CDC Telebriefing: Update on Ebola Response Tool

OPERATOR: Welcome and thank you for standing by. At this time all participants are in listen only mode. After the presentation, there will be a question and answer session. To ask a question, you may press star 1 and record your name when prompted. Limit your questions to one question and one follow-up. Today's conference is being recorded. If you have any objections, please disconnect at this time. I would now like to turn the call over to Mr. Tom skinner. Go ahead, sir, you may begin.

TOM SKINNER: Thank you, Sharon. And thank you all for joining us today for this tele briefing regarding an update of an Ebola response tool chronicled in an MMWR article that CDC is publishing today. With us, we have the director of the Centers for Disease Control and Prevention, Dr. Tom Frieden and special assistant to the President of the United States and Senior Director of the National Security Council, Ms. Gayle Smith. Both will provide some opening remarks and then we'll get to your questions. So Dr. Frieden.

TOM FRIEDEN: Good morning and thanks very much for joining us. The 2014 Ebola outbreak is the largest in history. It's the first in West Africa, the first to have spread to urban areas and it's the first Ebola epidemic the world has ever known, affecting multiple countries and widely spreading particularly in Liberia. Although the current epidemic doesn't pose a significant risk to the U.S., public, we're taking precautions at home, in addition to the activities that we're doing abroad. What we're releasing today is a useful tool. It comes with an online spreadsheet so that planners in countries as well as in international organizations can model what might happen in different circumstances. The tool was created several weeks ago with data that was available several weeks ago and a lot has happened since then. From my standpoint, the tool is very similar in its projections of what might happen to other tools that have been released. And basically, shows an unsurprising finding, which is that if cases continue to increase exponentially, there will be a lot of them fairly soon. But the bottom line here is, and I think what's really important in this tool, is that the model shows -- and I don't think this has been shown by other modeling tools out there -- that a surge now can break the back of the epidemic. It also shows that there are severe costs of delay. And that the importance of implementing effective programs rapidly can't be overemphasized. It's definitely still possible to reverse the epidemic. And that's why the initiatives announced by President Obama last week and that we are already seeing on the ground in Monrovia this week are so incredibly important and are exactly what's needed to reverse the epidemic. The model shows several things that are really, I think, encouraging and one cautionary note. The first encouraging thing is, if you get enough people effectively isolated, the epidemic can be stopped. And related to that, when you reach a high enough number, and the higher you get, the better you do. But when you reach a high enough number, the number of cases plummets rapidly, almost as rapidly as the exponential rides we're seeing now. The cautionary finding of the modeling is the enormous cost of delay that for each month of delay, there's a big increase in the number of cases. And it gets that much more difficult to control the epidemic. And so it really does emphasize exactly what the president said when he was here in Atlanta last week: that if the outbreak isn't stopped now, it creates a severe problem. That's why the U.S. is taking a whole of government intensive approach. We continue at CDC to have an extensive on the ground presence helping countries improve their response. Ms. Gayle Smith will speak in a moment about the broader U.S. and global response, which is extremely encouraging. We've seen a real stepping up of how things are going. And before I turn it over to MS. Smith, I’ll just mention one last observation from my point of view. One of the things that's been so striking about the Ebola situation in West Africa is how fluid things have been on the ground. So even a week or two ago, I would have expected things to look differently, particularly in Guinea and Sierra Leone than they actually look today. This is a fluid and dynamic situation. What the modeling shows us is that even in dire scenarios, if we move fast enough, we can turn it around. And I’m confident that the most dire projections are not going to come to pass, given what we've already seen on the ground in terms of the response and what we're beginning to see in terms of some of the data coming in. So over to Gayle Smith.

GAYLE SMITH: Thank you, Tom. Good morning, everybody, and thanks for joining us. I would only add two things. One is that the value of data in this entire response, this is something we know how to respond to. And that it’s the facts, the data and the evidence that leads us to the solution. A planning tool, as Tom suggested, is very key here. It tells us how to bend the curve. The other thing is that some of the projections that you will be seeing don't take into account something that Tom just referred to, which is the tremendous surge in resources and response, even in the last few weeks. As you know, President Obama announced that we would be sending in a joint force command, which has been stood up in Monrovia to support the regional civilian effort. They have provided more personnel on the ground since the force commander deployed last week. They are calling in assets and capabilities to rapidly get to scale a response that will provide more advisable treatment units, training at scale and logistics to support what is a complex region wide operation. We are also continuing to build out our civilian response, CDC is over 100 experts in the field and continues to add capabilities to the mix. We have a disaster assistance response team in the region which is led by the USA, but includes a CDC deputy personnel from DOD, which is pushing out again, aggressively on, for example, community care so that we can get as much coverage in terms of responding to the outbreak as is possible. The third line of effort is work very aggressively with countries all over the world to urge and urge them to ramp up their responses. We're very encouraged to see since the president's announcement, we have seen announcements from the UK of their intention to stand up seven hundred beds or the equipment of 7 Ebola treatment units in Sierra Leone. We're hearing from other European partners that they will support this intermediate staging base out of Dakar to provide logistics for the operation, as well as additional assistance. We're getting a good response from Asian countries, as well. Significantly, the African union is deploying health care workers. South Africa has indicated it will be responding. Cuba is responding. So we are starting to see a significant surge from members of the international community. Great reception to our joint force command, which is just for your awareness, the kind of model we have used in Haiti or in the typhoon in the Philippines. Lastly, we're very encouraged to see that the United Nations already has advanced teams on the ground to stand up a mission. The secretary general announced this week the UN mission for emergency Ebola response. We think all of these things that were not fully in play when some of this data was first examined are the things that can contribute to bending the curve, as Dr. Frieden suggests. That said, we think it's imperative that we keep the pressure on the international community to respond as quickly as possible. So we can get ahead of this and get ahead of it quickly.

TOM SKINNER: Sharon, I think we're ready for questions, please.

OPERATOR: Thank you. If you would like to ask a question, please press star, then 1 on your phone and record your name when prompted. Please limit your question to one question and one follow-up. Our first question comes from Richard Besser of ABC News. Go ahead sir, your line is open.

OPERATOR: Thanks very much can you hear me?

TOM SKINNER: Yes, Rich.

RICHARD BESSER: Yes. I have one question and a follow up. In looking at the model, it doesn't seem dependent at all on the quality of care provided in the treatment center. It's focused on the isolation. I'm wondering if there's a way to factor in the model, the quality of care, as a way of looking at increasing people's willingness to leave the community and be isolated?

DR. FRIEDEN: I think it's a good point. It's really implicit. You get people into care if they feel that they're going to be well cared for. We're seeing, for example in Guinea, of the patients with confirmed Ebola virus disease are being discharged alive. So care in a treatment unit can, we believe, probably double your chances of success and more that's known, the more patients will come in for care.

RICHARD BESSER: My follow-up question has to do with the lack of concrete plans for identifying people to provide that quality care. In particular, why is the U.S. not stepping up in a big way to provide care, direct patient care in the treatment centers?

DR. FRIEDEN: Well, what we figured out basically is we need to take a two-track approach. Scale up the treatment centers as rapidly as possible and provide, in an interim basis, as safe and effective care as we can outside Ebola treatment centers. For the first of those tracks, there’s a very intensive effort underway now where the USAID is contracting with non-governmental organizations to operate Ebola treatment units. Today, yesterday, and tomorrow, CDC is undertaking the first ever training in Ebola care and treatment. So we're training trainers who will be able to scale up the number of people that will be able to go in and provide assistance. The armed forces of Liberia are already constructing additional ETUs. The department of defense is already scoping out with engineers and other rapid assistance, creation of more Ebola treatment units. So, I think we're going full speed ahead. USAID has put on it’s website a way for doctors and students is local. We know that in ETUs, more than 90 percent of the staffing is local. So identifying local staff will be one of the things that people managing the treatment units will do and the Department of Defense plans to operate a high quality training operation for that. So I think we're moving fast to expand ETUs. We're also working closely with the government of Liberia and with communities throughout Liberia to identify effective ways to care for people until ETUs are established. That means Ebola care units where people can get oral rehydration, pain relief, food and shelter, nourishment and care by one designated family member, whose provided personal protective equipment. And that’s one of the implications of the model that we are going to need to that while we go full speed ahead on the ETUs.

TOM SKINNER: Next question please.

OPERATOR: Our next question comes from Mariam Falco of CNN Medical News. Go ahead your line is open.

MARIAM FALCO: Good Morning and thank you for taking my questions. I’ve got on and a follow up too. Number one, the projections in this MMWR, unless I missed it, do not provide any projected stats. It's only 550,000 based on current numbers as of the end of August and 1.4 million based on the underreporting. But what are the projected stats? And then my follow-up is a follow-up to Dr. Besser's question. As these clinics or ETUs or whatever are being established, how effective can they be? Just this morning, the WHO released a report in their six-month analysis about the new clinic that was established in Monrovia. And their assessment was that patients and their families stood in line and were grateful for this new clinic being opened while our own correspondent, Elizabeth Cohen, was there and saw that patients were being dropped off and if they couldn't get into the clinic, they just fell to the ground and stayed there or were in an ambulance outside and died. So there’s still a disconnect. So until all these other measures are put in place, what's being done immediately to make the new established places for care effective?

TOM FRIEDEN: First off, I want to just get a term right. These are not projections. So what we're -- what we have done is to outline what might happen in different scenarios. The scenario in the MMWR is the scenario as of the data three weeks ago in terms of both case counts and the response status. And events on the ground have changed quite a bit since. Things are looking more encouraging in Guinea and Sierra Leone, for example, and we're seeing a rapid scale up of the response. The New England Journal article from WHO has a death rate of all diagnosed patients. But what we do believe is that even core clinical services can result in a -- can cut the death rate in half, particularly with rehydration and fluid management. And the fact that the ETUs or Ebola Treatment Units are full is requiring us to come up with innovations to try to care for patients in a way that is safe for their care givers and effective for them. And that's the order of the day in both Liberia and Sierra Leone where ETUs are full. There, the key is to identify what may happen to provide, for example, a school or a health facility no longer in use or another community structure and to provide food, liquids, painkillers, oral rehydration, to both reduce the death rate in people who have Ebola and to reduce the risk that they'll spread it to others. And that's the initiative that's being urgently implemented in both Liberia and Sierra Leone.

GAYLE SMITH: I would only add one quick thing to this. The essential ingredients here are speed and scale. And Dr. Frieden, I think has laid out what this joint force command combined with our civilian capabilities provides us. The ability, for example, to do training at as many as 500 a week of the kind of training that is required for people to manage ETUs and do it safely. We've got to do that at the same time as we are pushing out on the community care models that were just described. So the aim here is to immediately target 400 thousand of the most vulnerable households and push out on that.
 

OPERATOR: Next question, Eben Brown of Fox News Radio.

EBEN BROWN: Good morning and thank you all for taking the calls and doing this. That number that was put out, 550 thousand to 1147 million cases is getting a lot of attention. It's already hitting other news agencies now. I know in the same paragraph in the news relief, it's tempered by saying it's from data available in August, not accounting for relief efforts. Is there going to be a number that is updated because of better data or more current data and factoring in the relief efforts? If not, is there any way to at least quantify it or take a stab at it?

TOM FRIEDEN: Yeah. It takes time both to see the data and the trends. But we are able to give something as far as where we are and where it is we think we are going. I think it's unavoidable that that's the focus of the coverage. I think we've said clearly we don't think that will come to pass. And the important findings of the models are that a surge now can predict the back of the epidemic, but delay is extremely costly in terms of lives and effort. And I think that last point, when I looked at the model results, the thing that made the biggest impact on me was the mathematical documentation of the urgency that we feel in the field. That for each day that we're not effectively isolating people, not only are people potentially dying and potentially affecting others, but the job of stopping the outbreak, turning it around, gets much bigger and much, much more difficult.

GAYLE SMITH: I would have said one thing. The other thing that is a moving target but in a positive way is the response. We are finding every day in our conversations with other countries, which are going on at all levels of our government and across all agencies on the fairly constant basis, we are getting more information about what countries are prepared to do. So you can't quantify that absolutely, I think, in terms of talking about what resources and inputs are on the table now that were not in august. But I think you can refer, again, to what was in our fact sheet when the president made that announcement. If they don't have it, the announcement from the UK, there are several announcements through the United Nations, I would like to what we're hearing from Germany, from France, from the Nordics, from the Asian countries, as well. And i think you will see that there is a regular and by now daily positive change in terms of what resources and capabilities countries are willing to take. So that's the other variable here.

EBEN BROWN: Great. Thank you. Next question, Sharon.

OPERATOR: Our next question comes from Maggie Fox of NBC News. Go ahead, your line is up next.

MAGGIE FOX: Thanks. Can you kind of qualify the response that is happening now? Is it the beginning of what's needed? The scenarios say if you can get just 70 percent of people isolated, it would end the epidemic, I believe, by January 20th under the best case. How far are we down the road to getting there and what more would be needed if we're not well on the way?

TOM FRIEDEN: Well, I think it's important to take the three countries separately in Guinea. We already have essentially spare capacity in the Ebola treatment units, except in some of the forest areas where there have been security problems and difficulty getting in. In Sierra Leone, we've seen that the ETUs are full, but we're not yet seeing very large numbers outside of the ETUs as far as we know, again, with the unknown of that worst area. In Liberia, we are seeing patients unable to access ETUs, so the portion is significantly less than 70 percent still. But the data here is a month old. It's from the end of august. The situation on the ground is quite fluid. What we're seeing now is rapid coming on to line of more ETU beds as well as decision and commitment of the government of Liberia that work with communities to find the safest possible alternative locations for care and that is a critical interim strategy, as well.

MAGGIE FOX: So can you say how far down the road it is towards getting what is needed to reverse the epidemic?

TOM FRIEDEN: We think there is a lot needed as quickly as possible. And what will be needed to reverse the epidemic is not a fixed number. It depends on the speed with which we deploy the response. That's why the D.O.D already being on the ground and already helping with accelerating ETU establishment is so incredibly important.

GAYLE SMITH: And there's some other pieces of this response that are critical to our collective success. So that is a major logistical operation, which D.O.D is putting in place. The world food program is doing logistics as is the United Nations. There is a huge response needed in terms of training and some of the other things that are essentially enablers for the approach that Dr. Frieden outlines to bending the actual curve. I would say that we've seen a tremendous surge in the last week in responses from around the world. But given the realities of this virus and the fluidity that Dr. Frieden describes on the ground, that momentum must be at least maintained so that we can ensure that we are way out ahead of this. And not assuming that just because we've seen a great surge from the international community in the last week, we don't need more from a number of countries and all of us to stay on this for as long as it takes.

TOM SKINNER: Next question, Sharon.

OPERATOR: Our next question comes from Lena Sun of Washington Post, go ahead your line is open.

LENA SUN: Hi. Gayle, I wondered whether you could make quantify or be more specific about when the -- excuse me -- 1700 treatment beds that the U.S. has pledged are actually going to be on -- because that will take time, so it sounds like it's going to be months before those are going to come online.

GAYLE SMITH: I'm not going to give an exact date because I don't want to prejudge our folks that are out in the field doing this. What I will say is the Department of Defense; along with our sibling agencies -- because both sides of our government are actively involved -- are working on an extremely fast basis to move this as quickly as possible. So that's identifying the sites, getting the sites ready, getting the construction up and running. For a command that's been on the ground for a week, I think we are all very satisfied with the speed with which they are moving. So I think those will happen on a fast trajectory. You're right, it does take time to get them stood up, which is one of the reasons that, again, as Dr. Frieden has explained, we are also putting in on the community care side. Also, I think it's important, Dr. Frieden mentioned one other thing, which is significant. All of these things have to happen together to take us to success. But another component, he referenced U.S.A.I.D. working with a number of partners to stand up ETUs. This is a positive sign. I think we have more partners who are going into the region and standing up operations, as well. We've got multiple trajectories that will lead us to having more ETUs. On our side, D.O.D. is working extremely quickly and as fast as they can to get these moving as fast as possible as we get closer on to, you know, actual completion, we will be happy to share more details with you.

LENA SUN: And I have a follow-up on the separate subject. Is the reason that the MMWR did not include Guinea because they are doing better, is that why they are not model in there?

TOM FRIEDEN: If you look at the Guinea data, you said multiple three separate waves of bases which are increased in amplitude. But it's just not possible to model the trajectory of cases is such that no model can predict what will happen. And I think what that reflects on the ground is that the situation in Guinea is still very much in the balance. And they have the potential was as they have done now to stop it from spreading. But that forest area, which is the center, the epicenter of the grout break with the three country borders, is that where most or their cases are coming from what they will do. It emphasizes the regional response is so important because Guinea will face continuous importations for various borders as well as great difficulties in their forest areas. But the reason they weren't included was basically given the saw-toothed nature of their cases, it was not possible to come up with valid model.

TOM SKINNER: Questions from two more callers, please.

OPERATOR: Our next question comes from Dennis Thompson of HealthDay. Go ahead, your line is open.

DENNIS THOMPSON: Thank you for taking my call. Could you provide some more detail in terms of the actual presence that is over there right now and the presence that is projected to be in the coming weeks in terms of manpower?

TOM FRIEDEN: So from CDC's standpoint, we currently have about 120 people on the ground. We have people in all three countries as well as in other countries like Nigeria and Senegal, which have had imported cases and countries that are at risk for having cases. That response is assisting all aspects of the effort from tracking cases to improving contact investigation to training and being a critical part of the U.S.A.I.D’s DART team, where we provide the technical leadership for health, public health and health care and A.I.D. is providing a robust response in terms of logistics and overall disaster response. And as has been mentioned, D.O.D. is on the ground. Miss Smith.

GAYLE SMITH: Let me just say something about how a joint force command works. They go in with a small team in the force commander and then continue to add personnel based on their assessments. So the estimate, when this was announced is roughly in the ballpark of 3,000. The commander typically does is goes in with a team that can scope the logistics, the engineering, the other requirements to move out as quickly as possible on the mission and calls in the additional personnel and capabilities in a sequence that will match sort of the rhythm on the ground for how they move out. So they are bringing in new personnel, pretty much every day as well as calling in the capabilities. I think on the specifics of numbers on the ground, give us time, we would refer those questions to D.O.D. But having watched our defense department do this in other cases, again, in Haiti and the Philippines, it's a rapid buildup. But importantly, it's sequenced less on getting to a certain number and more on the specific capability needed to work in sequence as quickly as possible. I would just add one other thing to something that was raised before about Guinea, which gets to, again, some of the information that we have now and capabilities we have now that we did not have earlier that France has announced that they're going to set up a medical facility in the forest of guinea, which dr. Frieden referred to as the epicenter of the epidemic. So that's the response we're beginning to see about which we're very encouraged.

TOM FRIEDEN: I would add that we've seen health workers from the African union in country beginning to provide care. So we're seeing a robust response from the U.S. and globally.

TOM SKINNER: Last question, Sharon, please.

OPERATOR: Comes from Donna Young of Scripps News. Go ahead, your line is open.

DONNA YOUNG: Thank you for taking my question. My question was, since you've already acknowledged that you don't think the 550,000 number will come to pass, and you've acknowledged, you know, that you think that this could be turned around if efforts were continuing and is that the data is already out of date, what was the point in putting it out there? Was it to create the hysteria that it appears to be creating to get the international community more on board or kind of what was the point, then, if it's already out of date data?

TOM FRIEDEN: So what we've released today is a model that people can use and plug in their own data to see what may happen and what the impact of different interventions is. Part of the point of having a projection of what might happen if we don't take urgent action is to make sure that it doesn't happen. And that's what we hope and anticipate this will result in. I think the model has very important findings. And I’ll make this as a last comment and ask Miss Smith if she wants to make a last comment, that a surge now can break the back of the epidemic. It is possible and we can be on track to turning it around. But the costs of delay are significant and that is why the response that we're seeing from the U.S. and from others is so incredibly important. Because every day counts. And it will make a difference in our ability to control this. Miss Smith.

GAYLE SMITH: Yes, I’m just underscoring everything my colleague just said; I think our messages are first and foremost that as Dr. Frieden says, this is an unprecedented outbreak and in fact epidemic. Every hour counts, Every minute counts, the data makes that very clear. It counts with respect to what the world mobilizes to response. So we very much want people to understand that there is data that can guide us in the response. There is data that shows that if we do not respond steadily, effectively and on time, we will be looking at even more unprecedented situations. But again, as he said, the data tells us now that if we move now and quickly, we cannot only bend the curve, but as you pointed out at the top of the call, the curve goes the other direction very quickly.

TOM SKINNER: Okay. Thank you all. Sharon, this concludes our call. Reporters wanting additional information or follow-up questions can call the CDC press office at 404-639-3286. Thank you all for joining us today.

OPERATOR: This concludes today's conference. Thank you for your participation. You may now disconnect.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES