDES A TIMELY ELECTRONIC-BASED BIOSURVEILLANCE
SYSTEM. ALSO, A DEDICATED WORK FORCE OF
MEDICAL AND PUBLIC HEALTH PROFESSIONALS, INCLUDING AT
LEAST ONE TRAINED EPIDEMIOLOGIST FOR 200,000 POPULATION, AND A
PUBLIC HEALTH EMERGENCY OPERATIONS CENTER, OR EOC, ABLE
TO COORDINATE AN EFFECTIVE EMERGENCY RESPONSE WITHIN 120
MINUTES FOR ACTIVATION. TO MEET THE OBJECTIVES OF THESE
TARGETS, WE WILL HAVE TO COMBINE EFFORTS ACROSS SECTORS.
FOR INSTANCE, REPORTABLE DISEASE SURVEILLANCE SYSTEMS BACKED BY
COMPETENT NATIONAL REFERENCE LABORATORIES ARE INSTRUMENTAL IN
MONITORING AND REDUCING THE RISKS OF ANTIMICROBIAL
RESISTANCE AND THE SPILLOVER OF DISEASES.
IT'S ALL CROSS-CUTTING. WHEN ALIGNED WITH THE
INTERNATIONAL HEALTH REGULATIONS, MOST OF THE IDEAS
BEHIND THE GLOBAL HEALTH SECURITY AGENDA ARE
COMPLEMENTARY. GLOBAL HEALTH SECURITY AGENDA
BUILDS ON THE AGREEMENTS AND THE COMMITMENTS COUNTRIES HAVE
ALREADY MADE. THE AGENDA WAS DEVELOPED TO
ADVANCE THE IHR BY PROVIDING A PATH WITH CLEAR TARGETS AND
MILESTONES TO STRENGTHEN THE CORE CAPACITIES AND ACHIEVE IHR
COMPLIANCE. THEREBY, ENABLING A WORLD MORE
SAFE AND SECURE FROM INFECTIOUS DISEASE THREATS.
IN FACT, THE EBOLA CRISIS IS A PRIME EXAMPLE OF THE IMPORTANCE
OF BEING PREPARED AND THE URGENT NEED FOR GLOBAL HEALTH SECURITY.
SINCE ITS DISCOVERY IN 1976, MORE THAN 20 EBOLA OUTBREAKS
HAVE BEEN RECOGNIZED IN EAST AND CENTRAL AFRICA, AND THEY WERE
ALL CONTAINED RELATIVELY QUICKLY.
IN DECEMBER OF 2013, EBOLA EMERGED FOR THE FIRST TIME IN
WEST AFRICA WHERE IT SPREAD UNNOTICED FOR MONTHS.
WHAT WAS DIFFERENT THIS TIME? THE THREE COUNTRIES LACKED THE
PUBLIC HEALTH INFRASTRUCTURE TO QUICKLY DETECT AND RESPOND TO
THE OUTBREAK. THERE WAS DELAYED REPORTING AND
BORDER CONTROL WAS SPOTTY IN AN AREA WITH HIGH POPULATION
MOBILITY, AND THERE WAS A LACK OF INFECTION CONTROL IN HEALTH
CARE FACILITIES, INCLUDING THE ABSENCE OF BASIC PROTECTIVE
GLOVES, SOAP, AND RUNNING WATER. BY LATE JULY, EBOLA HAD REACHED
THE URBANIZED AND DENSELY POPULATED CAPITALS OF ALL THREE
NATIONS, AND THE FIRST TIME THE DISEASE CAUSED COMMUNITY WISE
TRANSMISSION IN CROWDED AREAS. IN AUGUST, MONROVIA, LIBERIA,
WAS EXPERIENCING THE FIRST EBOLA EPIDEMIC WITH CATASTROPHIC
RESULTS. HEALTH CARE WORKERS WERE
BECOMING INFECTED. MEDICAL FACILITIES THROUGHOUT
THE CAPITAL CLOSED. ROUTINE HEALTH CARE SERVICES
CAME TO A GRINDING HALT. THE MEDICAL NGO, DOCTORS WITHOUT
BORDERS, WAS THE ONLY REMAINING MEDICAL NGO TREATMENT UNIT IN
THE THREE AFFECTED COUNTRIES. WE KNOW FROM 40 YEARS OF
EXPERIENCE THAT A CRITICAL STEP IN STOPPING AN EBOLA EPIDEMIC IS
TO FIRST IDENTIFY AND ISOLATE CASES AND THEIR SYMPTOMATIC
CONTACTS. THEN REDUCE THE RISK OF DEATH BY
HALF BY ACCESS TO CARE. THEN ENSURE SAFE BURIALS FOR
PERSONS DYING FROM EBOLA. IN LIBERIA, THERE WERE TOO FEW
TRAINED CONTACT TRACING TEAMS TO FOLLOW KNOWN CONTACTS.
DESPITE MSF'S INTENSIFIED EFFORTS TO EXPAND TREATMENT, THE
NUMBER OF BEDS COULD NOT CATCH UP WITH THE GROWING NEED.
AS A CONSEQUENCE, CONTACTING TEAMS THAT DID IDENTIFY
SYMPTOMATIC CONTACTS COULD NOT REFER THEM TO AN EBOLA TREATMENT
UNIT, LEADING SOME TO RETURN TO THEIR HOME VILLAGE, RESULTING IN
NEW TRANSMISSION HOT SPOTS THROUGHOUT THE COUNTRY.
THERE WAS ALSO RESISTANCE FROM COMMUNITIES TO SAFE BURIAL
PREVENTION METHODS THAT CONFLICTED WITH TRADITIONAL
PRACTICES. IN MONROVIA, ONLY FOUR OUT OF AN
ESTIMATED NEED FOR 32 TRAINED AND EQUIPPED BURIAL TEAMS WERE
AVAILABLE TO REMOVE HIGHLY INFECTIOUS CORPORATIONS.
AS A RESULT, EBOLA CASES AND DEATHS GREW EXPONENTIALLY,
RESULTING IN MORE UNSAFE BURIALS AND NEW TRANSMISSION CHAINS.
CALLS FOR FOREIGN MEDICAL TEAMS WENT UNANSWERED OUT OF FEAR.
COMMERCIAL AIRLINES WERE CANCELING SERVICES.
NATIONS WERE THREATENING TO CLOSE THEIR BORDERS.
NGO VOLUNTEERS WORRIED THEY WOULD BE STRANDED, THAT SAFETY
MEASURES WERE INADEQUATE, AND THAT THEY WOULD BE DENIED
REPATRIATION FOR TREATMENT AT HOME IF THEY BECAME INFECTED.
UTTER CHAOS ERUPTED IN MONROVIA. MARSHAL LAW WAS DECLARED AND
CURFEWS WERE IMPOSED. AS MONROVIA WAS SINKING INTO
CHAOS, ANOTHER NIGHTMARE SCENARIO WAS UNFOLDING IN
NIGERIA. AN ILL TRAVELER FROM LIBERIA
ARRIVED AT A REGIONAL TRAVEL HUB FOR AFRICA'S MOST POPULATED
COUNTRY. IF EBOLA TOOK HOLD IN THE SLUMS,
THE ENTIRE CONTINENT WOULD BE AT RISK.
UNLIKE GUINEA, LIBERIA HAD ELEMENTS IN PLACE TO RESPOND.
THE NIGERIAN CDC HAD AN EXISTING EMERGENCY OPERATIONS CENTER AND
INCIDENT MANAGEMENT STRUCTURE FOR POLIO ERADICATION THAT WAS
LEVERAGED FOR AN EMERGENCY EBOLA RESPONSE.
NIGERIA ALSO HOSTS A CDC FIELD EPIDEMIOLOGY FIELD TRAINING
PROGRAM MODELED AFTER CDC'S EPIDEMIC INTELLIGENCE SERVICE.
WITHIN DAYS, CDC DISEASE DETECTIVES JOINED 13 NIGERIAN
TRAINEES AND GRADUATES TO HALT THE OUTBREAK WITHIN THREE
GENERATIONS OF TRANSMISSION. CONTAINING AN OUTBREAK TO JUST
19 CASES IN TWO CITIES REQUIRED AN ENORMOUS LIFT FROM THE
NIGERIAN EOC AND EPIDEMIOLOGY TEAM.
NIGERIA RESPONDED. THEY IDENTIFIED 894 CONTACTS.
THEY COMPLETED 19,000 CONTACT TRACING HOME VISITS TO MONITOR
SYMPTOMS AND TEMPERATURE. THEY IMPLEMENTED A SOCIAL
MOBILIZATION REACHED 26,000 HOUSEHOLDS OF
PEOPLE LEAVING NEAR THE CONTACTS, AND THEY ESTABLISHED
AN ETU AND TRAINED EBOLA CAREGIVERS IN JUST TWO WEEKS'
TIME. WITH JUST TWO ELEMENTS OF THE
GLOBAL HEALTH SECURITY AGENDA IN PLACE, NIGERIA WAS ABLE TO
CONTAIN A POTENTIALLY DISASTROUS EPIDEMIC.
AS THE TIDE WAS TURNING FOR THE BETTER IN NIGERIA, HOPE WAS ALSO
EMERGING IN LIBERIA. IN SEPTEMBER, PRESIDENT OBAMA
VISITED CDC, WHERE HE WAS FULLY BRIEFED ON THE GROWING CRISIS.
FOLLOWING THE BRIEFING, PRESIDENT OBAMA ANNOUNCED THAT
THE U.S. DEPARTMENT OF DEFENSE WOULD DEPLOY AS MANY AS 4,000
MILITARY PERSONNEL TO PROVIDE THE LOGISTIC AND COMMUNICATIONS
SUPPORT ACROSS THE REGION AND IN LIBERIA TO BUILD ETUs THROUGHOUT
THE COUNTRY. IN ADDITION, DOD ANNOUNCED THAT
THE FIRST FACILITY IT WOULD BUILD AND MAINTAIN WOULD BE A
FIELD HOSPITAL MANAGED BY THE U.S. PUBLIC HEALTH SERVICE.
THE NEW HOSPITAL WAS OPERATIONAL BY NOVEMBER.
THIS ANNOUNCEMENT WAS A GAME CHANGER THAT BOLSTERED THE
CONFIDENCE OF THE LARGER MEDICAL NGO COMMUNITY.
OTHER RESPONDERS AND OTHER AGENTS TO ENGAGE IN THE FIGHT,
EVENTUALLY PUTTING LIBERIA ON ROAD TO ZERO.
IN MID-DECEMBER, THE U.S. CONGRESS ALSO RESPONDED TO THE
UNPRECEDENTED EBOLA EPIDEMIC, PASSING THE PRESIDENT'S
EMERGENCY FUNDING REQUEST OF OVER $6 BILLION.
CDC RECEIVED $1.8 BILLION TO END THE EPIDEMIC, ENHANCE EBOLA
PREPAREDNESS IN THE AT-RISK COUNTRIES, ITS NEIGHBORS, AND
THE UNITED STATES AND IMPLEMENT GLOBAL HEALTH SECURITY AGENDA IN
WEST AFRICA AND BEYOND. THESE EMERGENCY FUNDS HAVE
ALREADY ENABLED THE U.S. GOVERNMENT TO BEGIN WORK IN 17
COUNTRIES, INCLUDING THE THREE AFFECTED BY EBOLA.
AT LEAST 13 MORE COUNTRIES WILL BE ADDED IN THE COMING DAYS IN
LINE WITH THE U.S. GOVERNMENT GOAL OF IMPLEMENTING THE AGENDA
IN AT LEAST 30 COUNTRIES BY 2020.
USING THIS FUNDING, CDC WILL CONTINUE TO FOCUS ON GETTING TO
ZERO AND STAYING AT ZERO IN THE EBOLA AFFECTED COUNTRIES WHILE
ALSO HELPING TO BUILD BETTER PUBLIC HEALTH SYSTEMS IN
COUNTRIES AT RISK FOR EBOLA AS WELL AS IN THE 30 COUNTRIES
WHERE THE U.S. GOVERNMENT HAS COMMITTED TO PARTNERING ON
GLOBAL HEALTH SECURITY AGENDA IMPLEMENTATION.
OVER THE NEXT FIVE YEARS, WE WILL WORK IN PARTNERSHIP WITH
OTHER NATIONS TO IMPLEMENT THE AGENDA IN THE HOPE OF AVERTING
TRAGEDIES LIKE THE WEST AFRICAN EBOLA EPIDEMIC FROM EVER
HAPPENING AGAIN. THIS IS CRITICAL BECAUSE
OUTBREAKS ARE INEVITABLE. CDC'S GLOBAL DISEASE DETECTION
CENTER TRACKS OUTBREAKS BASED ON OUR ASSESSMENT OF THE RISKS THEY
CAN POSE TO THE GLOBAL COMMUNITY.
BETWEEN MARCH 2014 AND JULY 2015, IN ADDITION TO EBOLA, WE
ACTIVELY MONITORED OVER 140 OUTBREAKS OF PUBLIC HEALTH
CONCERN ACROSS 170 COUNTRIES. LIKE MIDDLE EASTERN RESPIRATORY
SYNDROME, SEVERAL OF THESE OUTBREAKS HAVE AFFECTED MANY
LIVES AND JUSTIFIED GLOBAL CONCERN.
THE LESSON IS THAT WE CANNOT FOCUS OUR ENERGIES ON ANY SINGLE
PATHOGEN OR ANY PART OF THE WORLD BUT INSTEAD FOCUS ON WHAT
EVERY COUNTRY NEEDS TO DO TO PREVENT, DETECT, AND RESPOND TO
INFECTIOUS DISEASE THREATS BEFORE IT BECOMES AN EPIDEMIC,
THAT BEING INVEST AND ROUTINELY PRACTICE GLOBAL HEALTH SECURITY
AGENDA PRINCIPLES TO ENSURE A ROBUST AND RESILIENT PUBLIC
HEALTH SYSTEM. IN SUMMARY, THE GLOBAL HEALTH
SECURITY AGENDA ADDRESSES THREE RISKS.
NEW EMERGING ORGANISMS, DRUG RESISTANCE, THE INTENTIONAL
CREATION AND/OR RELEASE OF DANGEROUS PATHOGENS.
IT ALSO PROVIDES THREE OPPORTUNITIES.
STRENGTHEN THE EXISTING PUBLIC HEALTH FRAMEWORK COMMITTED TO BY
ALL NATIONS UNDER THE IHR AND DEVELOP AND UTILIZE NEW
LABORATORY AND SURVEILLANCE TOOLS TO SUCCESSFULLY CONTROL
OUTBREAKS. AND IT FOCUSES ON THREE
PRIORITIES OUTLINED IN A PREVENT, DETECT, AND RESPOND
MODEL. THANK YOU FOR YOUR ATTENTION,
AND I'D LIKE TO INVITE DR. FRIEDEN BACK TO THE PODIUM.
[ APPLAUSE ]
>> WE'RE A BIT OVER TIME. I'LL BE VERY QUICK TO LEAVE A
FEW MINUTES FOR QUESTIONS AT THE END TO MAKE FIVE POINTS.
FIRST, TO THANK OUR SPEAKERS FOR EXCELLENT, INTERESTING,
INFORMATIVE TALKS. THANK YOU VERY MUCH.
SECOND, TO SUMMARIZE SOME OF THE THINGS WE HEARD IN 30 SECONDS OR
LESS. THE IMPORTANCE OF SURVEILLANCE,
THE IMPORTANCE OF A MEDICAL CLINICAL SURGE, THE COMPLEXITY
OF THE FEDERAL/STATE INTERACTION IN THE U.S., THE SLIPPERY SLOPE
TO ZERO RISK, UNDERSTANDING THAT WE CAN'T SAY ZERO RISK, AND YET
THAT IS WHAT THE PUBLIC WANTS SOMETIMES AND HOW DO WE MANAGE
THAT DYNAMIC. THE IMPORTANT CAPACITY AS THE
DEPARTMENT OF DEFENSE AND HOW WE CAN SINNER JAZZ WITH THOSE AT
HOME AND ABROAD. THE EBOLA TEST BEING USED IN THE
U.S. IS A DOD TEST THAT WAS APPROVED BY THE FDA UNDER EUA.
AND THINKING ABOUT EBOLA, NEVER FORGETTING THAT THOUGH LOTS WENT
WRONG AND LOTS WENT RIGHT, IN THE END WE AVERTED A FAR WORSE
CATASTROPHE THAT COULD HAVE OCCURRED IF EBOLA HAD CONTINUED
TO SPREAD UNCHECKED IN WEST AFRICA OR HAD SPREAD IN NIGERIA.
THE WORLD WOULD LOOK VERY DIFFERENT TODAY IF WE WERE
DEALING WITH ENDEMIC EBOLA IN MANY COUNTRIES IN AFRICA.
THAT WAS DEFINITELY WITHIN THE REALM OF POSSIBILITY.
SO THANKS. BRIEF SUMMARY.
THIRD, GLOBAL HEALTH SECURITY IS THE NEXT BIG THING IN GLOBAL
HEALTH. THIS IS OUR UNIQUE OPPORTUNITY
TO MAKE RAPID IMPROVEMENTS IN PUBLIC HEALTH CAPACITY AROUND
THE WORLD. FOURTH, WE DON'T KNOW WHAT THE
NEXT OUTBREAK OR EPIDEMIC WILL BE, BUT WE KNOW THERE WILL BE
ONE. WE DON'T KNOW FROM WHERE.
WE DON'T KNOW WITH WHAT. WE WOULDN'T HAVE PREDICTED H1N1
FROM MEXICO OR MERS FROM THE MIDDLE EAST.
BUT WHAT WE'RE SEEING IS THE INEVITABILITY OF THE EMERGENCE
OF NEW ORGANISMS. WHAT'S NOT INEVITABLE IS THAT
THEY SPREAD AS RAPIDLY AND TRAGICALLY AS EBOLA DID.
FIFTH AND FINALLY, THE REAL SYNERGY BETWEEN THE GLOBAL
HEALTH SECURITY AGENDA AND INTERNATIONAL HEALTH
REGULATIONS, THIS IS A WAY OF ACCELERATING ADHERENCE TO THE
IHR. AS PRESIDENT OBAMA NOTED A YEAR
AGO, QUOTE, WE'VE GOT TO TURN THOSE COMMITMENTS INTO CONCRETE
ACTION. THANK YOU VERY MUCH.
[ APPLAUSE ] >> ONE QUESTION FROM OUR ONLINE
AUDIENCES. EDITING FOR TIME, WHAT MAIN
FACTORS COMPROMISED THE EARLIEST MULTICOORDINATED NATIONAL
RESPONSE TO THIS, AND WHAT SHOULD BE DONE NOW BY PRIORITY
AND BY WHOM TO MINIMIZE THESE CONSTRAINTS IN FUTURE EVENTS?
WHAT MAIN FACTORS COMPROMISED THE EARLIEST POSSIBLE
COORDINATED MULTINATIONAL RESPONSE TO THIS EMERGENCY
EVENT, AND WHAT SHOULD BE DONE NOW BY PRIORITY AND BY WHOM TO
MINIMIZE THESE CONSTRAINTS IN FUTURE EVENTS?
>> I CAN TAKE A FIRST CRACK AT IT.
I THINK ONE OF THE THINGS THAT BROUGHT THINGS TOGETHER WAS
TAKING ACTION UNDER THE INTERNATIONAL HEALTH REGULATIONS
AND DECLARING A PUBLIC HEALTH EVENT -- PUBLIC HEALTH EMERGENCY
OF INTERNATIONAL CONCERN. I THINK THAT REALLY RAISED THE
IRE OF MANY AROUND THE WORLD AND THE ATTENTION NEEDED TO HAVE A
GLOBAL RESPONSE. CDC HAD ACTIVATED ONE MONTH
BEFORE THAT EVENT WITH OUR EMERGENCY OPERATIONS CENTER.
SO CLEARLY WE WERE DEPLOYING PEOPLE AND EXTREMELY CONCERNED.
BUT I THINK THAT WAS THE FIRST GALVANIZING EFFORT AND PERHAPS
WE NEED TO MAKE SURE THAT WE LOWER THE BAR FOR WHEN WE
DECLARE PUBLIC HEALTH EMERGENCIES OF INTERNATIONAL
CONCERN. ANYONE ELSE WANT TO ADD TO THAT?
>> I WOULD AGREE. I THINK THAT WAS ONE OF THE
GREAT CHALLENGES AND SOMETHING WE HAVE TO LEARN FROM GOING
FORWARD. YOU KNOW, WHAT WE CHARACTERIZE
AS A PHIC, THAT'S WHAT THEY CALL IT VERSUS WHAT WE DON'T.
I THINK THERE HAVE BEEN A NUMBER OF EFFORTS TO TRY TO REFORM THAT
PROCESS THAT ARE ONGOING, AND WE SHOULD CONTINUE TO SUPPORT THAT.
>> ALL RIGHT. THANKS TO OUR SPEAKERS AGAIN.
PLEASE JOIN US NEXT MONTH FOR PUBLIC HEALTH GRAND ROUNDS ON
E-CIGARETTES. LET'S HAVE ANOTHER HAND FOR OUR
SPEAKERS. [ APPLAUSE ]