Board on Health Sciences Policy Board on Population Health Board on Global Health Board on Life Sciences http://iom.edu/EbolaTransmissionResearch

Research Priorities to Inform Public Health and Medical Practice for Domestic Ebola Virus Disease: A Workshop November 3, 2014 National Academy of Sciences - Auditorium 2101 Constitution Ave NW Washington, DC 20418 Background: The current epidemic of Ebola, a hemorrhagic filovirus, has spread internationally throughout parts of West Africa (Guinea, Liberia, Sierra Leone, Nigeria, and Senegal), now affecting multiple continents, and has become the worst Ebola Virus Disease (EVD) outbreak in history since its discovery in 1976. The U.S. medical and public health systems are now preparing for and responding to domestic cases of Ebola. While the Ebola virus has typically been studied in laboratory settings, additional biomedical and public health research in real world setting should be conducted to best prepare the U.S. to safeguard the public. The workshop will inform the U.S. Department of Health and Human Services, the biomedical and public health communities, and other stakeholders about what research would be most beneficial to conduct now to provide public health officials, healthcare providers, and the general public with the most up-to-date information about transmission, health risks, and measures that should be taken to prevent spread of the disease in the U.S. Research topics that may be considered during the workshop include routes of virus transmission, persistence of the virus on various types of surfaces and the ability to transfer viable virus to other locations, effective methods for viral inactivation and disinfection, and other strategies to protect at-risk responders and the general public. In addition, the workshop will explore research that may inform strategies to address issues of concern to healthcare workers and the general public, including the efficacy and use of personal protective equipment and personal protective behaviors to prevent spread and reduce exposure. Discussions will focus primarily on basic science and public health issues of specific concern to affected and potentially affected communities in the U.S. Meeting Objectives: • Explore potential research priorities arising as a result of the emergence of EVD in the U.S. • Consider what research needs to be performed now to provide public health officials, providers, and the general public with the most up-to-date information about transmission, health risks, and measures that should be taken to prevent spread of EVD in the U.S. • Explore research that may inform the deployment and use of personal protective equipment and personal protective behaviors to prevent spread and reduce exposure.

NOTE: Breakfast and Lunch will be on your own. Boxed lunches will be available for $15 (CASH ONLY), and there is a cafeteria located in the basement of the NAS building. 8:30 a.m.

Welcoming Remarks VICTOR DZAU President Institute of Medicine

8:45 a.m.

Workshop Objectives and Introductions LYNN GOLDMAN, Workshop Chair Dean, School of Public Health George Washington University

9:00 a.m.

Charge to Participants NICOLE LURIE Assistant Secretary for Preparedness and Response Department of Health and Human Services

9:15 a.m.

Characteristics of the Ebola Virus in the U.S. Environment: What do we know? • Are there assumptions being made based on the science? JAMES LEDUC Director Galveston National Laboratory University of Texas Medical Branch

9:40 a.m.

Existing Research Landscape on Ebola: Past and Ongoing Initiatives Where can current research inform this effort? Where are the gaps in previous and existing research? • Transmission Routes and Routes of Entry of the Virus • Survival and Infectivity of the Ebola Virus in the Environment • Personal Protective Equipment and Personal Protective Behaviors to Prevent Transmission and Reduce Exposure to Ebola • Handling of Potentially Infected Materials, Waste Management, and Disinfection Methods C.J. PETERS Director for Biodefense Center for Biodefense and Emerging Infectious Diseases University of Texas Medical Branch JOHN HOWARD Director National Institute for Occupational Safety and Health Centers for Disease Control and Prevention MICHAEL HODGSON

Chief Medical Officer Occupational Safety and Health Administration Department of Labor PAUL M. LEMIEUX Associate Division Director NHSRC/DCMD National Homeland Security Research Center US EPA Office of Research and Development 10:40 a.m.

Observations from Africa to Inform a Research Agenda DANIEL BAUSCH Head, Virology and Emerging Infections Department U.S. Naval Medical Research Unit No.6 Lima, Peru

10:55 a.m.

Discussion with Attendees LYNN GOLDMAN, workshop chair Dean, School of Public Health George Washington University

11:15 a.m.

Preparing for Breakout Sessions: Charge to Attendees LYNN GOLDMAN, workshop chair Dean, School of Public Health George Washington University

11:30 a.m. Breakout Discussions and Working Lunch (Lunch available in Great Hall) Session Objectives: Consider important research questions that fit within the parameters of: • Research that must be performed now to provide public health officials, providers, and the general public with the most up-to-date information about transmission, health risks, and measures that should be taken to prevent spread of the disease in the U.S. • Will inform strategies to address issues of concern to healthcare workers and the general public. Note: Each breakout will start with one or two presentations to provide context for the follow-on discussions. Lecture Room:

Transmission Routes and Routes of Entry and Exit of the Virus 

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Modes of transmission of the virus to the new host • Person to person i.e., bodily fluids, touch, saliva, air • Fomites i.e., medical equipment, patient clothing or bedding • Water and food Impact of the characteristics of healthcare settings and procedures Household and mass transit risks

Speakers:

GARY KOBINGER (VIA TELECON) Head of Special Pathogens Head, Vector Design and Immunotherapy, Special Pathogens Program, National Microbiology Laboratory Public Health Agency of Canada VINCENT MUNSTER Chief, Virus Ecology Unit National Institute of Allergy and Infectious Disease, NIH FACILITATORS: THOMAS KSIAZEK AND ANDREW PAVIA RAPPORTEURS: GEORGE RUTHERFORD AND ERIC TONER Room 125:

Survival and Infectivity of the Ebola Virus in the Environment  

Host Infectivity • Incubation period • Viral load in bodily fluids over time Survival of the virus outside the host • On varying surfaces (i.e., fomites such as doorknobs, clothing, skin) • On clinical lab testing equipment, dialyzers, ventilators • Virus sensitivity to environmental conditions, (e.g., temperature, humidity, sun exposure)

Speakers: JOSEPH FAIR (VIA TELECON) Senior Advisor Merieux Foundation

FACILITATORS: TRISH PERL AND JEFF DUCHIN RAPPORTEURS: JACK HERRMANN AND ERIN MULLEN Members Room: Personal Protective Equipment and Personal Protective Behaviors to Prevent Transmission and Reduce Exposure to Ebola     

Appropriate PPE equipment (respirators, gloves, gowns, etc.) – protection factors, high risk procedures PPE use – donning, doffing, decontamination Hierarchy of controls – engineering and environmental controls (e.g., air exchanges and negative pressure rooms) and administrative controls (e.g., patient access, source control, supervision) Safe worker practices Systems for training and education

Speakers:

DONNA GALLAGHER Co-Director, Office of Global Health University of Massachusetts Medical School LISA BROSSEAU Professor, Environmental and Occupational Health Sciences University of Illinois FACILITATORS: MELISSA MCDIARMID AND BILL KOJOLA RAPPORTEURS: ELAINE LARSON AND MARTIN SEPULVEDA Auditorium: Handling of Potentially Infected Materials, Waste Management, and Disinfection Methods    

Safe decontamination processes for water, PPE, personal belongings Validation of virus inactivation Fatality cadaver management issues Current training practices for healthcare and non-traditional workers for handling infected materials

Speakers: PATRICIA OLINGER Director of the Environmental, Health and Safety Office (EHSO) Emory University JOHN LOWE Assistant Professor Department of Environmental, Agricultural and Occupational Health College of Public Health University of Nebraska Medical Center FACILITATORS: SUZET MCKINNEY AND SUSAN SANTOS RAPPORTEURS: DAN HANFLING AND DEBRA SHARPE

Report Back to Plenary – NAS Auditorium

3:00p.m.

Open Session: What important Ebola issues remain to be addressed that were outside the scope of the workshop discussions? What additional questions warrant attention? LYNN GOLDMAN Dean, School of Public Health

VICTOR DZAU President

George Washington University

3:45p.m.

Institute of Medicine

Report back by breakout facilitators and rapporteurs LYNN GOLDMAN Dean, School of Public Health George Washington University

4:30 p.m.

Discussion with attendees • What questions are missing? • Are there specific topics that deserve immediate research?

5:30 p.m.

Wrap up and Adjourn VICTOR DZAU President Institute of Medicine