World Health Organization March 18 Briefing Transcript

Tariq: (00:13) You need to use mic when you speak. Good afternoon everyone. Apologies for the delay. First, welcome everyone for this regular press conference on COVID-19. We are today in executive boardroom of the World Health Organization, and this is basically to give us a little bit more space so we can all follow the good practice of physical distancing. Tariq: (00:44) We have our regular guests bu now, Dr. Tedros director general, Dr. Maria Van Kerkhove, who is our technical lead for COVID-19 response, and Dr. Mike Ryan, director of emergencies. I understand that Dr. Tedros may leave at some point, but hopefully we will have questions for other guests. Before I give the floor to Dr. Tedros, just to remark that we had some technical issues with sending media advisories. We had some meetings just few hours ago, and hopefully this will be sorted and everyone who is on our lists will be getting the notes from WHO including media advisories, press releases and all the other notifications. We will have an audio file as we always do and hopefully a transcript will be available tomorrow. Dr. Tedros please. Dr. Tedros: (01:37) Thank you. Thank you Tariq. And good morning and good afternoon everybody. It's now more than a month since the last case of Ebola in DRC. If it stays that way, the outbreak will be declared over in less than a month's time. We would like to thank all our partners for their solidarity in staying the course in the service of the people of DRC, and my special appreciation especially to the government and people of the Democratic Republic of Congo. That same spirit of solidarity must be at the center of our efforts to defeat COVID-19. More than 200,000 cases of COVID-19 have been reported to WHO. And more than 8,000 people have lost their lives. And more than 80% of all cases are from two regions, the Western Pacific and Europe. We know that many countries now face escalating epidemics and are feeling overwhelmed. We hear you. We know the tremendous difficulties you face and the enormous burden you are under. Dr. Tedros: (02:59) We understand the heart-wrenching choices you are having to make. We understand that different countries and communities are in different situations with different levels of transmission. Every day WHO is talking to ministers of health, heads of states, health workers, hospital managers, industry leaders, CEOs and more to help them prepare and prioritize according to their specific situation. Don't assume your community won't be affected. Prepare as if it will be. Don't assume you won't be infected. Prepare as if you will be. But there is hope. There are many things that all countries can do. Physical distancing measures like canceling sporting events, concerts and other large gatherings can help to slow transmission of the virus. They can reduce the burden on the health system, and they can help to make epidemics manageable, allowing targeted and focused measures. But to suppress and control the epidemics, countries must isolate, test, treat, and trace. If they don't, transmission chains can continue at a low level than research. Once physical distancing measures are lifted, WHO continues to recommend that isolating, testing and treating every suspected case and tracing every contact must be the backbone of the response in every country. This is the best hope of preventing widespread community transmission. Most countries with sporadic cases or clusters of cases are still in the position to do this. Many countries are listening to our call and finding solutions to increase their ability to implement the full package of measures that have turned the tide in several countries. But we know that some countries are experiencing intense epidemics with extensive community transmission. We understand the effort required to suppress transmission in this situation, but it can be done. A month ago, the Republic of Korea was faced with accelerating community transmission, but it didn't surrender. It educated, empowered and engaged communities. Dr. Tedros: (05:56) It developed on innovative testing strategy and expanded lab capacity. It rationed their use of masks. It did exhaustive contact tracing and testing in selected areas. And it isolated suspected cases in designated facilities rather than hospitals or at home. As a result, cases have been declining for weeks. At the peak, there were more than 800 cases, and yesterday the report was only 90 cases. WHO is working in solidarity with other countries with community transmission to apply the lessons learned in Korea and elsewhere and adapt them to the local context. Likewise, WHO continues to recommend that wherever possible, confirmed mild cases should be isolated in health facilities where trained professionals can provide good medical care and prevent clinical progression and onward transmission. If that's not possible, countries can use community facilities to isolate and care for mild cases and refer them for specialized care quickly if needed. Dr. Tedros: (07:22) If health facilities are at risk of being overwhelmed, people with mild disease can be cared for at home. Although this is not the ideal situation, WHO has advice on our website for how home care can be provided as safely as possible. WHO continues to call on all countries to implement a comprehensive approach with the aim of slowing down transmission and flattening the curve. This approach is saving lives and buying time for the development of vaccines and treatments. As you know, the first vaccine trial has begun just 60 days after the genetic sequence of the virus was shared by China. This is an incredible achievement. Dr. Tedros: (08:25) We commend the researchers around the world who have come together to systematically evaluate experimental therapeutics. Multiple small trials with different methodologies may not give us the clear, strong evidence we need about which treatments help to save lives. WHO and its partners are therefore organizing a study in many countries in which some of these untested treatments are compared with each other. This large international study is designed to generate the robust data we need to show which treatments are the most effective. We have called this study the solidarity trial. The solidarity trial provides simplified procedures to enable even hospitals that have been overloaded to participate. Many countries have already confirmed that they will join the solidarity trial. Dr. Tedros: (09:41) And these countries are Argentina, Bahrain, Canada, France, Iran, Norway, South Africa, Spain, Switzerland, and Thailand, and I trust many more will join. I continue to be inspired by the many demonstrations of solidarity from all over the world. The COVID-19 solidarity response fund has now raised more than 43 million US dollars from more than 173,000 individuals and organizations few days since we launched it. I would especially like to thank FIFA for its contribution of 10 million US dollars. This and other efforts give me hope that together we can and will prevail. This virus is presenting us with an unprecedented threat, but it's also an unprecedented opportunity to come together as one against a common enemy, an enemy against humanity. I thank you. Tariq: (11:04) Thank you very much Dr. Tedros for these remarks. We will start with the questions. I will just remind once again if it's possible to have only one question per person so we can get as many questions as possible. So if we are ready, we can start with Babel from Poland, from the [crosstalk 00:11:27]. Babel, can you hear us? Babel: (11:30) Yeah. Can you hear me? Hello? Hello? Tariq: (11:35) Yes, we hear you. Go ahead please. Babel: (11:38) Okay. Hello. Up to today, Poland around 9,000 tests on a population of 38 million, which many consider as far too few. Do you have any recommendation on how much testing is advisable for a country in containment phase like Poland? And when can we expect cheaper version of diagnostic tests to be available in Europe? Thank you. Tariq: (12:03) If I understood well, the question is about how much testing should be done in a country of a size of Poland. Babel: (12:12) Yes, yes. Tariq: (12:13) And when the tests would be available in Poland? Babel: (12:18) No. When a cheaper version of diagnostic tests will be available in Europe. Tariq: (12:26) When cheaper tests will be available in Europe. Dr. Mike Ryan: (12:33) First of all, the volume of testing is clearly determined by the number of suspect cases that you have. So I think the focus here is not how much testing needs to be done to reach a certain number. The real challenge us are you testing every single suspect case? Every suspect case should be tested, their contacts identified. If those contacts are sick or showing symptoms, they should be tested. That requires a scale up because many countries have not been systematically testing all suspect cases, and it's one of the reasons why we're behind in this epidemic. So we need that to happen. Secondly, there are many manufacturers producing tests. WHO has contracted with a manufacturer of production of tests mainly aimed at supporting developing countries. I am sure that Poland and through the European Union and others has access to many companies who are producing tests either in the academic or in the private sector. But if there is a need, any country may contact WHO and we will either point them to a manufacturer or if needed, provide them with emergency testing capacities. Tariq: (13:46) Thank you very much. Hope this answers a question from Babel. If we can go now to Simon Ateva from Today News Africa. Simon, can you hear us? Simon Ateva: (13:58) I can hear you. Can you hear me? Tariq: (14:03) We will try to level up the sound a little bit. Please go ahead, Simon. Simon Ateva: (14:13) Okay. Thank you for taking my question. My name is Simon Ateva from Today News Africa in Washington D.C. I know that coronavirus is spreading in Africa in largely over 30 countries, and almost 600 people have been affected. But there's a problem. You still have big gatherings, you still have big religious gatherings, you still have big weddings. For instance, a popular pastor in Nigeria, the prophet TB Joshua, has told his followers that the virus would be defeated on the 27th of March, and he's not the only one. So my question is, do you think this is the time to stop big religious gatherings, big weddings and all the things that bring us together in Africa... Simon Ateva: (15:03) Then and all the things that bring us together in Africa and [inaudible 00:15:05] for the first time. Tariq: (15:06) Okay. Thank you very much Simon. The line was not the best, but I will just repeat the question for everyone. The question is about big religious gatherings in Africa and is this a risky thing for spreading the virus on the continent? Dr. Mike Ryan: (15:23) First of all, congratulations to many of our member States in Africa who've reacted very quickly to put in place the necessary surveillance, the laboratory testing and another major, Africa is a resilient continent with a resilient population who've dealt with and deal with epidemics every day of every year unfortunately. Dr. Mike Ryan: (15:47) At the moment the incidence of a COVID-19 in Africa is low. It may be higher due to lack of detection, but within reason, Africa still has a major opportunity to avoid some of the worst impacts of the epidemic and to prepare. Prepare its public health system and its health system. With this in mind, African countries are looking at all of the different options and I'm sure they're looking at the experience in Asia, the experience in Europe and looking at what options work best for them. Certainly at this moment in time, all countries that have disease inside their borders need to examine the appropriate measures to limit contact between individuals, particularly large mass gatherings that have the potential to amplify disease. Dr. Mike Ryan: (16:35) We fully understand that depending on where countries are in the disease development or in the evolution of the epidemic, those decisions are based on different risk management factors. But in principle, WHO's view at this moment, is all countries with community transmission or clusters of cases inside the country, in order to avoid the disease amplification should be seriously considering delaying or reducing mass gatherings that bring people together in an intense way and have the potential to amplify and spread disease. Particularly in large religious type gatherings that bring people from very far away into a very close contact. Dr. Tedros: (17:19) I'd like to add to what Mike said. As of today, the number of cases reported from sub Saharan Africa is 273 cases and four deaths. It's actually in terms of confirmed cases, it's the lowest region. But as Mike said, we cannot take this number as the number of cases we have in Africa, probably we have undetected cases or unreported cases. In addition to that, even if we take this 233 cases are true, we have to prepare for the worst. In other countries we have seen how the virus actually accelerates after a certain tipping point. So the best advice for Africa is to prepare for the worst and prepare today. It's actually better if these numbers are really true to cut it from the bud. Dr. Tedros: (18:29) That's why we're saying we have to do the testing, we have to do the contact tracing, we have to do the isolation and cut it from the bud. With regard to mass gathering and so on, it will help if we avoid that. WHO recommendation is actually, mass gatherings should it be avoided and we should do all we can to cut if from the bud expecting that the worst could happen because we have seen how the virus really speeds up and accelerates in either continents or countries. Dr. Tedros: (19:09) So that's our advise and I think Africa should wake up. My continent should wake up. Thank you. Tariq: (19:16) Thank you very much, Dr. Tetris and Dr. Ryan. Tariq: (19:21) Let's try to get to Musef from [inaudible 00:19:25]. Musef: (19:23) [foreign language 00:19:41]. Out of [foreign language 00:19:37]. The fact that the Central American at the [foreign language 00:19:44]. Tariq: (19:23) [foreign language 00:20:06]. Tariq: (19:23) Our friend Musef from Maya Dean is asking about sanctions to Iran and how sanctions on Iran have impacted the capacity of the country to respond to this outbreak. Dr. Mike Ryan: (20:23) We've been working very closely with the authorities in Iran and with many, many countries around the world now who have worked with us to ensure that Iran gets the assistance and help that it needs. We've again said right the way through this epidemic that we want to avoid politicization of these events and we thank those members States. There are a wide range of member States from different political and different persuasions and ideologies who have agreed to act in solidarity together to support Iran's situation. Dr. Mike Ryan: (20:59) We are focused as we have been on providing lab supplies and reagents in supplying PPE and in ensuring that Iran has access to the markets it needs to do that. We've been working at a very detailed level, not only through the sanctions, but through the banking system and others to free up the necessary resources and to free up and provide the necessary assurances to companies and others that they can with comfort and without fear of any consequence, supply Iran with the essential medical equipment and supplies for the purposes of the control of COVID-19. Dr. Mike Ryan: (21:34) The DG may wish to speak on some of his political engagements that have successfully ensured that the circumstance has come to pass. Dr. Mike Ryan: (21:43) We are in solidarity with our brothers and sisters in Iran and all over the world and will ensure that every citizen in every country has the opportunity to access global goods at this point in time. Tariq: (21:57) Goodness. Dr. Tedros: (21:58) Yep. Thank you very much. Dr. Tedros: (22:03) The only thing I would like to add to that is we're already in contact with senior officials from Iran. I had spoken to the minister of health yesterday and also had a chance to speak to secretary Pompeo yesterday and we have underlined the need for solidarity. I remind all of us or the statement that the United States and especially secretary Pompeo issued some weeks ago and we have discussed on how best that can be implemented. Dr. Tedros: (22:40) As Mike said, some of the process, especially with banking and so on, but in emergency situations, the sanctions can be addressed and this is already agreed from the U.S. side and that's why we had the statement. We hope that we will have the needed solidarity to fight this enemy together. Dr. Tedros: (23:13) At the same time, I would like to use this opportunity to tank the crown Prince. He sent the second round of support to Iran the day before yesterday, aircraft charters, shipping materials needed, and that's what we're calling for, the whole world for the time. I think we're in the most important solution and fighting an enemy like this dangerous virus is solidarity and we hope this spirit will continue. Tariq: (23:55) Thank you very much. And really sorry Musef, we'll try to take your second question next time. Just to say that we all miss our Geneva press Corps. Tariq: (24:03) So speaking about, let's go to Jamie. We miss Jamie as well. Jamie, please go ahead and ask your question. One question. Jamie: (24:13) Can you hear me Derek? Tariq: (24:14) Yes, please go ahead. Jamie: (24:16) Okay, great. Hi, this is Jamie from The Associated Press. We're wondering why might the death rates across Europe be so variable? Jamie: (24:26) Italy's death rate is at about 11% and they were soon overtake [inaudible 00:24:30] province in terms of numbers of deaths. While other countries like Germany, France, Spain, and the UK have reported far lower death rates, closer to one to 2 percent. What might explain that discrepancy? Thanks. Dr. Mike Ryan: (24:47) Hi Jamie. Yeah, I almost miss you as well. It's a good question. There are a number of factors that might explain that, but certainly one of them is testing. If you look at Germany and we had some very good communication with Germany today. They've had a very aggressive testing process. They've, they've tested and confirmed over 6000 cases with just 13 deaths, but that may reflect the fact that they're really aggressive in their testing strategy. So the number of tests and the number of confirmed cases may be detecting more mild cases as a proportion of all cases. That's an important determination. Dr. Mike Ryan: (25:29) The second issue is the evolution or the time of evolution and the outbreak. What we do see as a pattern of long hospital admission. So Italy, having experienced the first wave of major transmission much earlier than other European countries is now experiencing those debts because a lot of people reach a point where they can no longer be saved in the clinical system. Dr. Mike Ryan: (25:53) So therefore the deaths occur sometimes two to three to four weeks after the infection starts. So again, you have to look at where each country is in the epidemic cycle. Dr. Mike Ryan: (26:05) The other factor may be to do with the age profile of populations. For example, Italy has a much older age profile and there's a higher proportion of people in the very elderly category. In some ways easily has been a poster child for healthy people living into old age. We've always asked ourselves the question, why Italians and people living on the Mediterranean are healthier and live longer lives. Unfortunately in this case, having that older population may mean that the fatality rate appears higher because of the actual age distribution of the population underneath. Dr. Mike Ryan: (26:47) There may be technical reasons as well in terms of the ability to provide standard of care. We this in China, we saw this and who Bay when you looked at the case fatalities inside who Bay and outside who Bay, there were significant differences in case fatality. Dr. Mike Ryan: (27:04) Anyone who's ever worked in the front line of an emergency, when patient numbers begin to overwhelm, it becomes a simple factor of your ability to provide adequate care and react to every change in the patient's condition in an intensive care environment. So I think there are circumstances in which the standard of care cannot be maintained when patients are being overwhelmed. I appoint you to the tremendously courageous and brave physicians and nurses and intensivists in Italy who haven't been dealing with one or two patients in intensive care, but for example, in Northern Italy, over 1200 patients in intensive care at the same time. It's an astonishing number. The fact that they're saving so many is a miracle in itself. Dr. Mike Ryan: (27:48) I think there are many factors, Jamie and they all play into the actual numbers and Maria may offer more technical advice on that. Maria: (28:00) The only thing to add is exactly where the virus is circulating in each country. You have to look at the demographics of where it is circulating. Maria: (28:09) In Korea, we had these clusters, these very large clusters related to a church, and that the age distribution of those cases were much younger than what we're seeing in Northern Italy, for example. Maria: (28:21) You may see outbreaks in longterm care facilities where the age is much higher and so it's important where those clusters are occurring and where you're capturing your cases from. But we do need to be very careful when we look at mortality rates and we compare mortality rates. It's not right to compare them yet. What we need to do is find out why we're seeing differences and what that actually means in terms of our understanding of this virus and how it impacts different populations. Maria: (28:47) We've said previously that we need to be very careful when we compare a calculation of the number of deaths over the number of cases that are reported per country. Mike has outlined the reasons why that is difficult. We have not seen the way this virus will behave in other vulnerable populations. We have not seen how this virus will behave if and when we see in vulnerable populations have high prevalence of HIV for example, or malnutrition children for example. That's what we need to prepare for. Maria: (29:18) Every death is significant regardless of where this takes place. We need to ensure that all of the measures that we take are preventing transmission because every step that we take there will prevent death. Dr. Mike Ryan: (29:32) Supplement here on the issue of severity. If you look at the case series that are produced and published from Korea, almost 20% of their deaths have occurred in people under 60, so the idea that this is purely a disease that causes death in older people. We need to be very, very careful with, and physicians again in Italy will attest to this and in Korea. This isn't just a disease of the elderly. There is no question that younger, healthier people experienced... Dr. Mike Ryan: (30:03) Question that younger, healthier people experience a much overall less severe disease, but a significant number of otherwise healthy adults can develop a more severe form of the disease, and that's why we need to be ever vigilant and ensuring that we observe everyone, even the mild cases, for any signs of clinical progression to a more serious disease. Tariq: (30:25) Thank you very much. We go for next question. That would be Diego from Brazil. Diego, can you hear us? Diego: (30:36) Yes, I can. Can you hear me? Tariq: (30:37) Yes, please. Go ahead. Diego: (30:40) Yes, there's a lot of speculation about cases regarding children, so if you could please clarify what is the data right now about the symptoms on children and how fast the virus can spread on children? Tariq: (31:01) Thank you, Diego. Maria: (31:03) I can start with that. We know that children are susceptible to infection. We know that children are infected with this virus, but in terms of the reporting of cases across a large number of countries now where we have data, the number of reported cases in children is lower than adults. We know that children can develop disease, and the disease that they develop, in terms of the signs and the symptoms, are similar to what we're seeing in adults, which include fever, which include dry cough, which include fatigue and muscle pain. Overall, the majority of children that are infected will experience mild disease, but that is not universal. Maria: (31:48) There's a recent study that came out in China that showed that a number of children have developed severe disease and critical disease, and, in China, one child has died. What we need to prepare for is the possibility that children can also experience severe disease, but the evidence so far is that children have mild disease and only one death reported in China so far. Tariq: (32:14) Thank you very much, Dr. Van Kerkhove. We will take one question from a journalist who are, for some reason, unable to get on the line. Here's Camilla Hodgson from Financial Times asking, is there a shortage of tests and or test processing centers in Europe? Is that a reason that more testing isn't being done in countries like the United Kingdom? Dr. Mike Ryan: (32:46) I think countries in Europe have been scaling up their capacity to do testing over the last number of weeks. There are different options for countries. One is lab testing kits, which do a small number of tests per kit. The other are automated machines that allow you to test a number of samples at one time, and then there are high throughput machines that are low up to 5,000 samples to be processed per day, and many European countries are moving through to put in place those more high throughput mechanisms to be able to test more and more cases. Yes, I think there's a scale up going on in testing, but I don't believe that the ability to test has been the reason for the not testing. I don't think that's been the limitation. Dr. Mike Ryan: (33:40) I think it comes down to what the strategy of an individual country is. If you're going to make an attempt to detect every suspect case and test every suspect case, then I believe countries in Europe do have the capacity to do that. The tough part is then when you get those cases, being able to identify contacts and follow those contacts and quarantine contacts, then you need to leverage a much larger public health response that comes in behind that lab testing and allows you then to suppress the virus through those individual isolation mechanisms. Dr. Mike Ryan: (34:13) Isolating individuals or quarantining contacts is about removing people who are potentially infectious from the community. Well, in balance with that and in line with that, the social distancing or physical distancing measures, in a sense, ask everybody to separate themselves from everybody else on the basis that we're not quite sure where the virus is. A combination of those two allows you to really suppress the virus. If you really focus on individual measures to try and take people who are known to have the virus or could have the virus out of the general population for a period of time and, at the same time, you create some physical separation at the population level, those two combined can be very effective at suppressing a transmission of the virus. In order for that strategy to work, you must have the capacity to do more extensive lab testing as you really try to search for and identify all of those suspect cases, and countries are coming up with different strategies to meet the testing demands, and maybe Maria can explain a little more on what those strategies are. Maria: (35:20) There's three major areas in which countries are working on to increase their testing capacity. The first is the kits themselves that Mike has described. The sheer number of available tests and companies that are developing tests and countries that have developed tests is incredible considering we're 12 weeks into this outbreak, this pandemic. The second area is increasing the number of labs that can actually run these tests. In every country, there are national labs that can do PCR, where they're building on a national influenza system that has been in existence for decades, but increasing the number of labs that can actually run those tests is an important part of the strategy. Whether you're using public health labs or using private labs or academic labs, whatever it may be, the number of labs that can do those tests needs to be increased. The third area is the number of people, the workforce, who are actually going to run these tests. This three pronged approach of being able to have more labs that can run these assays, more people who can run this, and have more tests available are really critical. Maria: (36:27) We've also seen, and the DG gave a good example in Korea, where countries, not only in Korea, but countries are finding innovative ways to test people, so finding individuals, how can we run these tests? We saw this drive through system, for example, but countries need to be creative in the way, use the fundamentals of public health in terms of tackling this virus, but think of innovative ways and creative ways in which you can find people that fit your transmission scenario. Tariq: (36:58) Thank you very much. Let's go to next question. Helen [Branswell 00:07:01]. Helen? Helen Branswell: (37:04) Hi. Thanks for taking my question. I was hoping you could give us some more information about the solidarity trial. Could you please tell us what drugs have been prioritized? Dr. Mike Ryan: (37:22) Hi, Helen. Ana Maria Henao [inaudible 00:37:25] will join us to give you the specifics on the trial, but it's a multi-arm trial, and countries are able to choose between any one, I think, or more of five therapeutics that are currently being evaluated, but it may be more. Ana Maria will speak to this and give you the detail. Ana Maria Henao: (37:42) Good afternoon, Helen. It is an adaptive design. Initially, we have five arms. The first arm is the standard of care, the usual care that is provided to the patients in the country. The second arm is render severe. The third arm is lopinavir/ritonavir. The fourth arm is lopinavir/ritonavir with interferon beta. The fifth arm includes chloroquine. Ana Maria Henao: (38:08) The good thing about the trial is, as Mike indicated, that the randomization could be adjusted to the drugs by level in each individual hospital over time. The other good thing about adaptive design is that we can include additional arms or drop arms as our Global Data Safety Monitoring Committee advises we should do. Finally, Dr. [Davros 00:38:31] mentioned that this is a very simple trial, and we think that it's very important that other research goes on that will contribute to our understanding of this disease, but this trial focused on the key priority questions for public health. Does any of these drugs reduce their mortality? Does any of these drugs reduce the time a patient is in hospital and whether or not the patients receiving any the drugs needed ventilation or intensive care unit? Tariq: (39:04) Thank you very much, Dr. Henao. If needed, we will provide the exact title of Dr. Henao, but now we will go to next question to South Africa. We have Steven from Hot 91.9. Steven, can you hear us? Steven: (39:25) Yes, I can. Thank you very much for taking my question. I was going to ask [inaudible 00:39:29]- Tariq: (39:30) Steven, Steven, we don't hear you very well. Can you speak a little bit- Steven: (39:34) I can. You're right. How's that? How's that? Tariq: (39:36) It's a little bit better. Steven: (39:40) Okay. I wanted to ask, we've seen some schizophrenic government activity. I have to say, looking at the way our government here in South Africa has responded, I have been fairly impressed as a journalist and the response that the government has given. It's a important factor for the government to be unified on this. Opposition politicians come out and say they support the government. We seem to be on the same page. I don't know what sort of interaction the WHO has had with South African. Maybe you are. You are the people at the top [inaudible 00:40:16] day-to-day interaction, but in terms of the communications of our South African response, I'd like to get an insight from you as [inaudible 00:10:24]. Dr. Mike Ryan: (40:30) Again, as the director general has said many times, an all of government approach is it absolutely underpins success in fighting any emergency, but, in this particular case, all the more. I think that has been the case in many countries, including South Africa. Dr. Mike Ryan: (40:51) Another point to make here is that African countries have been dealing with emergencies, climate disasters, natural disasters, epidemics for a very long time. South Africa has had to deal with a terrible HIV epidemic over many, many decades. The ability to create coherent responses to what are biologic threat-