Briefing on Biosecurity
MODERATOR: Thank you very much, and thanks to all those who’ve joined us this afternoon for our on-the-record conference call on biosecurity. The first thing I’d like to do is introduce our two speakers this afternoon. We’re joined first by William A. Walters, M.D. Dr. Walters is the managing director for Operational Medicine at the Bureau of Medical Services here at the U.S. Department of State. We’re also joined by Joseph P. Lamana, the director of the operations division of the Office of Emergency Management in the Office of the Assistant Secretary for Preparedness and Response at the Department of Housing – excuse me, Health and Human Services.
As a reminder, this call is on the record, and we will embargo this call until the conclusion of the call. And with that, I’ll turn it over to Dr. Walters.
MR WALTERS: Thank you. President Trump has placed significant emphasis on keeping Americans safe. Secretary Tillerson has identified safety as a core value for the U.S. Department of State. The department holds a mandate to promote the safety and security of U.S. citizens traveling, working, or residing overseas, including those who courageously volunteer to respond to public health emergencies such as the 2014 Ebola outbreak. During that outbreak, the department leveraged a nascent capability for biocontainment medical evacuation to support over 30 partner nations and organizations. In partnership with the Department of Health and Human Services and the international community, the Department of State coordinated the evacuation of 46 health care providers infected with or exposed to the Ebola virus, enabling for the first time the international response that ultimately contained the West African Ebola threat.
The Department of State maintains the world’s only all-hazard biocontainment transport capability through our contract with Phoenix Air Group in Cartersville, Georgia. While the Phoenix Air Group’s small-jet biocontainment capability received a fair amount of press coverage during the outbreak and performed flawlessly during dozens of evacuations, it was clearly – it was clear early in the outbreak that a larger transport capability was needed.
The Containerized BioContainment System is the product of a $5 million public-private partnership between State and the Paul G. Allen Foundation. The CBCS, Containerized BioContainment System, was designed as a first-response capability to manage clusters of patients during the first days of an outbreak, whether intentional release or naturally occurring, allowing international responders to focus immediately on containment. Developed in response to the Ebola virus disease epidemic, the CBCS represents a revolutionary step toward meeting the biosecurity needs of the future, assuring the United States has the strategic options necessary to lead or support the next global response.
On April 10th, 2017, an interagency task force jointly led by the U.S. Department of State’s director of Operational Medicine and the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response initiated the largest overseas biocontainment exercise in history, designed to assess the readiness of federal, state, local, and private partners to respond to an outbreak overseas. This exercise, Tranquil Shift, tested the U.S. Government’s maximum lift capability in response to a simulated outbreak of a highly contagious pathogen, deploying a combination of Aeromedical BioContainment Systems used during the Ebola outbreak and Containerized BioContainment Systems to evacuate 11 simulated American patients to Ebola treatment centers across the United States. On April 11th, a total of five aircraft – two 747s and three Gulfstream IIIs – departed Atlanta, Georgia, traveled to Dakar, Senegal, where they prepared for the evacuation. On April 12th, all these aircraft flew to Freetown, Sierra Leone to pick up their patients and flew on to Washington Dulles Airport to clear customs.
Once the aircraft, patients, and crew had cleared customs, they flew on to one of five receiving facilities across the country, including Bellevue Hospital in Manhattan, Johns Hopkins University in Baltimore, University of Minnesota Medical Center in Minneapolis, and Denver Health Medical Center in Denver, and the University of Nebraska Medical Center in Omaha, to transfer their patients to waiting ground ambulance crews. The scope of this exercise is unprecedented and a testament to the lessons learned and the changes made in the aftermath of the Ebola outbreak.
I’d say this: Tranquil Shift prepares us today for what we were largely unprepared for in 2014. This is not about Ebola. This is about the Middle East respiratory syndrome coronavirus, MERS-CoV, in Qatar, with outbreaks every month for the past several months; Lassa fever in Benin, Togo, and Burkina Faso from February of this year; plague in Madagascar in December of last year. Infectious disease outbreaks happen all the time. They’re usually contained, largely to the efforts of local health systems augmented by international health responders. The United States Government has a responsibility globally and to its American citizens to continue to support those ongoing efforts to prevent catastrophe in the future.
I’ll pass it off to Mr. Lamana to talk about ASPR’s role. State takes – sort of initiates things overseas, manages the transport, gets them through customs. When that plane lands and those patients are offloaded, it’s HHS ASPR that picks up the ball and carries it the last mile.
MR LAMANA: Thank you. So I’ll start by saying that in 2006, the assistant secretary of preparedness and response was – the office of – was created as a result of the Pandemic All Hazards Preparedness Act. So it was fairly consistent with what this exercise was attempting to prove, was our ability to manage public health and medical crisis here in the United States. The ASPR was created as a lead for HHS for preparing and responding for and recovering from health effects from disasters and public health emergencies, which in this case was the simulated 11 patients across – over in – outside of our borders.
So the United States has the ability to – our preparation and ASPR’s preparation to prepare for here back in the United States with hospitals that can be ready to go in case there is a bio disaster somewhere. We picked five specific regional Ebola treatment centers, of which there are actually 10 across the country, but for this exercise we used five.
ASPR’s role in this exercise was to coordinate that transportation and reception once the patients were dropped off here in the States. We have various folks that are regionally located to be able to do that coordination with those 10 Ebola treatment centers, and that was what we set out to do during this exercise, was to be able to coordinate that local ground transportation from the airport to the regional Ebola treatment center. Part of that is ensuring that those regional Ebola treatment centers are adequately informed, notified, and then through the ASPR and through the grant funding that we have available in ASPR, we were able to provide some grants to these facilities – some grant funding to these facilities to be able to prepare their biocontainment units, train staff, and build the necessary plans to be able to do the reception.
So all in all, it was a good handoff from State to HHS in this exercise.
MODERATOR: Thanks, gentlemen. And I would love to open it up for questions now.
OPERATOR: Ladies and gentlemen, if you wish to ask a question, please press * then 1 on your touchtone phone. You will hear a tone indicating you’ve been placed in queue. You may remove yourself from queue at any time by pressing the pound key. Once again, ladies and gentlemen, if you have a question, please press *1 at this time. One moment, please, for the first question.
Our first question comes from the line of Matthew Lee, Associated Press. Please, go ahead.
QUESTION: Hi, thanks a lot. You mentioned in your opening remarks that the President is very committed to the safety of the American people. And I’m just wondering how this fits into that, given the fact that during the Ebola crisis, when the previous administration was bringing patients into the United States, the President was – the current president was very critical, saying that Obama was incompetent, that this was a huge mistake to bring these people here. Has that position changed as far as you know, and did the – was the White House aware that this drill that you were doing last week was actually going on?
MR WALTERS: Matt, thank you very much. So what I would say is this capability, at the time, two thousand – early in 2014, early in the outbreak, was largely unproven. It had been developed during the SARS outbreak and H5N1, and early on a decision was made that we were going to reach out and fulfill our commitment to American citizens overseas, and that’s what we did. And ultimately, Brantly, Writebol, and some 40 patients afterwards were safely transported. That changes the perspective. The doctrine at the time was we don’t transport Category A pathogens. We’ve learned. And what we know now going forward is that it can be done safely as long as these exercises take place, that the stakeholders are identified early, that there’s careful coordination. There is no room for mistakes on these, but the mortality rate for Zaire strain Ebola in West Africa in 2014 was 70 percent. The mortality rate for patients that we got to within seven days of onset of fever was zero. That was a game changer that nobody saw coming, but we learn, we adapt, and we move forward.
QUESTION: So the White House was or was not on board with this?
MR WALTERS: I can’t speak for the White House on that.
MODERATOR: Next question.
OPERATOR: Our next question comes from the line of Carol Morello, Washington Post. Please go ahead.
QUESTION: Hi, thank you for doing this. I was hoping you could give a few more details about the experience on the ground and how various people and institutions performed, from the hospitals to getting people through customs. Were there any glitches along the way, or anything that you learned? I was just looking for some more details of what the experience was actually like.
MR WALTERS: So Tranquil Shift is the third exercise of the Containerized BioContainment System. And the first exercise was last August; the most recent exercise was in April. With each exercise, just as with each evacuation during the outbreak, we learned things. This is an – a complex aviation operation. Airplanes have mechanical problems, electrical problems that have to be resolved in the midst. Negotiations with the Governments of Dakar or Senegal or the Government of Sierra Leone, these things – there were glitches, absolutely, and we worked through them as only the State Department can, working on the ground between the U.S. embassy, the government of, the civil aviation authority, ministries of defense and so forth.
So yeah, there were lessons learned. We are adapting our operations, but these were all things that we had seen before in previous real missions, and we had a game plan for them.
QUESTION: What were some of those negotiations involved with the governments of – in Senegal, Sierra Leone, what were the glitches?
MR WALTERS: We were able to – not so much glitches as anticipated friction points. So we moved a large number of Americans into Dakar – Senegal, put them up in a hotel overnight for crew rest and then had to bring all through in one giant horde through security and facilitate that. We anticipated that would be a friction point, and so we had ground – we had handling folks there to facilitate movement through the airport.
At the same time, one of the G-IIIs had an electrical issue. Well, that drew one of the handlers away from the crowd and caused a delay getting through the airport. We had anticipated that, so we made the flight schedule a little bit flexible in order to stay roughly on schedule. So it’s those small details that you get in these exercises; these are not big showstoppers, there were no big showstoppers. We worked through it and that was it. But as far as patient care, safety of operations, there were no lessons learned; there were lessons reinforced.
MR LAMANA: Yeah, I think that the one aspect I would say is when we started this operation we had the capability to move one patient at a time. And that was a lot easier to have to manage one aircraft, one patient. Getting one patient from the wherever – from out in the bush, to the aircraft, that always seemed to be a little bit of a challenge, but once they got to the airport and got to the aircraft, that was fine.
Now, we’re dealing with, in this last exercise, to move 11 patients at one time. That adds to the logistics of what you’re trying to accomplish, and it is no small feat to be able to do that. This is the – what we had before was good in the sense that we had a capability. Now, we’ve got a broader capability, a much better capability than what we had before.
MR WALTERS: I think one of the other points that we – that was reinforced in this exercise is that no single federal agency is capable of doing this type of operation safely. What Tranquil Shift did is what the Trump administration has been pushing all along. What you saw was six different federal agencies, the leads being HHS and State, working hand-in-hand very tightly, minute by minute, hour by hour, over the course of four days to make sure that all of the logistics fell in place.
MODERATOR: Thanks. Next question?
OPERATOR: Thank you. And once again, ladies and gentlemen, if you have a question, please, press * then 1 on your phone. Our next question comes from the line of Ike Swetlitz with Stat. Please, go ahead.
QUESTION: Hi, thank you. So I had two questions, actually. One was – I just wanted to confirm, these simulated patients, were these real people that you were transporting? And then, what exactly is a Containerized BioContainment System, and what was the $5 million spent on from the Paul Allen Foundation that you mentioned?
MR LAMANA: Thanks, Ike. So two questions; your first was: Were they real people? And the answer was yes. In the last exercise, Tranquil Surge, we used two volunteers and one mannequin to exercise different non-ambulatory capabilities. In this one, they were all volunteers, they were all real people, and they were all ambulatory, as all of the Ebola patients were at the time – and frankly, looking forward, almost regardless of the pathogen involved, most likely will be in the future.
With regard to what is the Containerized BioContainment System – so the airborne – Aeromedical BioContainment System that we used during the Ebola outbreak is a soft plastic tent that is set up inside a steel frame. And it’s good for what it’s good for. It’s good for single patient movement and a specifically engineered aircraft. What the Paul Allen Foundation allowed us to do is open the aperture wider. What other pathogens did we have to worry about and how did – how do we move four people at a time, and how do we not tie it to a specific aircraft? The CBCS is a 40-foot long container built to ISO standard, so think the back of a tractor trailer.
Inside that – and there will be some photos that go out from the press office – inside that 40-foot container are three chambers. There is a large chamber where all four patients are cared for in an ICU-like environment, there is a middle chamber where the staff members don and doff their protective equipment, and then there is a smaller chamber where once out of their protective equipment, they can rest and sort of set up a crew rotation.
The CBCS can be loaded onto a number of different aircraft; it’s not tied to a specific aircraft. It was designed that way. It can be used on a 747-400, an Ilyushin-76, an Antonov, a C-17, or a C-5. When it was built, it was – it went through the C-17 “safe to fly” program through DOD, working – so we worked closely with DOD in its design and testing. But it is specifically designed for State Department requirements to load aboard non-military aircraft so that we can get into places where the U.S. military may not be welcome for the next outbreak.
QUESTION: Okay, and it is ready for deployment right now?
MR LAMANA: It was ready for deployment about six months ago, and it’s been deployed now. We’ve flown it three times.
QUESTION: Three times outside of the simulations?
MR LAMANA: No, it has never – it has not flown an infected patient.
QUESTION: Okay, okay.
MR LAMANA: We had the ribbon-cutting on this in May of 2015, so it is ready for use now and it has been since then.
QUESTION: Okay. Thank you.
MODERATOR: Thanks very much. And going to our last question now.
OPERATOR: Our last question comes from Laurie Mylroie with Kurdistan24. Please, go ahead.
QUESTION: Hi. Thank you for doing this. My question is probably more for Dr. Lamana. You’ve talked about – well, let me say I was at – I heard Secretary Kelly speak earlier this morning, and he was asked what the thing that most frightens him is and he said it’s, like, biological agents being taken across the southern border for terrorism. And I wonder if you would agree with that assessment that biological terrorists, the agents being brought into the country, are a very serious threat, and do you think we are prepared for it?
MR LAMANA: Well, thanks for the question. Unfortunately, I haven’t seen those remarks, so it would be probably inappropriate for me to be able to comment. But I know we built the system the way we did to be able to manage, as Dr. Walter said, pretty much what the next crisis is, not just Ebola but any Category A pathogen that we may be faced with in the future.
QUESTION: So you think, like, if there were a biological terrorist attack in Washington, D.C., the plan that the city has laid out – everyone should follow the evacuation routes – would work and those would – streets would not become parking lots?
MR LAMANA: Again, unfortunately, I can’t speculate on that either, because I haven’t seen the local plan. Every one of the – and I know that this is a challenge, and I know every local community, every state, every region is working on what their response plans are. I know that some are very thorough, very well written, and others are still in the process of trying to refine them. That was one of the benefits of this exercise, was it gave the state and local authorities an opportunity to be able to test their plan and to see whether or not what they have written will fit with the scenario that we laid out. And hopefully in future exercises, we’ll be able to continue to refine those plans. So unfortunately, I have not seen the plans that you’re referencing.
MR WALTERS: All I would say is that whether there is an outbreak in Paducah or in Pretoria, at the end of the day, there will be a requirement for safe and effective and efficient movement of patients to the appropriate care. We can’t have a biocontainment unit in every hospital across the United States, so regionalizing it and then having safe transport mechanisms is going to be critical now and in the future.
OPERATOR: Thank you, ladies and gentlemen. We have no further questions from the phone lines.
MODERATOR: Okay. Thank you very much, Operator, and thanks to all those who joined us on the call. As a reminder, this was on the record. And the embargo, now that the call has concluded, has been lifted. Thanks very much.