We will hear from senior cdc officials and agencies former director. The center for Strategic International studies hosted this event. Welcome to this discussion. Im very pleased to introduce our guest in a moment. Were going to be discussing the evolution of our integrated strategies. Im wearing a different hat in the context of this meeting as the cochair of the bipartisan alliance on Global Health security. I welcome you and i will make sure there is time for questions at the end of our discussion, so be prepared for that as well if youd like to participate in the conversation. We also welcome our online guests to this discussion. So why are we here . We are operating under the basic premise that cdc has a Critical Role to play in interNational Security. We try to be productive in helping the cvc build its capacity in this regard and really look at what is necessary for the cvc two in a sense recover from some of the issues that emerged during the global pandemic. We had a wonderful working group under the auspices of the alliance from Johns Hopkins university that really examines what was going on at cvc, what were the opportunities for improvement, what were the strengths, where investments needed, both actions by cdc but actions on behalf of cvc to really respond to what i think was the soundbite from the working groups report that cdc is in peril, and yet it is so important to our National Security that it was an urgent priority to step forward and try to understand what can be done. A report was published on building the cdc the country needs. There were many stakeholders and experts who participated in this working group report. One of the things you will hear today if you saw that report is that our leaders from the cvc have already taken steps to respond to some of the recommendations in the report, particularly two recommendations that specifically address Global Health issues. First and foremost, what really was the best way to integrate cdcs Global Health work with its domestic bio security agenda. And second, what were the investments, the budget, the workforce, the practical policy authorities, etc. , that cdc really needed to acquire in order to successfully fulfill its Global Mission . In the time since that report, there has been significant progress. I just want to take a moment to highlight some of those areas of progress. In particular, the cdc director has been very visible globally as have some of the cdc leaders who are here today. Regional offices have been open around the world to try to coordinate cvcs agenda, particularly its Global Security agenda, and specific investments have been made. What was probably most exciting for us was the recognition that the whole is greater than the sum of its parts. We can move them in a direction where we have a more powerful, a more successful global agenda. Let me introduce our panelists. I like to start by introducing the director of the Global Health center at cdc. Sitting to her left is the director of the National Centers for emerging infectious diseases. How do you pronounce that . [laughter] she is checking. To the left is the director of the National Center for immunization and respiratory diseases, and a leader in the hiv arena, and someone i have long held in highest esteem. Finally at the other end of the panel is the director of the office of readiness and response , someone who is in the hot seat during covid but continues to provide a really unique frame of leadership for the cvc. I like to maybe give our panelists a chance to say a few words, really focusing not so much on what is ahead in the context of the strategy, but what has already been accomplished, but actions have you taken maybe since january of 2023 when the report came out, but in the recent months that really are moving us in a new direction. Kayla, i will start with you because you probably have the view of the overall strategy. Thank you so much, and thanks to everyone for being here and everyone online. Today we wanted to talk a little bit about sort of a unifying framework for cdcs Global Health work. Really fits into the cvc directors 2024 priorities of readiness and response, to look at Data Infrastructure and modernization, quality and safety and overall prioritization. So the global framework with those larger priorities. We have learned a lot from covid, both domestically and globally. We wanted to put it all together in our global work. We know that in order to protect the u. S. , to protect the work and our lives here, we need to be working globally to do that. Our global work leverages many of the platforms that we work in overseas, much of the work we do with the president s Malaria Initiative or the work with influenza, all of that global work we leverage both for the vertical programs, but also horizontally, to have system strengths for our global work. When we work overseas, we have over 60 Country Offices and six regional offices. We really work shoulder to shoulder with ministries and governments and with the community in the countries where we are, and we really have a trusted partnership and for that reason we are the first call when something happens. Weve seen that repeatedly, and especially since covid. But that has been going on for decades. So it is really important that we frame our work. What we have done is put together a global strategic framework, its elements are not new and the capacity and mission and vision globally or not new. But there is a new way of framing and ensuring that across the entire agency, across all of our different programs and in our country and regional offices, we are all working together, pushing in the same way to be the most effective, the most efficient and you have the most impact. The framework really has four major goals to why we are working overseas. The first goal is to stop health risks at their source. That is cdcs really fundamental goal, stopping outbreaks at their source so they dont live anywhere, or to the u. S. The second is to prevent or contain disruptive outbreaks. Its very disruptive to societies, two economies, to the health of nations, and its very important to work on that. The third goal is really around Global Knowledge and how we can use it both globally and domestically. That Something Like our influenza strains that we know from around the world that go into our vaccines, and that Global Knowledge of disease elsewhere and how we use it domestically. The fourth and final goal is really the platforms that we build that really prevent mortality. Thats the pep far, the malaria, the flu, to reduce morbidity and reduce mortality, but also serve as a platform where we build system strength so that we can then respond to outbreaks, that we give clinics and training and that helps with all our work overseas. There are six pillars that get us to those goals. Data and surveillance, laboratories, prevention and response, innovation and research. Workforce and institutions, and communication, policy, and diplomacy. Through all those pillars of work, we reach those goes. We want to share with you the ways the recent outbreaks are showing how we are using that framework, working within that frame globally, and how it connects to our Domestic Work and vice versa. When i am struck by in this conversation is that none of this has a disease name. You are talking about the crosscutting capacities and capabilities that distinguish the cdcs expertise that you can apply to whatever the threat is, domestic or global. We certainly have plenty of those in play right now. I thought maybe i would ask dan to Start Talking about mpox and how that is playing out and how this approach is illustrated in the context of this arguably primarily global outbreak, but certainly with u. S. Implications as well. Sure. Mpox is one of the pathogens that requires the all of Agency Activity forced to be able to respond to it. We did have cases previously, 30,000 in the United States. But we have right now is something happening in the democratic republic of congo which has a higher severity and higher transmissibility. We are seeing about 4000 cases from the first part of this year. It really demonstrates the threats we have with emerging infections. The world is more connected than ever. You can get from the democratic republic of congo just anywhere in the world within the incubation period. The world is more crowded than ever before, and the worlds of animals and humans are converging like never before. Right now, mpox is showing that come rodents getting it to kids, kids getting it within the family. You can have sexual transmission and then get outside the drc. We want to have that capability inside the United States to have diagnostic tests, to have the right surveillance in place. This framework really helps us see what data we need both in the United States and for the things in the drc. Both the coordination between the country teams, the experts that are being deployed, the laboratories we have in the United States. We need to think of this across the spectrum, domestic all the way to global so that we are not thinking in one place or another, but thinking across the spectrum, and how do we use the breath of all the capabilities we have across these Different Centers and across the usg in order for us to have the most optimal response had keep mpox from coming in and causing another set of cases in the u. S. Potential even worse. And in thinking about how you actually implement that response , one of our greatest strengths globally is deplatform. Dimitri, can you say a little bit about how that vertical gets leveraged in the context of this new strategy . Sure, and i will say it was remarkable seeing it in action for mpox in cambodia. I thought it was really important to see how that was leveraged globally. It was reflective on how the work happened domestically during the outbreak. Still thinking about cap far about pepfar, looking at the hiv platform globally and domestically to really up reach communities that need to be reach, but also address some of the gaps that are wellknown in hiv treatment and prevention and how that speaks to the populations that were having the worst outcomes for mpox. It is in the image of this framework where we are, in a disease agnostic way, stepping back and saying what did you leverage and how far can we push it. That is some of the great leadership michaela has shown. It demonstrates the importance of saying where can we leverage, where do we have infrastructure like influenza, which is now the center that i work over. How can we leverage that not only for our seasonal flu but also our more emergent or urgent passages we are seeing, and also in a more panrespiratory fashion . It really is a package in agnostic strategy. How can you leverage the platforms . How can you look at the laboratories . And really make those systems Work Together to achieve a Better Public Health outcome . I think we all realized in covid how important the pepfar assessments were as well as the Global Fund Investments in countries that did not have infrastructure for laboratory and surveillance and the capacity to understand pcr and convert it into tools for covid, etc. That is kind of an occult knowledge, because not most americans understand that was incredibly important in supporting the outbreak response in many countries, and it was the value from that investment i dont think we predicted back when george bush implemented pepfar. Sometimes that leveraging capability gets is far more than we bargained for. We will come back to the issue of funding and budget. What i want to bring henry into this conversation a little bit. We have another very worrisome situation emerging in the u. S. , the Avian Influenza. If you are a bird, it is a pandemic. Certainly, even this week, we learned that pigeons, which were thought not to be susceptible to h5n1, now, at least in michigan, they have been shown to have been infected. But i want to talk about dairy cattle, because i know that is what is on peoples mind. You are the head of the preparedness and Response Center at cdc. What is going on in your center, both domestically and internationally in this context of this outbreak . Domestically, we at the cdc are trying to coordinate together a us multiple Centers Across multiple centers. It was actually in dimitris center we restood up a Management System to coordinate all the activities. There has been one case in texas, a human case, so far. It is detected in multiple herds across the u. S. It requires collaboration with other sectors to ensure that milk is safe. This is an interagency collaboration. Not only this particular outbreak, but as it was in ebola, in zika, and mpox. It is not just the cdc coordinating within itself, but it is also the cdc coordinating across hhs and across interagency. Domestically, the usda has the lead on the animal side. We obviously have a leading role on the domestic side. We continue to try to investigate potential cases on farms, but it has been quite difficult to get access to some of those farms and understand the epidemiology and where the risk is. We are supporting the states, supporting this migrant population that is working. The farms are a difficult population to reach, so we are working with different organizations to gain that trust so we can actually do more epidemiological investigations. The fda is responsible for the quality of the milk. We are working quite closely with fda. You will see a lot of information coming out around pasteurization of milk. Yes, the milk is safe. Dont drink raw milk. So, i think within cdc, certainly we have multiple groups engaged, including dimitris center. We have our one health group that is in dans center, and we have forecasts as well to try to predict, if this does take off, what the future holds. Fortunately now are vaccines will work. Our Laboratory Testing can pick up this particular strain. And therapeutics as well also work. It is reassuring at the moment. We learned we need to learn more about where the risk is. And our surveillance with these cattle, is it milk surveillance, heard surveillance, among dairy farm workers . Wastewater. And of course wastewater. You will see more results coming out fairly soon, im looking at dimitri come around wastewater. Dr. Gerberding kayla, right now we are kind of managing this as a u. S. Centric situation though h5n1 is not just a u. S. Centric problem. Communication has to be relevant globally. I am sure there is a lot of anxiety as far as the Food Production industry in terms of trade and the Global Impact of the safety of our cattle industry, etc. How are you managing the Global Communication around this unfolding . This is the hardest part of the outbreak, when there is so much uncertainty, how bad is it, who is effected, how far it will go. You just do not know. How are you handling that . Kayla a couple of things we have done so far. Everything on the cdc websites we are pushing out to all of our global partners, but also we just did a webinar with our country and regional cdc teams to make sure everybody was fully informed, had a chance to ask questions. We just met with the state department and talked about ways we can push out another seminar and webinar to get everybody uptodate on what is happening and to make sure questions are answered, keeping awareness very high. If countries are interested in getting engaged and looking at surveillance, we want to support that. Right now it is mostly domestic, but we are insuring all of our partners are aware and ready and watching so that in case anything is needed, we are right there. For Avian Influenza in cambodia, our team is there. We are right on those cases. It just happened recently. A couple have been right as we were there. Our teams are well trained and ready to respond and did respond quite quickly. With the capacities they have from the work we have been doing there for years, and also in the whole region. That was the u. S. Global link between all of this. One of the strengths of the cdc is the international workforce. That would is not as optimized as i think it could or should be , and that was one of the findings of the commission report, that this incredible investment in talent and publichealth capacity in over 100 countries is still not managed as a global asset, it is managed as a therapeutic area or an assignment on a temporary basis. There is no real Career Development or planning. Will this strategy be able to interrupt that opportunity to really strengthen the workforce internationally . One of the starkest parts of ac dc workforce is the staff around the world. We have spent a lot of energy and investment to ensure great training amongst the staff, whether they are trained in epidemiology or laboratory response. Now we are having more and more opportunities for the staff to move from country to country, so the development of the locally employed staff is extremely important. On top of that, we have the field epidemiology Training Programs and we have Emergency Management training, Laboratory Management training. We are building the workforce overseas, bringing people to atlanta for training, for rotations throughout the cdc, throughout washington sometimes. We are really trying to build up that workforce and also have cross communicati