[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
EBOLA IN THE HOMELAND: THE IMPORTANCE OF EFFECTIVE INTERNATIONAL,
FEDERAL, STATE, AND LOCAL COORDINATION
=======================================================================
FIELD HEARING
before the
COMMITTEE ON HOMELAND SECURITY
HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
__________
OCTOBER 10, 2014
__________
Serial No. 113-88
__________
Printed for the use of the Committee on Homeland Security
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Available via the World Wide Web: http://www.gpo.gov/fdsys/
__________
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COMMITTEE ON HOMELAND SECURITY
Michael T. McCaul, Texas, Chairman
Lamar Smith, Texas Bennie G. Thompson, Mississippi
Peter T. King, New York Loretta Sanchez, California
Mike Rogers, Alabama Sheila Jackson Lee, Texas
Paul C. Broun, Georgia Yvette D. Clarke, New York
Candice S. Miller, Michigan, Vice Brian Higgins, New York
Chair Cedric L. Richmond, Louisiana
Patrick Meehan, Pennsylvania William R. Keating, Massachusetts
Jeff Duncan, South Carolina Ron Barber, Arizona
Tom Marino, Pennsylvania Donald M. Payne, Jr., New Jersey
Jason Chaffetz, Utah Beto O'Rourke, Texas
Steven M. Palazzo, Mississippi Filemon Vela, Texas
Lou Barletta, Pennsylvania Eric Swalwell, California
Richard Hudson, North Carolina Vacancy
Steve Daines, Montana Vacancy
Susan W. Brooks, Indiana
Scott Perry, Pennsylvania
Mark Sanford, South Carolina
Curtis Clawson, Florida
Brendan P. Shields, Staff Director
Joan O'Hara, Acting Chief Counsel
Michael S. Twinchek, Chief Clerk
I. Lanier Avant, Minority Staff Director
C O N T E N T S
----------
Page
STATEMENTS
The Honorable Michael T. McCaul, a Representative in Congress
From the State of Texas, and Chairman, Committee on Homeland
Security:
Oral Statement................................................. 1
Prepared Statement............................................. 4
The Honorable Bennie G. Thompson, a Representative in Congress
From the State of Mississippi, and Ranking Member, Committee on
Homeland Security:
Oral Statement................................................. 5
Prepared Statement............................................. 7
The Honorable Sheila Jackson Lee, a Representative in Congress
From the State of Texas:
Prepared Statement............................................. 8
WITNESSES
Panel I
Dr. Toby Merlin, Director, Division of Preparedness and Emerging
Infection, National Center for Emerging and Zoonotic Infectious
Diseases, Centers for Disease Control and Prevention, U.S.
Department of Health and Human Services:
Oral Statement................................................. 11
Prepared Statement............................................. 12
Dr. Kathryn Brinsfield, Acting Assistant Secretary and Chief
Medical Officer, Office of Health Affairs, U.S. Department of
Homeland Security:
Oral Statement................................................. 17
Joint Prepared Statement....................................... 19
Mr. John Wagner, Acting Assistant Commisioner, Office of Field
Operations, U.S. Customs and Border Protection, U.S. Department
of Homeland Security:
Oral Statement................................................. 21
Joint Prepared Statement....................................... 19
Panel II
Dr. David Lakey, Commissioner of Health, Texas Department of
State Health Services:
Oral Statement................................................. 54
Prepared Statement............................................. 57
Dr. Brett P. Giroir, Executive Vice President and CEO, Texas A&M
Health Science Center, and Director, Texas Task Force on
Infectious Disease Preparedness and Response:
Oral Statement................................................. 60
Prepared Statement............................................. 61
Hon. Clay Lewis Jenkins, Judge, Dallas County, Texas:
Oral Statement................................................. 65
Prepared Statement............................................. 66
Ms. Catherine L. Troisi, Ph.D., Associate Professor, Division of
Management, Policy, and Community Health Center for Infectious
Diseases, The University of Texas:
Oral Statement................................................. 67
Prepared Statement............................................. 69
FOR THE RECORD
The Honorable Michael T. McCaul, a Representative in Congress
From the State of Texas, and Chairman, Committee on Homeland
Security:
Letter From Chairman Michael T. McCaul and Senator John Cornyn. 48
The Honorable Bennie G. Thompson, a Representative in Congress
From the State of Mississippi, and Ranking Member, Committee on
Homeland Security:
Chart.......................................................... 7
The Honorable Sheila Jackson Lee, a Representative in Congress
From the State of Texas:
Press Release.................................................. 31
Chart.......................................................... 77
Letter from Rep. Jackson Lee to Director Frieden............... 87
The Honorable Kenny Marchant, a Representative in Congress From
the State of Texas:
Letters........................................................ 46
APPENDIX
Questions From Honorable Lamar Smith for Toby Merlin............. 93
Questions From Honorable Beto O'Rourke for Toby Merlin........... 93
Questions From Honorable Eric Swalwell for Toby Merlin........... 93
Questions From Honorable Lamar Smith for John P. Wagner.......... 94
EBOLA IN THE HOMELAND: THE IMPORTANCE OF EFFECTIVE INTERNATIONAL,
FEDERAL, STATE, AND LOCAL COORDINATION
----------
Friday, October 10, 2014
U.S. House of Representatives,
Committee on Homeland Security,
Dallas, TX.
The committee met, pursuant to call, at 12:10 p.m., in the
In-Transit Lounge, D-31, Dallas-Fort Worth International
Airport, 233 South International Drive, Dallas, Texas, Hon.
Michael McCaul [Chairman of the committee] presiding.
Present: Representatives McCaul, Chaffetz, Sanford,
Clawson, Thompson, Jackson Lee, Barber, O'Rourke, Vela, and
Swalwell.
Also present: Representatives Farenthold, Marchant, Barton,
Burgess, Veasey, and Johnson.
Chairman McCaul. The Committee on Homeland Security will
come to order. The committee is meeting today to examine the
coordinated Federal, State, and local response to the recent
Ebola case right here in Dallas, Texas. First, I want to thank
everybody, including the witnesses, for attending this hearing
today, and I appreciate the efforts taken on behalf of all
those involved to have this important field hearing.
This is an official Congressional hearing as opposed to a
town hall, and as such, we must abide by certain rules of the
committee and the House of Representatives. I would like to
kindly remind our guests that demonstrations from the audience,
including applause and verbal outbursts, as well as the use of
signs or placards are a violation of the rules of the House of
Representatives, and it is important that we respect the
decorum and the rules of this committee. I have also been
requested to state that photography and cameras are limited to
accredited press only.
Before I recognize myself for an opening statement, I also
ask unanimous consent that the gentlemen from Texas, Mr. Joe
Barton, Mr. Michael Burgess, Mr. Kenny Marchant, Mr. Blake
Farenthold, and Mr. Mark Veasey, and the gentlelady from Texas,
Ms. Eddie Bernice Johnson, be permitted to sit on the dais and
participate in today's hearing. Without objection, so ordered.
I will now recognize myself for an opening statement.
We are here today to discuss the threat to the United
States homeland from the Ebola virus and what is being done to
stop the spread of this terrible disease. This crisis is
unfolding at an alarming pace. Thousands have died in Africa
and thousands more have been infected, including four selfless
Americans working in Liberia who have been flown home for
treatment.
Now the virus has begun to spread to other parts of the
world, and the American people are rightfully concerned. They
are concerned because the Ebola virus is an unseen threat, and
it is only a plane flight away from our shores. We have
witnessed that with the recent case here in Dallas, the first
fatality from Ebola in the United States. But we must be sure
to confront this crisis with the facts. Blind panic will not
help us stop this disease from spreading, and fear-mongering
will only make it harder to do so.
That is why we are here today, to ask the American people's
questions and get answers from the experts. Americans are
seeking assurance that our Federal, State, and local officials
are doing everything in their power to keep this virus outside
of the United States. Already there has been a vigorous
international, Federal, State, and local response, and we hope
to hear more today about exactly what has been done and what
needs to be done going forward.
Two weeks ago, Thomas Eric Duncan traveled here from
Liberia by way of Brussels and Dulles Airports. He fell ill and
presented himself for treatment at Texas Health Presbyterian
Hospital here in Dallas. Mr. Duncan's diagnosis set in motion
an extensive public health operation involving Federal, State,
and local officials to identify and assess any individuals with
whom he may have had contact, a process called contact tracing.
That contact tracing effort continues today, and our prayers
are with everyone who is currently being monitored as part of
this incident.
We are thankful that today there have been no additional
cases of Ebola stemming from this case. Contact tracing is
time-consuming and difficult, but it is one of the few ways to
contain the disease. Containment also requires swift,
coordinated action. In this committee's hearings and
investigation on the Boston Marathon bombings, we heard
testimony about the importance of the incident command system.
The system is a vital tool for making sure first responders at
all levels engage quickly and decisively rather than argue
about who is in charge. The importance of such a response
mechanism was highlighted in the 9/11 Commission Report, and it
has since saved countless lives.
I was encouraged to learn officials here in Texas
instituted the structure, and today State and Federal officials
are co-located in the Dallas County Emergency Operations
Center, enabling vital information sharing and coordination. To
be clear, the situation here at home is far different than what
is happening in West Africa. We have a strong public health
infrastructure in place, particularly here in Texas, which
enables us to work to contain this virus more effectively.
But Dallas is not the only area that we must be vigilant.
We need to ensure that State and local responders Nation-wide
are prepared to move quickly if the virus is detected anywhere
else within our borders. Hospitals are recognizing this and
have made nearly 190 inquiries with the CDC about cases they
believe could be Ebola. Thankfully, testing was only warranted
in about 24 of these cases, and only one case was confirmed as
Ebola.
Public health and medical personnel must remain vigilant,
ensure all hospital personnel are informed, follow protocols to
identify the virus, and take appropriate quarantine measures.
We must reinforce the importance of taking travel histories and
sharing that information with all relevant personnel.
Protecting the homeland from the Ebola virus also requires
us to put measures in place at our airports. I am pleased the
President announced earlier this week additional entry
screening efforts that are being launched. Beginning tomorrow,
enhanced screening measures will be activated at JFK Airport,
and soon after at Dulles, O'Hare, Newark, and Atlanta. These
airports receive more than 94 percent of all travelers from
Liberia, Sierra Leone, and Guinea. I look forward to hearing
more about these enhanced screening efforts from our witnesses.
The Department of Homeland Security has been actively
involved in this response, and I commend Secretary Johnson for
his leadership. But we also must closely monitor the situation
overseas and continue our global response efforts. I have
spoken with the President's homeland security advisor, Lisa
Monaco, numerous times to ensure our Government is doing all
that is necessary. We recently discussed exit screening
procedures that have been put in place in Liberia, Sierra
Leone, and Guinea by CDC-trained personnel. In the past 2
months, the screening has stopped 77 travelers with Ebola-like
symptoms or contact history from boarding airplanes out of a
total of 36,000 individuals screened. Fortunately, none of
those 77 have been diagnosed with Ebola.
While there have many positive aspects of this response,
there have also been missteps. For instance, here in Dallas,
Mr. Duncan's travel history was not communicated to all
relevant medical personnel when he first sought treatment,
which led to his release from the hospital and the potential
that additional people were exposed to the virus. There were
also problems removing hazardous biomedical waste from the
apartment where Mr. Duncan's family was quarantined. The soiled
materials remained in the home with the quarantined individuals
for days after the Ebola diagnosis was confirmed.
We must learn from these missteps and ensure that proper
procedures are established and followed should another case
arise in the United States. Going forward, we must consider all
policy options for stopping the spread of this horrific
disease. I have heard many ideas directly from my fellow
Texans, everything from stopping in-bound flights from specific
countries to additional screenings at home and abroad. We hope
our witnesses will discuss options that are being considered in
the trade-offs that we have to confront.
We also have to ensure unnecessary Government red tape does
not slow down the response. In fact, I know a reprogramming
request was approved in the House seeking $750 million towards
response efforts, and I would urge the Senate to follow the
lead of the House and approve the Pentagon's request to
transfer additional resources to this fight.
Now is not the time for politics. Congress has been loath
to get anything done this session, and if there's ever been a
time to come together and put pettiness aside, it is now. We
must get this right and make sure that Federal protocols are
put in place and communicated to our State and local partners
when a situation this critical occurs. My hope today is that we
do not focus on gotcha politics, but instead hear from our
panel and focus on solutions. We are all in the same boat, and
we need to work hard to make sure that our Nation is protected
from this threat.
I want to thank the Ranking Member for being here today in
my home State of Texas and showing his support for this shared
goal. Before I turn it over to him, I would also like to
commend our first responders, our medical personnel and public
health officials, who have responded courageously to the case
here in Dallas. Most importantly, our thoughts and prayers are
with the victims and the families affected by this crisis. I
look forward to hearing from the witnesses and hear from them
what more can be done to keep Americans safe.
[The statement of Chairman McCaul follows:]
Statement of Chairman Michael McCaul
October 10, 2014
We are here today to discuss the threat to the U.S. homeland from
the Ebola virus and what is being done to stop the spread of this
terrible disease. The crisis is unfolding at an alarming pace.
Thousands have died in Africa and thousands more have been infected,
including 4 selfless Americans working in Liberia who have been flown
home for treatment. Now the virus has begun to spread to other parts of
the world, and the American people are rightfully concerned. They are
concerned because the Ebola virus is an unseen threat, and it is only a
plane-flight away from our shores. We've witnessed that with the recent
case here in Dallas--the first fatality from Ebola in the United
States.
But we must be sure to confront this crisis with the facts. Blind
panic won't help us stop this disease from spreading, and fear-
mongering will only make it harder to do so. That is why we are here
today: To ask the American people's questions and get answers from our
experts. Americans are seeking assurance that our Federal, State, and
local officials are doing everything in their power to keep this virus
out of the United States.
Already, there has been a vigorous international, Federal, State,
and local response. We hope to hear more today about exactly what has
been done--and what needs to be done going forward. Two weeks ago,
Thomas Eric Duncan traveled here from Liberia by way of the Brussels
and Dulles airports, fell ill, and presented himself for treatment at
Texas Health Presbyterian Hospital here in Dallas. Mr. Duncan's
diagnosis set in motion an extensive public health operation involving
Federal, State, and local officials to identify and assess any
individuals with whom he may have had contact, a process called
``contact-tracing.''
That contact-tracing effort continues today, and our prayers are
with everyone who is currently being monitored as part of this
incident. We are thankful that, to date, there have been no additional
cases of Ebola stemming from this case. Contact-tracing is time-
consuming and difficult, but it is one of the few ways to contain the
disease. Containment also requires swift, coordinated action. In this
committee's hearings and investigation on the Boston Marathon bombings,
we heard testimony about the importance of the ``incident command
system.''
The system is a vital tool for making sure first responders at all
levels engage quickly and decisively, rather than argue over who is in
charge. The importance of such a response mechanism was highlighted in
the 9/11 Commission report, and it has since saved countless lives. I
was encouraged to learn officials here in Texas instituted this
structure. Today, State and Federal officials are co-located in the
Dallas County Emergency Operations Center, enabling vital information
sharing and coordination.
To be clear, the situation here at home is far different than what
is happening in West Africa. We have a strong public health
infrastructure in place, particularly here in Texas, which enables us
to work to contain this virus more effectively. But Dallas is not the
only area that must remain vigilant. We need to ensure that State and
local responders Nation-wide are prepared to move quickly if the virus
is detected anywhere else within our borders. Hospitals are recognizing
this and have made nearly 190 inquiries with the CDC about cases they
believed could be Ebola. Thankfully, testing was only warranted in
about 24 of those cases, and only 1 case was confirmed as Ebola.
Public health and medical personnel must remain vigilant, ensure
all hospital personnel are informed, follow protocols to identify this
virus, and take appropriate quarantine measures. We must reinforce the
importance of taking travel histories and sharing that information with
all relevant personnel. Protecting the homeland from the Ebola virus
also requires us to put measures in place out our airports. I am
pleased the President announced earlier this week additional entry
screening efforts are being launched. Beginning tomorrow, enhanced
screening measures will be activated at JFK airport and soon after at
Dulles, O'Hare, Newark, and Atlanta. These airports receive more than
94% of all travelers from Liberia, Sierra Leone, and Guinea. I look
forward to hearing more about these enhanced screening efforts from our
witnesses. The Department of Homeland Security has been actively
involved in the response, and I commend Secretary Jeh Johnson for his
leadership in bringing Federal resources to the fight.
We must also closely monitor the situation overseas and continue
our global response efforts. I have spoken with the President's
Homeland Security Advisor Lisa Monaco numerous times to ensure our
Government is doing all that is necessary. We recently discussed exit
screening procedures that have been put in place in Liberia, Sierra
Leone, and Guinea by CDC-trained personnel. In the past 2 months, this
screening has stopped 77 travelers with Ebola-like symptoms or contact
history from boarding planes, out of a total of 36,000 individuals
screened. None of those 77, that we are aware of, has been diagnosed
with Ebola. While there have been many positive aspects of this
response, there have also been missteps.
For instance, here in Dallas Mr. Duncan's travel history was not
communicated to all relevant medical personnel when he first sought
treatment, which led to his release from the hospital and the potential
that additional people were exposed to the virus. There were also
problems removing hazardous biomedical waste from the apartment where
Mr. Duncan's family was quarantined. The soiled materials remained in
the home with the quarantined individuals for days after the Ebola
diagnosis was confirmed.
We must learn from these missteps, and ensure the proper procedures
are established and followed should another case arise in the United
States. Going forward, we must consider all policy options for stopping
the spread of this horrific disease. I have heard many ideas directly
from my fellow Texans--everything from stopping in-bound flights from
specific countries to additional screenings at home and abroad. We hope
our witnesses will discuss options that are being considered and the
trade-offs we may have to confront.
We also have to ensure unnecessary Government red tape does not
slow down the response. I urge the Senate to follow the lead of the
House and approve the Pentagon's request to transfer additional
resources to the fight. The Defense Department is seeking to move $750
million toward response efforts, and we should move swiftly to satisfy
that request.
Now is not the time for politics. Congress has been loathe to get
much done this session, and if there has ever been a time to come
together and put pettiness aside, it is now. We must get this right and
make sure that Federal protocols are put in place and communicated to
our local and State leaders when a situation this critical occurs.
My hope today is we won't focus on gotcha politics, instead hearing
from our panels and focusing on a solutions-based hearing. We are in
the same boat. And we need to work hard to make sure that our Nation is
protected from this threat. I want to thank the Ranking Member for
being here in my home State of Texas in a show of support for this
shared goal.
Before we begin, I also want to commend the first responders,
medical personnel, and public health officials who have responded
courageously to the case here in Dallas. Most importantly, our thoughts
and prayers are with the victims and families affected by this crisis.
I look forward to hearing from our distinguished panel of witnesses
today on the recent response efforts and what more can be done to keep
America safe.
Chairman McCaul. With that, the Chairman now recognizes the
Ranking Member, Mr. Thompson.
Mr. Thompson. Good afternoon. I want to thank the Chairman
for holding this timely hearing on our efforts, both domestic
and international, to contain and prevent the spread of the
Ebola virus. I also thank the witnesses for appearing here
today, and I look forward to their testimony. Additionally, I
want to thank Chair Biggins and the board of directors of the
Dallas-Fort Worth Airport and executive staff for hosting the
committee today.
I also want to extend my condolences to the family of
Thomas Eric Duncan, the first person diagnosed with Ebola on
American soil. We are not here to dehumanize Mr. Duncan, but
unfortunately his diagnosis and the procedures that followed
raise critical questions about our preparedness for highly
infectious diseases, such Ebola, and how Federal, State, and
local authorities coordinate in their aftermath.
As the Ranking Member of this committee, I often urge my
colleagues not to use our positions of influence to promote
fear in the public. Hence, I want to clarify that while it is
proper to have serious concerns about the Ebola virus, it would
be irresponsible for us to foster the narrative that an Ebola
epidemic in the United States is imminent. Rather, this hearing
provides us an opportunity to review our State, local, Federal,
and global public health infrastructure, learn where there are
inconsistencies and gaps, and lay the foundation for
eliminating these disparities.
While the Ebola virus has caused the United States to
institute new screening procedures at airports, it is incumbent
upon us to work with our international partners to eradicate
the virus at its origin in West Africa. The current Ebola
outbreak is the deadliest outbreak on record. According to the
Assistant Secretary General of the United Nations, it is also
impairing National economies, wiping out livelihoods and basic
services, and could undo years of efforts to stabilize West
Africa. Eliminating this virus at its source is a sure-fire way
to prevent more Ebola cases in the United States.
As citizens of the global community, it is our moral
obligation to not only eradicate this virus that is devastating
West Africa, but also ensure that these countries can continue
to function and recover. The United States' response to the
current Ebola outbreak will affect the ways it works to
coordinate international responses to future disease outbreaks.
In this case, it seems as if the United States and the
international community did not act aggressively soon enough.
In March, the World Health Organization issued a notice of an
Ebola outbreak in Guinea after the virus spread to Sierra Leone
and Liberia. There was a lull in new cases in the spring, and
as a result efforts waned. In June, Doctors Without Borders, a
nongovernmental organization, declared the outbreak out of
control. However, the World Health Organization and the
international community did not improve on its efforts until
August.
According to a chart that I have here, we had a lull until
the spike started in August of this year. Mr. Chairman, I will
submit for the record this chart.
Chairman McCaul. Without objection, so ordered.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Thompson. Thank you. Earlier I stated that an Ebola
outbreak in the United States is not imminent. But what should
be discussed post haste is the value of our public health
infrastructure and the cost of maintaining it. Many times
public health is used as a pawn for partisan bickering.
However, Mr. Chairman, viruses such as Ebola, the flu, and EV-
D68, which has affected over 500 children in the United States,
do not know political parties.
Cuts to public health preparedness grants from the
Department of Homeland Security, and Health and Human Services,
the Centers for Disease Control, and the Office of the Surgeon
General hit already struggling State and local health
departments hard. As Members of Congress, we can use our
platforms to restore grant funding and support the Federal cost
of maintaining a public health infrastructure.
I hope that our discussion today can yield a step in this
direction, and I also support the Chairman's comment that this
disease does not see party or anything. It is an American
problem that the world needs our best minds to address. I look
forward, Mr. Chairman, to the testimony and witnesses and yield
back the balance of my time.
[The statement of Ranking Member Thompson follows:]
Statement of Ranking Member Bennie G. Thompson
October 10, 2014
I want to thank the Chairman for holding this timely hearing on our
efforts--both domestic and international--to contain and prevent the
spread of the Ebola virus. I also thank the witnesses for appearing
today, and I look forward to their testimony. Additionally, I want to
thank Chair Biggins and the board of directors of the Dallas Fort Worth
Airport and the executive staff for hosting the committee today.
I also want to extend my condolences to the family of Thomas Eric
Duncan, the first person diagnosed with Ebola on American soil. We are
not here to dehumanize Mr. Duncan, but unfortunately his diagnosis and
the procedures that followed raise critical questions about our
preparedness for highly-infectious diseases such as Ebola and how
Federal, State, and local authorities coordinate in their aftermath.
As Ranking Member of this committee, I often urge my colleagues not
to use our positions of influence to promote fear in the public. Hence,
I want to clarify that while it is proper to have serious concerns
about the Ebola virus, it would be irresponsible for us to foster the
narrative that an Ebola epidemic in the United States is imminent.
Rather, this hearing provides us the opportunity to review our
State, local, Federal, and global public health infrastructure, learn
where there are inconsistencies and gaps, and lay the foundation for
eliminating these disparities. While the Ebola virus has caused the
United States to institute new screening procedures at airports, it is
incumbent upon us to work with our international partners to eradicate
the virus at its origin in West Africa.
The current Ebola outbreak is the deadliest outbreak of record.
According to the assistant secretary general of the United Nations, it
is also impairing national economies, wiping out livelihoods and basic
services, and could undo years of efforts to stabilize West Africa.
Eliminating this virus at its source is a surefire way to prevent more
Ebola cases in the United States.
As citizens of the global community, it is our moral obligation to
not only eradicate this virus that is devastating West Africa, but also
ensure that these countries can continue to function and recover. The
United States' response to the current Ebola outbreak will affect the
way it works to coordinate international responses to future disease
outbreaks. In this case, it seems as if the United States and the
international community did not act aggressively soon enough.
In March, the World Health Organization issued a notice of an Ebola
outbreak in Guinea after the virus spread to Sierra Leone and Liberia.
There was a lull in new cases in the spring, and as a result, efforts
waned. In June, Doctors Without Borders, a non-Government organization,
declared the outbreak out of control. However, the World Health
Organization and the international community did not improve on its
efforts until August. According to this chart from the Washington Post,
the rate of new cases and fatalities appears to have grown
exponentially during this time. We must do better, and I want to learn
how the international community will be more engaged in the future.
Earlier, I stated that an Ebola outbreak in the United States is
not imminent, but what should be discussed post haste is the value of
our public health infrastructure and the cost of maintaining it. Many
times, public health is used as a pawn for partisan bickering. However,
viruses such as Ebola, the flu, and EV-D68 which has affected over 500
children in the United States do not know political parties.
Cuts to public health preparedness grants from the Departments of
Homeland Security and Health and Human Services, the Centers for
Disease Control, and the Office of the Surgeon General hit already
struggling State and local health departments hard. As Members of
Congress, we can use our platforms to restore grant funding and support
the Federal costs of maintaining a public health infrastructure. I hope
that our discussions today can yield a step in this direction.
Chairman McCaul. I thank the Ranking Member for his
thoughtful comments and spirit of bipartisanship. Other Members
are reminded that statements may be submitted for the record.
[The statement of Hon. Jackson Lee follows:]
Statement of Honorable Sheila Jackson Lee
October 10, 2014
Good morning. I would like to begin by thanking Chairman McCaul and
Ranking Member Thompson, for convening this hearing on ``Ebola in the
Homeland: The Importance of Effective International, Federal, State,
and Local Coordination.''
I would also like to thank all the witnesses testifying before us
today:
Dr. Toby Merlin, director of the Division of Preparedness
and Emerging Infection Office for the National Center for
Emerging and Zoonotic Infectious Diseases with the Center for
Disease Control;
Dr. Kathryin Brisfield, acting assistant secretary for
health affairs and chief medical officer with the Department of
Homeland Security;
John P. Wagner, acting assistant commissioner, with the
Office of Field Operations (OFO) with U.S. Customs and Border
Protection;
Dr. David L. Lakey, commissioner, Texas Department of State
Health Services;
Dr. Brett Giroir, executive vice president & CEO Texas A&M
Health Science Center, who is also a professor in the College
of Medicine at Texas A&M Health Science Center;
Dr. Catherine L. Troisi, Ph.D., associate professor in the
divisions of management, policy, and community health and
epidimiology.
The Hon. Clay Jenkins, judge, for Dallas County, TX.
Thank you all for being here and sharing your expertise and
valuable experience with us as the Nation addresses the global Ebola
crisis and the first U.S. patient, Mr. Thomas Eric Duncan, who became
ill with Ebola after returning from West Africa and succumbed to the
disease.
The topic of today's hearing clearly highlights the scope and
responsibility of the House Committee on Homeland Security and the
important role that the Homeland Security Department fulfills in
protecting our Nation's people and securing our borders.
The World Health Organization reports that the numbers of deaths
from Ebola is approaching 4,000. Medical experts are certain that this
number is much higher than the deaths that have been reported.
Today, the goal of this committee, the Obama administration, and
the governments around the world, both inside and outside of America,
is to prevent Ebola from becoming the next AIDS.
As a senior Member of the House Committee on Homeland Security and
the Ranking Member of the Subcommittee on Border Security, I am pleased
that the Centers for Disease Control, the Department of Homeland
Security's U.S. Customs and Border Protection Agency, and the United
States Coast Guard are coordinating to establish a new level of
screening for international air travelers during the global Ebola
health crisis that is impacting the United States.
I understand this coordinated effort will add new screening
protocols beginning Saturday, October 11, 2014 for passengers with
flight itineraries originating in the countries of Guinea, Liberia, or
Sierra Leone. I have requested that the George Bush Intercontinental
Airport serving the Houston area be included among the airports where
these protocols will be applied.
The Ebola virus cannot be ignored, it cannot be locked away and
kept at bay, and it must be aggressively treated at its source--in
Africa.
This is no time for hand-wringing or finger-pointing regarding this
Ebola outbreak--this is the time for action. I commend this committee's
leadership, President Obama; and the doctors and medical professionals
who are bringing attention and resources to the forefront to stop this
terrible disease.
I would offer that Members of this committee must renew our efforts
to end sequestration. We cannot wage the fight that lies ahead without
the full measure of resources that must be brought to contain and
ultimately end this Ebola outbreak.
Ebola is not airborne.
It is only transmitted through body fluids when a person is
symptomatic,--(i.e. has a fever from the disease and experiencing other
symptoms.)
Incubation of the Ebola virus in victims can range from 2 to 21
days before signs of the illness emerge.
The Ebola virus is a single strain of RNA that is comprised of 7
genes that can attach to healthy red blood cells, invade the blood
cell, and use the blood cell's environment to rapidly reproduce.
Typically a little over a week after exposure a patient may begin
to exhibit symptoms, which include fever, chills, muscle pain, sore
throat, weakness, and general discomfort.
The Ebola virus attacks immune cells in the bloodstream, which take
the infection to the liver, spleen, and lymph nodes. Ebola then blocks
the release of interferon, a protein made by immune cells to fight
viruses.
At this stage of the infection, other tissues and organs can become
compromised along with other cellular functions that disrupt vital
organ function and autonomic processes that are carried out by cells.
Surviving Ebola requires the body to have time for the immune
system to figure out how to fight the Ebola virus. Patients get time
from receiving aggressive supportive care as early as possible in the
Ebola infection process.
Supportive care begins with proper identification of symptoms and
signs of the disease causing stress or distress to organs or body
functions and using the appropriate symptom management treatments.
Active treatment to stave off the effects of the disease can
include:
1. ibuprofen to address fevers;
2. transfusion of blood to deal with bleeding, moderate to severe
pallor or signs of emergency circulatory shock;
3. pain reduction; and
4. difficulty in respiration and dehydration.
Providing supportive care as early as possible to stabilize the
Ebola victim and allow the patient's immune system time to learn how to
fight the disease is the most important factor for successful recovery.
There are several experimental treatments that have been used in
patients, but it is too early to say whether these medicines have made
a difference in their recoveries.
The disease is not just a threat to the patient; it also poses a
significant threat to first-line responders that provide critical
health care to Ebola patients.
Doctors Without Borders have developed a very detailed and care
process that health care workers around the world must follow without
deviation to make sure that they are protected, while providing care to
Ebola patients.
The posture of the United States must be one of vigilance, and for
this reason, I recently wrote to President Obama to thank him for his
leadership, both globally and Nationally, in addressing the threats
posed by the largest Ebola outbreak in history.
I mentioned earlier, I also requested that George Bush
Intercontinental Airport be included on the list of airports to receive
the enhanced Ebola screening protocols for those passengers whose
flight itineraries indicate that the air travel originated in the
countries of Guinea, Liberia, or Sierra Leone.
The George Bush Intercontinental Airport serves the Houston area
and is a major originating and connecting hub for international air
travelers. From January to August 2014, there were 99,452 West African
passengers traveling into and out of the George Bush Intercontinental
Airport with a total of 1,856,421 international travelers.
In 2013 nearly 40 million passengers traveled through the George
Bush Intercontinental Airport of which 8.9 million were international
travelers.
George Bush Intercontinental Airport ranks as the 9th largest
airport in the United States for flight operations and ranks as one of
our Nation's busiest airports.
I requested that George Bush Intercontinental Airport be added to
the list of airports receiving new layers of entry screening.
I look forward to the testimony of today's witnesses and what they
believe we are doing to be helpful to them in their work and where we
can do better in supporting their efforts to stop the spread of Ebola.
Once again, I would like to thank you Chairman McCaul and Ranking
Member Thompson for convening this hearing. I yield back the balance of
my time.
Thank you.
Chairman McCaul. We have a very distinguished panel of
experts here today. First, Dr. Toby Merlin is the director of
the Division of Preparedness and Emerging Infections at the
National Center for Emerging and Zoonotic Infectious Disease at
the U.S. Centers for Disease Control and Prevention, CDC. In
this role, he is responsible for the CDC's Laboratory Response
Network, infectious disease emergency response coordination,
and emerging infections epidemiology, and laboratory capacity
programs. Thank you for being here, sir.
Next, Dr. Kathryn Brinsfield serves as the acting assistant
secretary of health affairs and chief medical officer for the
Department of Homeland Security's Office of Health Affairs. She
began her service with DHS in July 2008. She previously served
as associate chief medical officer and director of the Division
of Workforce, Health, and Medical Support within OHA. Prior to
serving as acting assistant secretary, she served on a detail
to the National security staff as the director of medical
preparedness policy. Thank you so much for being here.
Last, Mr. John Wagner. I want to thank you for the tour you
gave me earlier of this facility and how you would deal with
potential Ebola victims coming through this airport. Mr. Wagner
became acting assistant commissioner, Office of Field
Operations, for Customs and Border Protection in April 2014. In
his current position, he oversees nearly 28,000 employees with
more than 22,000 CBP Officers and CBP Ag Specialists that
protect our borders. An annual operating budget of $3.2 billion
provides for operations at over 329 ports of entry and programs
that support National security, immigration, customs, and
commercial trade related to the missions.
The full written statements will appear in the record. The
Chairman now recognizes Dr. Merlin for 5 minutes.
STATEMENT OF TOBY MERLIN, M.D., DIRECTOR, DIVISION OF
PREPAREDNESS AND EMERGING INFECTION, NATIONAL CENTER FOR
EMERGING AND ZOONOTIC INFECTIOUS DISEASES, CENTERS FOR DISEASE
CONTROL AND PREVENTION, U.S. DEPARTMENT OF HEALTH AND HUMAN
SERVICES
Dr. Merlin. Thank you, and good afternoon, Chairman McCaul,
Members of the committee, and members of the Texas delegation.
I appreciate the opportunity to be here today to discuss the
current epidemic of Ebola in West Africa, as well as the work
CDC is doing to manage the global consequences of this
epidemic. I have been particularly involved with colleagues
here in Dallas addressing the first U.S.-diagnosed Ebola case,
and like you, our hearts go out to the family and friends of
Mr. Duncan. As CDC Director Dr. Frieden noted, ``Mr. Duncan
puts a real face on the epidemic for all Americans.''
The Ebola epidemic in Guinea, Liberia, and Sierra Leone is
ferocious and continues to spread exponentially. The current
outbreak is the first that has been recognized in West Africa,
and the biggest and most complex Ebola epidemic ever
documented. As of last week, the epidemic surge passed 7,900
cumulative reported cases and nearly 3,800 documented deaths,
though we believe the numbers could be 2 or 3 times higher.
Fortunately, the United States and others in the global
community are intensifying our response in order to bring this
critical situation under control. From the time the situation
in West Africa escalated from an outbreak to an epidemic, we
have anticipated that a traveler might arrive in the United
States with the disease. The imported case of Ebola in Dallas
required the CDC and the Nation's public health system to
implement rapid response protocols that have been developed in
anticipation of such an event.
Within hours of confirming that the patient had Ebola, CDC
had a team of 10 people on the ground in Dallas to assist the
capable teams from the Texas State Health Department and local
authorities. We have worked side-by-side with State and local
health officials to prevent infections of others. Together, we
assessed all 114 individuals who might have possibly had
contact with the patient. We narrowed down the contacts to 10
who may have been around the patient when he was infectious,
and 30 others with whom possible infection could not be ruled
out. These individuals are being tracked and will be tracked
for 21 days for any signs of symptoms, and they will quickly be
isolated if symptoms develop.
We are also working to identify and learn lessons from the
initial patient encounter and other events that complicated our
response, and to apply them in any other responses. We are
confident that our public health and health care systems can
prevent an Ebola outbreak here, and that the authorities and
investments provided by Congress have put us in a strong
position to protect Americans.
To make sure the United States is prepared as the epidemic
in West Africa has intensified, CDC has done the following. No.
1, it has instituted layers of protection starting in affected
countries where our staff work intensively on airport exit
screening. No. 2, we have provided guidance for airline
personnel and for agents from DHS on how to identify sick
passengers and how to manage them.
No. 3, along with partners in DHS and State and local
health agencies, we have continually assessed and improved
approaches to in-bound passenger screening and management. As
the President announced on October 6, CDC is working with DHS
to intensify the screening at United States' airports. This is
something my colleagues from DHS will be discussing this
morning.
We have worked with American hospitals to reinforce and
strengthen infection controls. Fifth, with State health
departments, we have intensified training and outreach to build
awareness. Six, we have expanded lab capacity across the United
States to test for Ebola. Seven, we have developed response
protocols for the evaluation, isolation, and investigation of
symptomatic individuals. We have extensively consulted to
support evaluation, and when indicated, testing of suspected
cases.
We remain confident that Ebola is not a significant public
health threat to the United States. It is not transmitted
easily, and it does not spread from people who are not ill. It
is possible that another infected traveler might arrive in the
United States. Should this occur, we are confident that our
public health and health care systems can prevent the kind of
significant transmission of Ebola that would lead to an
outbreak here in the United States.
It is important to remember that the only way to protect
Americans, though, is to end this Ebola epidemic and to
continue our intensive focus on West Africa, and there
implement proven public health interventions. Working with our
partners, we have been able to stop every previous Ebola
outbreak, and we are determined to stop this one. It will take
meticulous work, and we cannot take shortcuts.
Thank you again for the opportunity to appear before you
today and for making CDC's work on this epidemic and other
health threats possible. Thank you, Mr. Chairman.
[The prepared statement of Dr. Merlin follows:]
Prepared Statement of Toby Merlin
October 10, 2014
Good afternoon Chairman McCaul, Members of the committee, and
members of the Texas Delegation. Thank you for the opportunity to
testify before you today and for your on-going support for the Centers
for Disease Control and Prevention's (CDC) work in global health. I am
Dr. Toby Merlin, director of CDC's Division of Preparedness and
Emerging Infections. I appreciate the opportunity to be here today to
discuss the epidemic of Ebola in West Africa, as well as the work the
CDC is doing to manage the global consequences of this epidemic in the
wake of the first diagnosed case here in the United States 2 weeks ago,
which ultimately and tragically, has become the first death from Ebola
in the United States.
From the time the situation in West Africa escalated from an
outbreak to an epidemic, we have anticipated that a traveler could
arrive in the United States with the disease. We have been preparing
for this possibility by working closely with our State and local
partners and with clinicians and health care facilities so that any
imported case could be quickly contained. This occurrence underscores
the need to carefully follow the protocols that have been developed, to
work closely across levels of government, and to continue our urgent
effort to address the epidemic in West Africa, which remains the
biggest risk to the United States.
As we work to learn from the recent case in Dallas and continue the
public health response there, we remain confident that Ebola is not a
significant public health threat to the United States. It is not
transmitted easily, and it does not spread from people who are not ill,
and cultural norms that contribute to the spread of the disease in
Africa--such as burial customs--are not a factor in the United States.
We know how to stop Ebola with strict infection control practices which
are already in wide-spread use in American hospitals, and the United
States is leading the international effort to stop it at the source in
Africa. CDC is committing significant resources both on the ground in
West Africa and through our Emergency Operations Center here at home.
We have been constantly monitoring our response in the United
States, and will continue to do so. The CDC and the U.S. Customs &
Border Protection (CBP) in the Department of Homeland Security (DHS)
announced this week that we will begin new layers of entry screening at
five U.S. airports that receive over 94 percent of travelers from the
Ebola-affected nations of Guinea, Liberia, and Sierra Leone. New York's
JFK International Airport will begin the new screening October 11. In
the 12 months ending July 2014, JFK received nearly half of all
travelers from those three West African nations. The enhanced entry
screening will also be implemented at Washington-Dulles, Newark,
Chicago-O'Hare, and Atlanta international airports.
This is a whole-of-Government response, with agencies across the
United States Government committing human and financial resources.
Across HHS, CDC is actively partnering with the Office of Global
Affairs, the Office of the Assistant Secretary for Preparedness and
Response, the National Institutes of Health, and the Food and Drug
Administration to coordinate and respond to this epidemic. Also, CDC
has embedded technical staff in the USAID-led DART team in West Africa.
Additionally, staff, logistical support, and resources from the
Department of Defense (DoD) are already being deployed to rapidly scale
up our efforts to include constructing Ebola treatment units and
training health care workers. We are working closely with our
international partners to scale up the response to the levels needed to
stop this epidemic.
Ebola is a severe, often fatal, viral hemorrhagic fever. The first
Ebola virus was detected in 1976 in what is now the Democratic Republic
of Congo. Since then, outbreaks have appeared sporadically. The current
epidemic in Guinea, Liberia, and Sierra Leone is the first time an
outbreak has been recognized in West Africa, the first-ever Ebola
epidemic, and the biggest and most complex Ebola challenge the world
has ever faced. We have seen cases imported into Nigeria and Senegal
from the initially-affected areas and we have also seen in Nigeria and
Senegal that proven practices such as contact tracing can contribute to
managing Ebola and preventing a small number of cases from growing into
a larger outbreak.
Ebola has symptoms similar to many other illnesses, including
fever, chills, weakness and body aches. Gastrointestinal symptoms such
as vomiting and diarrhea are common and profound, with fluid losses on
average of 5-7 liters in 24 hours over a 5-day period. These fluid
losses can result in life-threatening electrolyte losses. In
approximately half of cases there is hemorrhage--serious internal and
external bleeding. There are two things that are very important to
understand about how Ebola spreads. First, the current evidence
suggests human-to-human transmission of Ebola only happens from people
who are symptomatic--not from people who have been exposed to, but are
not ill with the disease. Second, everything we have seen in our
decades of experience with Ebola indicates that Ebola is not spread by
casual contact; Ebola is spread through direct contact with bodily
fluids of someone who is sick with, or has died from Ebola, or exposure
to objects such as needles that have been contaminated. While the
illness has an average 8-10 day incubation period (though it may be as
short as 2 days and as long as 21 days), we recommend monitoring for
fever and signs of symptoms for the full 21 days. Again, we do not
believe people are contagious during that incubation period, when they
have no symptoms. Evidence does not suggest Ebola is spread through the
air. Catching Ebola is the result of exposure to bodily fluids, which
we are seeing occur in West Africa, for example, in hospitals in weaker
health care systems and in some African burial practices. Getting Ebola
requires exposure to bodily fluids of someone who is ill from--or has
died from--Ebola.
The earliest recorded cases in the current epidemic were reported
in March of this year. Following an initial response that seemed to
slow the early outbreak for a time, cases flared again due to weak
systems of health care and public health and because of challenges
health workers faced in dealing with communities where critical
disease-control measures were in conflict with cultural norms. As of
last week, the epidemic surpassed 7,900 cumulative reported cases,
including nearly 3,800 documented deaths, though we believe these
numbers may be substantially under-reported. The effort to control the
epidemic in some places is complicated by fear of the disease and
distrust of outsiders. Security is tenuous and unstable, especially in
remote isolated rural areas. There have been instances where public
health teams could not do their jobs because of security concerns.
Many of the health systems in the affected countries in West Africa
are weak or have collapsed entirely, and do not reach into rural areas.
Health care workers may be too few in number or may not reliably be
present at facilities, and those facilities may have limited capacity.
Health care workers are at greater risk of Ebola due to conditions they
are working in and we must work to reduce that risk. Poor infection
control in routine health care, along with local traditions such as
public funerals and cultural mourning customs including preparing
bodies of the deceased for burial, make efforts to contain the illness
more difficult. Furthermore, the porous land borders among countries
and remoteness of many villages have greatly complicated control
efforts. The secondary effects now include the collapse of the
underlying health care systems resulting for example, in an inability
to treat malaria, diarrheal disease, or to safely deliver a child, as
well as non-health impacts such as economic and political instability
and increased isolation in these areas of Africa. These impacts are
intensifying, and not only signal a growing humanitarian crisis, but
also have direct impacts on our ability to respond to the Ebola
epidemic itself.
Fortunately, we know what we must do. In order to stop an Ebola
outbreak, we must focus on three core activities: Find active cases,
respond appropriately, and prevent future cases. The use of real-time
diagnostics is extremely important to identify new cases. We must
support the strengthening of health systems and assist in training
health care providers. Once active cases have been identified, we must
support quality patient care in treatment centers, prevent further
transmission through proper infection control practices, and protect
health care workers. Epidemiologists must identify contacts of infected
patients and follow up with them every day for 21 days, initiating
testing and isolation if symptoms emerge. And, we must intensify our
use of health communication tools to disseminate messages about
effective prevention and risk reduction. These messages include
recommendations to report suspected cases, to avoid close contact with
sick people or the deceased, and to promote safe burial practices. In
Africa, another message is to avoid bush meat and contact with bats,
since ``spillover events,'' or transmission from animals to people, in
Africa have been documented through these sources.
Many challenges remain. While we do know how to stop Ebola through
meticulous case finding, isolation, and contact tracing, there is
currently no cure or vaccine shown to be safe or effective for Ebola.
We are working to strengthen the global response, which requires close
collaboration with the World Health Organization (WHO) and additional
assistance from our international partners. At CDC, we activated our
Emergency Operations Center to respond to the initial outbreak, and are
surging our response. As of last week, CDC has over 139 staff in West
Africa, and over 1,000 staff in total have provided logistics,
staffing, communication, analytics, management, and other support
functions. CDC will continue to work with our partners across the
United States Government and elsewhere to focus on key strategies of
response:
Effective incident management.--CDC is supporting countries
to establish National and sub-National Emergency Operations
Centers (EOCs) by providing technical assistance and standard
operating procedures and embedding staff with expertise in
emergency operations. All three West African countries at the
center of the epidemic have now named and empowered an Incident
Manager to lead efforts.
Isolation and treatment facilities.--It is imperative that
we ramp up our efforts to provide adequate space to treat the
number of people afflicted with this virus.
Safe burial practices.--Addressing local cultural norms on
burial practices is one of the keys to stopping this epidemic.
CDC is providing technical assistance for safe burials.
Infection control throughout the health care system.--Good
infection control will greatly reduce the spread of Ebola and
help control future outbreaks. CDC has a lead role in infection
control training for health care workers and safe patient
triage throughout the health care system, communities, and
households.
Communications.--CDC will continue to work on building the
public's trust in health and Government institutions by
effectively communicating facts about the disease and how to
contain it, particularly targeting communities that have
presented challenges to date.
The public health response to Ebola rests on the same proven public
health approaches that we employ for other outbreaks, and many of our
experts are working in the affected countries to rapidly apply these
approaches and build local capacity. These include strong surveillance
and epidemiology, using real-time data to improve rapid response; case-
finding and tracing of the contacts of Ebola patients to identify those
with symptoms and monitor their status; and strong laboratory networks
that allow rapid diagnosis.
The resources provided for the period of the Continuing Resolution
will support our response and allow us to ramp up efforts to contain
the spread of this virus. More than half of the funds are expected to
directly support staff, travel, security and related expenses. A
portion of the funds will be provided to the affected area to assist
with basic public health infrastructure, such as laboratory and
surveillance capacity, and improvements in outbreak management and
infection control. Should other outbreaks occur in this region,
authorities will have the experience and capacity to respond without a
massive external influx of aid, due to this investment. The remaining
funds will be used for other aspects of strengthening the public health
response such as laboratory supplies/equipment, and other urgent needs
to enable a rapid and flexible response to an unprecedented global
epidemic. CDC is working to identify our potential resource needs for
the rest of the fiscal year, and possibly further, as we deal with this
evolving situation. CDC will continue to coordinate activities directly
with critical Federal partners, including the United States Agency for
International Development (USAID), DoD, DHS, and non-Governmental
organizations. Over the past few weeks, we have seen progress, as the
DoD has begun deploying assets to the area and laying the ground work
to construct 17 Ebola treatment facilities, train local workers to
staff the facilities, and move supplies into the area. In addition,
USAID is working closely with non-Governmental organizations to scale
up efforts in all areas of the response. Currently, there are over 50
burial teams in all 15 counties of Liberia for the management of safe
human remains. More than 70 organizations are providing Ebola education
and awareness in Liberia, Guinea, and Sierra Leone. Organizations are
also working to increase infection control practices in all health
facilities to ensure functionality of the health care system. We
continue to work with national governments, WHO, and USAID to provide
for interim measures such as isolation in community settings with
proper protections, and improvements to ensure the safe burial of those
who have died from the virus.
Though the most effective step we can take to protect the United
States is to stop the epidemic where it is occurring, we are also
taking strong steps to protect Americans here at home. The imported
case of Ebola in Dallas, diagnosed on September 30 in a traveler from
Liberia, required CDC and the Nation's public health system to
implement rapid response protocols that have been developed in
anticipation of such an event. Within hours of confirming that the
patient had Ebola, CDC had a team of 10 people on the ground in Dallas
to assist the capable teams from the Texas State health department and
local authorities. We have worked side-by-side with State and local
officials to prevent infection of others. Together, we assessed all 114
individuals who might possibly have had contact with the patient. We
narrowed down the contacts to 10 who may have been around the patient
when he was infectious and 38 others with whom infection cannot be
ruled out. These individuals will be tracked for 21 days for any signs
of symptoms, and they will quickly be isolated if symptoms develop. We
are also working to identify and learn lessons from the initial patient
encounter and other events that complicated our response, and to apply
them in any other responses. We are confident that our public health
and health care systems can prevent an Ebola outbreak here, and that
the authorities and investments provided by the Congress have put us in
a strong position to protect Americans. To make sure the United States
is prepared, as the epidemic in West Africa has intensified, CDC has
done the following:
Instituted layers of protection, starting in affected
countries where our staff work intensively on airport exit
screening, such as temperature scanning for outbound
passengers.
Provided guidance for airline personnel and for DHS Customs
and Border Protection Officers on how to identify sick
passengers and how to manage them. Though it was one of many
false alarms, the recent incident with an in-bound passenger to
Newark, New Jersey shows how CDC's quarantine station at the
airport worked with airline, DHS, airport, EMS, and hospital
personnel to assess and manage a sick passenger, and to protect
other passengers and the public.
Developed guidance for monitoring and movement of people
with possible exposures.
Along with partners in DHS and State and local health
agencies, continually assessed and improved approaches to in-
bound passenger screening and management, and as the President
announced on October 6, CDC is working with DHS to enhance
screening measures at United States airports.
Worked with American hospitals to reinforce and strengthen
infection controls, and CDC has provided checklists and
instructions to all health care facilities to assess patients
for travel history. We have also worked with State and local
health departments to ensure that these practices are being
followed.
With State health departments, intensified training and
outreach to build awareness since the Dallas case.
Through the Laboratory Response Network (LRN), expanded lab
capacity across the United States--in addition to CDC's own
world-class laboratories, 14 LRN labs now have capacity for
testing, ensuring that we have access to labs for timely
assessment--and surge capacity in case it is needed.
Developed response protocols for the evaluation, isolation,
and investigation of any incoming individuals with relevant
symptoms.
Extensively consulted to support evaluation and, when
indicated, tested suspect cases. With heightened alert, we are
receiving hundreds of inquiries for help in ruling out Ebola in
travelers--a sign of how seriously airlines, border agents, and
health care system workers are taking this situation. So far
just over a dozen of these hundreds of suspect cases have
required testing, and only one (the Dallas patient) has been
positive.
Our top priority at CDC is to protect Americans from threats. We
work 24/7 to do that. In the case of Ebola, we are doing that in many
different ways here at home, but we also need to retain our focus on
stopping the outbreak at its source, in Africa.
Working with our partners, we have been able to stop every prior
Ebola outbreak, and we will stop this one. It will take meticulous work
and we cannot take short cuts. It's like fighting a forest fire: Leave
behind one burning ember, one case undetected, and the epidemic could
re-ignite. For example, in response to the case in Nigeria, 10 CDC
staff and 40 top Nigerian epidemiologists rapidly deployed, identified,
and followed 1,000 contacts for 21 days. Even with these resources, one
case was missed, which resulted in a new cluster of cases in Port
Harcourt. However, due to the meticulous work done in Nigeria, no new
cases have been identified, and the outbreak appears to have been
extinguished there.
Ending this epidemic will take time and continued, intensive
effort. Before this outbreak began, we had proposed, in the fiscal year
2015 President's budget, an increase of $45 million to strengthen lab
networks that can rapidly diagnose Ebola and other threats, emergency
operations centers that can swing into action at a moment's notice, and
trained disease detectives who can find an emerging threat and stop it
quickly. Building these capabilities around the globe is key to
preventing this type of event elsewhere and ensuring countries are
prepared to deal with the consequences of outbreaks in other countries.
We must do more, and do it quickly, to strengthen global health
security around the world, because we are all connected. Diseases can
be unpredictable--such as H1N1 coming from Mexico, MERS emerging from
the Middle East, or Ebola in West Africa, where it had never been
recognized before--which is why we have to be prepared globally for
anything nature can create that could threaten our global health
security.
Investments in strengthening health systems in West Africa have
been very challenging due to the low capacity of the systems. However,
all of the donor partners agree that adequately strengthening the
public health infrastructure in West Africa could allow such outbreaks
to be detected earlier and contained. This Ebola epidemic shows that
any vulnerability could have wide-spread impact if not stopped at the
source.
In February, the United States Government joined with partner
governments, WHO and other multilateral organizations, and non-
Governmental actors to launch the Global Health Security Agenda (GHSA).
Over the next 5 years, the United States has committed to working with
over 40 partner countries (with a combined population of at least 4
billion people) to improve their ability to prevent, detect, and
effectively respond to infectious disease threats--whether naturally-
occurring or caused by accidental or intentional release of pathogens.
As part of this Agenda, the President's fiscal year 2015 budget
includes $45 million for CDC to accelerate progress in detection,
prevention, and response, and we appreciate your support for this
investment. We are working to evaluate the needs to strengthen the
Ebola-affected nations and neighboring ones most at risk, and are
asking that GHSA partners make specific commitments to establish
capacity in West African countries in 2 or 3 years to prevent, detect,
and rapidly respond to infectious disease threats. The economic cost of
large public health emergencies can be tremendous--the 2003 Severe
Acute Respiratory Syndrome epidemic, known as SARS, disrupted travel,
trade, and the workplace and cost to the Asia-Pacific region alone $40
billion. Resources provided for the Global Health Security Agenda can
improve detection, prevention, and response and can potentially reduce
some of the direct and indirect costs of infectious diseases.
Improving these capabilities for each nation improves health
security for all nations. Stopping outbreaks where they occur is the
most effective and least expensive way to protect people's health.
While this tragic epidemic reminds us that there is still much to be
done, we know that sustained commitment and the application of the best
evidence and practices will lead us to a safer, healthier world. With a
focused effort, and increased vigilance at home, we can stop this
epidemic, protect Americans, and leave behind a strong system in West
Africa and elsewhere to prevent Ebola and other health threats in the
future.
Thank you again for the opportunity to appear before you today. I
appreciate your attention to this terrible epidemic and I look forward
to answering your questions.
Chairman McCaul. Thank you, Dr. Merlin.
The Chairman recognizes Dr. Brinsfield for her testimony.
STATEMENT OF KATHRYN BRINSFIELD, M.D., M.P.H., F.A.C.E.P,
ACTING ASSISTANT SECRETARY AND CHIEF MEDICAL OFFICER, OFFICE OF
HEALTH AFFAIRS, U.S. DEPARTMENT OF HOMELAND SECURITY
Dr. Brinsfield. Chairman McCaul, Ranking Member Thompson,
distinguished Members, thank you for inviting me to speak with
you today. I appreciate the opportunity to testify on the
Department of Homeland Security's role in the Federal
Government's Ebola response. I am also honored to testify
alongside my colleagues from the Centers for Disease Control
and Prevention and U.S. Customs and Border Protection. I also
want to thank the Texas State and local officials who will be
testifying later. DHS works closely with the State of Texas on
a number of important issues, and we appreciate their hard
work, coordination, and collaboration.
As you know, DHS is responsible for securing our Nation's
borders and safeguarding the American public from communicable
disease that threaten to traverse our borders, including Ebola.
The DHS Office of Health Affairs is at the intersection of
homeland security and public health with a mission to advise,
promote, integrate, and enable a safe and secure workforce in
the Nation in pursuit of National health security. OHA achieves
this by enhancing the health and wellness of the DHS workforce,
and by protecting the Nation from the health impacts of events,
including diseases of public health significance.
In my role as acting chief medical officer for the
Department, I provide medical and health expertise to DHS
components and senior leadership. In this capacity, I am
helping to coordinate with components and provide them with
medical advice regarding the Department's efforts in preparing
for and responding to Ebola.
As my CDC colleague has noted, the 2014 Ebola epidemic is
the largest Ebola in history, and it has had devastating
impacts in multiple West African countries, the hardest-hit
being Liberia, Sierra Leone, and Guinea. On September 30, 2014,
CDC confirmed the first travel-associated case of Ebola in the
United States. The patient had traveled from Liberia to Dallas,
Texas, connecting through the Brussels airport in Belgium and
Dulles in Virginia. Sadly, he has since passed away.
The patient did not have symptoms when he left Liberia, nor
when he entered the United States, but developed them
approximately 5 days after his arrival. The public concern
surrounding this event and possible future public exposure to
Ebola from international travelers is understandable, although
it is important to remember that the CDC has stated that the
risk of an Ebola outbreak in the United States is very low.
The President has been focused every day on the
Government's response, and has stated to his senior health,
homeland security, and National security advisors that the
epidemic in West Africa is a top National security priority.
DHS takes this issue very seriously and has been closely
monitoring the Ebola virus since its outbreak in April.
We are actively engaged in the Ebola response working with
our Federal and international partners to develop multiple
mechanisms to allow screening at different stages of transit to
minimize the potential spread of Ebola outside of West Africa.
We are closely monitoring this situation, actively engaged with
our State and local partners and adjusting our processes as
needed.
DHS has executed a number of measures to minimize the risk
of individuals with Ebola from entering the United States, and
we take a layered approach to ensure there are varying points
at which an ill individual could be identified so that there is
no single point of failure. To this end, DHS is also focused on
protecting those traveling by air and taking steps to ensure
that passengers with communicable diseases like Ebola are
screened, identified, isolated, and quickly and safely referred
to medical personnel. We have been working with the CDC to
implement an additional layer of screening for travelers
entering the United States, which is scheduled to begin this
weekend.
These additional screening protocols are just some of the
many actions the Federal Government has taken in our layered
approach to help ensure the risk of Ebola in the United States
remains minimal. Assistant Commissioner Wagner will go into
more detail regarding the specific measures CBP is taking, but
I would like to highlight some other key actions we at DHS have
taken to date and will continue to take.
CBP and the Transportation Security Administration have
posted messages from the CDC at select airport locations that
provide awareness on how to prevent the spread of infectious
disease, typical symptoms of Ebola, and instructions to call a
doctor if the traveler becomes ill. TSA is engaging with
industry partners and domestic and foreign air carriers to
provide awareness on the current outbreak, and has issued an
information circular to air carriers reinforcing the CDC's
message on Ebola and providing guidance on identifying
potential passengers with Ebola.
OHA through our National Biosurveillance Integration Center
is continuing to monitor the outbreak and is producing tailored
Ebola products. These reports are disseminated to more than
15,000 Federal, State, and local public health and law
enforcement officials. The U.S. Coast Guard is monitoring
vessels known to be inbound from Ebola-affected countries, and
is providing information to the captain of the port, district,
and CDC representatives.
DHS is also committed to ensuring that our own employees
have up-to-date information. We have provided our personnel
with health advisories on the current outbreak, including
impacted regions, symptoms of the virus, and mode of
transmission, and operational procedures and precautions.
The Department of Homeland Security has worked closely with
its interagency partners to develop a layered approach to Ebola
response. DHS is always assessing the measures we have in place
and will consider additional actions moving forward if
appropriate to protect the American people. I look forward to
working with you to address any concerns or questions.
[The joint prepared statement of Dr. Brinsfield and Mr.
Wagner follows:]
Joint Prepared Statement of Kathryn Brinsfield and John Wagner
October 10, 2014
Chairman McCaul, Ranking Member Thompson, distinguished Members of
the committee, and the Texas Delegation, we appreciate the opportunity
to submit this statement on the U.S. Customs and Border Protection's
(CBP) and the Office of Health Affairs' (OHA) roles in the Federal
Government's Ebola response.
The 2014 Ebola epidemic is the largest in history with devastating
impacts in multiple West African countries--the hardest-hit being
Liberia, Sierra Leone, and Guinea. In the midst of this public health
event, it is important to remember that the Centers for Disease Control
and Prevention (CDC) has stated that the risk of a widespread Ebola
outbreak in the United States is very low. OHA and CBP, as part of the
Department of Homeland Security's (DHS) overall strategy, are engaged
on a daily basis with DHS interagency partners to prepare for and
respond to Ebola and other potential threats to public health.
As you know, DHS is responsible for securing our Nation's borders
and assisting the Department of Health and Human Services (HHS) in
safeguarding the American public from communicable diseases that
threaten to traverse our borders. In doing so, DHS is committed to
ensuring that our responses to the Ebola epidemic are conducted
consistent with established civil rights and civil liberties
protections. OHA is at the intersection of homeland security and public
health, better known as health security. OHA provides medical and
health expertise to DHS components and senior leadership, and is
helping to coordinate with components and provide them with medical
advice regarding the Department's efforts in preparing for and
responding to Ebola. In today's remarks, we will provide an overview of
the Department's efforts to protect the American people from Ebola, and
CBP's specific efforts within ports of entry to identify and respond to
travelers who may pose a threat to public health.
As the Nation's unified border security agency, CBP is responsible
for securing our Nation's borders while facilitating the flow of
legitimate international travel and trade that is so vital to our
Nation's economy. Within this broad responsibility, CBP's priority
mission remains to prevent terrorists and terrorist weapons from
entering the United States. CBP also plays an important role in
limiting the introduction, transmission, and spread of serious
communicable diseases from foreign countries.
The President has been focused every day on this response and has
stated to his senior health, homeland security, and National security
advisors that the epidemic in West Africa is a top National security
priority, and that we will continue to do everything necessary to
address it. Because of the steps we have taken, the President
reiterated that he is confident that the chances of an outbreak in the
United States are extraordinarily low.
screening and observation protocols
CBP and the CDC have closely coordinated to develop policies,
procedures, and protocols to identify travelers to the United States
who may have a communicable disease, responding in a manner that
minimizes risk to the public. These pre-existing procedures--applied in
the land, sea, and air environments--have been utilized collaboratively
by both agencies on a number of occasions with positive results.
As a standard part of every inspection, CBP Officers observe all
passengers as they arrive in the United States for overt signs of
illness, and question travelers, as appropriate, at all U.S. ports of
entry. CBP Officers are trained in illness recognition by the CDC.
Officers look for overt signs of illness and can obtain additional
information from the travelers during the inspection interview. If a
traveler is identified with overt signs of a communicable disease of
public health significance, the traveler is isolated from the traveling
public and referred to CDC's Regional Quarantine Officers or local
public health for medical evaluation.
It is important to note that the CDC has worked closely with
affected countries, and CBP has provided support and assistance, to
ensure that all out-bound travelers from the areas affected by the West
Africa Ebola outbreak are screened for Ebola symptoms before departure.
CDC provides ``Do Not Board'' recommendations to CBP and the
Transportation Security Administration (TSA) regarding individuals who
may be infected with a highly contagious disease, present a threat to
public health, and should be prevented from traveling via commercial
aircraft. TSA is performing vetting of all airline passengers coming
to, departing from or flying within the United States to identify
matches to the ``Do Not Board'' list and flag matched individuals'
records in the Secure Flight system to prevent the issuance of a
boarding pass. TSA is also supporting CDC requirements to identify all
passenger reservations on flights where it has been determined that one
or more passengers present an Ebola risk, such as when passengers have
traveled from the affected African areas and have exhibited Ebola
symptoms.
additional ebola screening measures
Although we have recently seen the first cases of Ebola virus in
the United States, the CDC believes that the U.S. clinical and public
health systems will work effectively to prevent the spread of the Ebola
virus. DHS has executed a number of measures to minimize the risk of
those sick with Ebola entering the United States, and we take a layered
approach to ensure there are varying points at which an ill individual
could be identified. To this end, DHS is also focused on protecting the
air traveling public and taking steps to ensure that travelers with
communicable diseases like Ebola are identified, isolated, and quickly
and safely referred to medical personnel.
On October 21, DHS announced travel restrictions in the form of
additional screening and protective measures at our ports of entry for
travelers from the three Ebola-affected countries in West Africa. As of
October 22, all passengers arriving in the United States whose travel
originated in Liberia, Sierra Leone, or Guinea are required to fly into
one of five airports including New York John F. Kennedy; Washington
Dulles; Newark; Chicago O'Hare; and Atlanta International Airport. DHS
is working closely with the airlines to implement these restrictions
with minimal travel disruption.
At these five airports, all travelers from the affected countries
undergo enhanced screening measures consisting of targeted questions
and a temperature check, through the use of non-contact thermal
thermometers, seeking to determine whether the passengers are
experiencing symptoms or may have been exposed to Ebola. Detailed
contact information is also collected in the event the CDC needs to
contact them in the future. If there is reason to believe a passenger
has been exposed to Ebola, either through the questionnaire,
temperature check, or overt symptoms, CBP refers the passenger to CDC
for further evaluation. The CDC has surged staff to these airports to
support this mission requirement.
In addition to these measures, CBP Officers are asking all
passengers traveling on a passport from Liberia, Sierra Leone, and
Guinea, regardless of where they traveled from, whether they have been
in one of the three countries in the prior 21 days. If the traveler has
been in one of the three countries in the prior 21 days, he or she will
be referred for additional screening and, if necessary, CDC or other
medical personnel in the area will be contacted pursuant to existing
protocols.
The U.S. Coast Guard is also monitoring vessels known to be in-
bound from Ebola-affected countries, and is providing information to
the Captain of the Port, District, and CDC representatives.
The CDC maintains Federal jurisdiction to determine whether to
isolate or quarantine potentially-infected arrivals. DHS personnel may
be called upon to support the enforcement of the CDC's determinations,
and we stand ready to help.
information sharing and training
DHS has prioritized sharing information and raising awareness as
important elements in combating the spread of Ebola, and CBP has a
unique opportunity to deliver critical information to targeted
travelers from the affected countries in ports of entry. Secretary
Johnson recently directed CBP to distribute health advisories to all
travelers arriving in the United States from the Ebola-affected
countries of Liberia, Sierra Leone, and Guinea. These advisories
provide the traveler with information on Ebola, health signs to look
for, and information for their doctor should they need to seek medical
attention in the future.
CBP and TSA have posted messages from the CDC at select airport
locations that provide awareness on how to prevent the spread of
infectious disease, typical symptoms of Ebola, and instructions to call
a doctor if the traveler becomes ill in the future.
We also share information with our non-Governmental and State and
local partners. TSA is engaging with industry partners and domestic and
foreign air carriers to provide awareness on the current outbreak, and
has issued an Information Circular to air carriers reinforcing the
CDC's message on Ebola and providing guidance on identifying potential
travelers with Ebola.
OHA, through the National Biosurveillance Integration Center, is
continuing to monitor the outbreak to coordinate information in
response to the event. These reports on biological events are
disseminated to more than 15,000 Federal, State, and local users, many
of whom work in the public health sector or support 78 fusion centers
across the Nation, helping to ensure that the most up-to-date
information is available.
DHS is committed to ensuring that our own employees have up-to-date
and accurate information. We have provided our own personnel with
background information on the current outbreak, information on the
regions of importance; symptoms of the virus and mode of transmission;
and operational procedures and precautions for processing travelers
showing signs of illness. CBP field personnel will be kept up to date
on National, regional, and location-specific information on Ebola
preparedness and response measures through regular field musters. CBP
has provided guidance to the field on baggage inspection for
international travelers from impacted countries, proper procedures for
inspection and handling of prohibited meat products, and proper
safeguarding and disposal of garbage from all in-bound international
flights.
CBP Officers receive the CDC's public health training, which
teaches officers to identify symptoms and characteristics of ill
travelers. CBP also provides operational training and guidance to
front-line personnel on how to respond to travelers with potential
illness, including referring individuals who display signs of illness
to CDC quarantine officers for secondary screening, the use of personal
protective equipment (which is available for employees at these
airports along with instructions for use), as well as training on
assisting CDC with implementation of its isolation and quarantine
protocols. CBP Officers are trained to employ universal precautions, an
infection control approach developed by the CDC, when they encounter
individuals with overt symptoms of illness or contaminated items in
examinations of baggage and cargo. Universal precautions assume that
every direct contact with body fluids is infectious and requires
exposed employees to respond accordingly. TSA also ensures that its
employees are adequately trained and, where appropriate, are provided
personal protective equipment. The health and safety of DHS employees
is also our priority as we carry out this critical mission.
conclusion
The Department of Homeland Security has worked closely with its
interagency partners to develop a layered approach to identifying ill
travelers and protecting the air traveling public. DHS is always
assessing the measures we have in place and continues to look at any
additional actions that can be taken to ensure the safety of the
American people. We look forward to working with you to address this
problem collaboratively. We will continue to closely monitor the Ebola
outbreak, and will evaluate additional measures as needed.
We thank you for your time and interest in this important issue. We
look forward to answering your questions.
Chairman McCaul. Thank you, Dr. Brinsfield.
Mr. Wagner, you are recognized for 5 minutes.
STATEMENT OF JOHN WAGNER, ACTING ASSISTANT COMMISIONER, OFFICE
OF FIELD OPERATIONS, U.S. CUSTOMS AND BORDER PROTECTION, U.S.
DEPARTMENT OF HOMELAND SECURITY
Mr. Wagner. Thank you, Chairman McCaul, Ranking Member
Thompson, and distinguished Members of the committee for the
opportunity to discuss the efforts of U.S. Customs and Border
Protection in deterring the spread of Ebola by means of
international travel.
Each day CBP processes over 1 million people into the
United States. About 280,000 of them enter at our international
airports each day. CBP is responsible for securing our Nation's
borders while facilitating the flow of legitimate trade and
travel that is so vital to our Nation's economy.
Within this broad responsibility, our priority mission
remains to prevent terrorists and terrorist weapons from
entering the United States. However, we also play an important
role in limiting the introduction, transmission, and spread of
serious communicable diseases from foreign countries. We have
had this role for over 100 years, and as travel and threats
change, CBP has changed as well.
In coordination with CDC, we have modern protocols in place
for well over a decade that have guided response to a variety
of a significant health threats over recent years. CBP Officers
at all ports of entry assess each traveler for overt signs of
illness. In response to the recent Ebola virus outbreak in West
Africa, CBP in close collaboration with the DHS Office of
Health Affairs and the Centers for Disease Control and
Prevention is working to ensure that front-line officers are
provided the information, training, and equipment needed to
identify and respond to international travelers who may pose a
threat to public health.
All CBP Officers are provided guidance and training on
identifying and addressing travelers with any potential
illness, including communicable diseases, such as the Ebola
virus. CBP Officer training includes CDC public health
training, which teach officers to identify through visual
observation and questioning the overt symptoms and
characteristics of ill travelers.
CBP also provides operational training and guidance on how
to respond to travelers with potential illness, including
referring individuals who display signs of illness to CDC
quarantine officers for secondary screening, as well as
training on assisting CDC with implementation of its isolation
and quarantine protocols. Additionally, CBP provides web-based
training for its front-line personnel, covering key elements of
CBP's blood-borne pathogens, exposure control plan, protections
from exposure, use of personal protective equipment, and other
preventive measures and procedures to follow in a potential
exposure incident.
We are committed to ensuring our field personnel have the
most accurate, updated information regarding the Ebola virus.
Since this outbreak began, CBP field personnel have been
provided a steady stream of guidance starting with initial
information on the current outbreak at the beginning of April
this year with numerous and regular updates since then. We have
provided field personnel information on the regions of
importance, the symptoms of the virus, and modes of
transmission, and operational procedures and precautions for
processing passengers showing signs of illness.
We will continue to provide our officers National,
regional, and location-specific----
Voice. Is your mic on, sir?
Mr. Wagner. Yes.
Voice. Can you lift your mic up?
Mr. Wagner. Absolutely. Sorry.
Voice. Thank you.
Mr. Wagner. We will continue to provide our officers
National, regional, and location-specific information on Ebola
preparedness and response measures through field musters. We
have also provided guidance to the field on baggage inspection
for travelers from impacted countries, proper procedures for
inspection and handling of prohibited meat products, and proper
safeguard against disposal of garbage from all in-bound
international flights.
Information sharing is critical, and CBP continues to
engage with health and medical authorities at the National,
State, and local level. Since January 2011, CDC's Division of
Global Migration and Quarantine has stationed a liaison officer
at the CBP National Targeting Center to provide subject-matter
expertise and facilitate requests for information between the
two organizations. CBP has also been actively engaged with the
air carrier industry and other Federal partners regarding Ebola
preparedness and potential response operations.
Now, in response to the current outbreak, CBP identifies
travelers whose travel originated in or transited through
Guinea, Liberia, and Sierra Leone. Starting October 1, CBP
began providing a CDC Ebola travel health alert notice to
travelers entering the United States from these affected
countries. This information notice provides the traveler
information and instructions should he or she have a concern of
possible infection.
In addition to visually screening all passengers for overt
signs of illness, starting October 11, CBP and CDC will begin
enhanced screening of travelers from the three affected
countries entering JFK Airport given that a significant number
of travelers from the affected countries enter at JFK. In
coordination with CDC, these targeted travelers will be asked
to complete a CDC questionnaire, provide contact information,
and have their temperature checked. Based on these enhanced
screening efforts, CDC Quarantine Officers will make a public
health assessment.
These enhanced efforts will roll out next week at Dulles,
O'Hare, Atlanta, and Newark. Combined approximately 94 percent
of all travelers from the affected countries entering the
United States come through these five airports. CBP will
continue to screen for overt signs of illness on all
passengers, and will also provide Ebola tear sheets to
travelers at all other locations who come in from these
affected countries.
While CBP Officers receive training in illness recognition
and response, if they identify an individual believed to be
ill, we will separate the traveler from the public and contact
the local CDC Quarantine Officer along with local public health
authorities to help with a further medical assessment.
CBP will continue to monitor the Ebola outbreak, provide
timely information and guidance to our field personnel, and
work closely with DHS and our interagency partners to develop
or adopt measures as needed to deter the spread of Ebola in the
United States. So thank you for the opportunity to testify
today, and thank you for the attention you are giving to this
very important issue. I am happy to questions.
Chairman McCaul. Thank you. The Chairman recognizes himself
for questions. You know, like any threat overseas, we would
rather eliminate that threat before it can get into the United
States, and this threat is no exception.
I commend the efforts overseas in Africa to contain and
control this. Part of that effort are flights into western
Africa with health care officials to help stop the spread of
this viral disease. But many of my constituents and many
Americans are asking the question, why are we not banning all
flights from West Africa into the United States. So, Dr.
Merlin, I want to give you an opportunity to answer that
question. Why should we not ban all flights from West Africa
into the United States?
Dr. Merlin. Mr. Chairman, I appreciate the opportunity to
speak to that because I know it is a concern of many people.
The disease outbreak in Liberia, Guinea, and Sierra Leone is
now at a point where we may be able to stop it if we focus our
efforts and our resources on stopping it. In order to stop it,
we need uninhibited transit into and out of the country so that
we can bring the resources there to bear that are needed to
stop it, as well as to keep the countries from collapsing.
If we do not do that, the disease will grow exponentially.
Our projections are there could be from 400,000 to 1.4 million
cases by the end of the year if we do not do anything. There is
no way in that circumstance to prevent disease from spilling
from those countries into neighboring countries and then out
into the rest of the world. So our opportunity now is to get
the disease at its source. What we want is to not do things
that may give the appearance currently of protecting us, but
actually put us at greater risk later on by allowing the
disease to grow there.
Chairman McCaul. I appreciate that. Dr. Brinsfield.
Dr. Brinsfield. So, sir, we work closely with our partners
in CDC. We work through an interagency process with this. DHS
is prepared to take any steps necessary, but want to make sure
that we defer the public health expertise in this issue to CDC.
Chairman McCaul. Dr. Merlin, you said that this is not a
significant health threat to the United States, I believe, in
your testimony. Dr. Brinsfield, you said the risk is very low.
I wanted to see if you could elaborate on that and explain how
this deadly, wicked virus is actually transmitted.
Dr. Merlin. Thank you, Mr. Chairman. As you say, the virus
is a horrible virus because it causes horrible disease. In
people who are infected, it has a high mortality rate. But we
know a lot about this virus, and we know from 40 years'
experience how to stop outbreaks of this virus. The virus is
acquired by people by direct contact from infected individuals
who are symptomatic. They do not get the disease from contact
with people who are asymptomatic. It is often contacted by
people caring for an individual who is infectious and sick.
After acquisition, there is an incubation period where the
person who has acquired the virus is not him or herself
symptomatic. That incubation period ranges usually about 8 to
11 days. It can be shorter. It can be longer. But then when the
person develops symptoms, and only when the person develops
symptoms, is the person capable of spreading the disease to
other individuals.
Chairman McCaul. Dr. Brinsfield.
Dr. Brinsfield. I would agree, sir. I would also point out
as the USAID director has stated, this is a disease that preys
on poor public health and poor public infrastructure. We have
excellent public health and public infrastructure in this
country.
Chairman McCaul. As I understand, it is bodily fluid
contact rather than influenza, which would be airborne.
Dr. Brinsfield. That is correct, sir. That is our current
knowledge.
Chairman McCaul. I think a lot of people want to know at
what point are we going to have a treatment, or a cure, or
vaccine for this disease. Where are we? What is the latest on
that?
Dr. Merlin. Mr. Chairman, I will provide a brief overview.
There are a number of investigational countermeasures that are
being explored for either vaccinating to prevent Ebola or drugs
or biologics that can be used to treat Ebola. The time course
when those would be available on a size and scale to treat
large populations is fairly prolonged. The clinical trials with
a vaccine will not take place until early next year.
Chairman McCaul. I would hope that the clinical trials
would be expedited in this case.
Dr. Merlin. They are being expedited as quickly as
possible. I should, you know, also say that this work is not
work that CDC itself does, but it is work that is done by NIH
and BARDA. They can provide more details on it. The point I
wanted to make is that these countermeasures, although they may
be available on an investigational new drug basis to treat
occasional cases in the United States and occasional cases in
Africa now, they are not a method that we can use now to attack
the outbreak, the epidemic in Africa. What we need to use now
is the standard public health methods of isolating infectious
people so they do not spread the disease to other individuals,
and safe burials of people because their bodies are infectious
and they need to be handled appropriately.
Chairman McCaul. Lastly, Dr. Brinsfield, in the Clinton and
Bush administrations, they had a senior biodefense advisor in
the White House to coordinate Federal, State, and local
efforts. That position was eliminated in the current
administration. Do you know why that was eliminated, and who is
responsible now for coordinating at the Federal, State, and
local level?
Dr. Brinsfield. I think, sir, that we have a very robust
interagency process. We have meeting regularly on this issue
and this particular disease for months. We believe very
strongly that the different and varied expertises available are
all necessary to come to the table and make educated decisions.
Chairman McCaul. I thank you. The Chairman now recognizes
the Ranking Member.
Mr. Thompson. Thank you very much, Mr. Chairman. When I
left the Jackson, Mississippi airport this morning, the news
talked about this hearing. A number of people saw me, and they
wanted to know: Is it safe, what do I have to have? So needless
to say, it is on the minds of a lot of people in this country.
To that extent, Dr. Merlin, I think it is important that to
the extent that we can sing off the same page of music as we
push information out, the better off we are. Can you provide
this committee with how that process works from a public health
standpoint and notification to State and local partners around
the country?
Dr. Merlin. Mr. Thompson, I will tell you how the process
works for identification of cases. Is that what you would like
me----
Mr. Thompson. That is fine.
Dr. Merlin. Okay. We have worked with our Federal partners
and our State and local partners to distribute information to
health departments, to health department personnel, as well as
to hospitals and physicians on the signs and symptoms of Ebola,
the travel history that is there for Ebola, and how to detect
Ebola infections.
We on our website have provided a checklist for facilities.
We have provided guidance for facilities on how to do this. We
have provided guidance on how facilities and physicians should
handle an individual who they think is suspected of Ebola and
how they can place them in isolation immediately so that they
do not infect others, and we have provided testing for Ebola
diagnostics around the country. We offer 24/7 consultative
services through the CDC for people who have questions about
how to handle a suspected case. Am I addressing your----
Mr. Thompson. That is it, but I want to go to a simpler
reference. Some people are saying, well, we had two people to
come and get treated from West Africa who lived, and Mr. Duncan
came and died. The public is trying to say, what happened? I
think we have to somehow provide a level of confidence to the
public that the difference is still part of the system. Can you
help me, if not other Members of the committee, with a response
for that?
Dr. Merlin. Yes, I will. Ebola is a horrible disease, as
many people have said. The virus infects many parts of the body
and interferes with the functions of many parts of the body. It
is in the gastrointestinal tract. It is in the heart. It is in
the liver. It is in the skin. People develop profound diarrhea
and profound nausea and vomiting. The outcome of untreated
Ebola cases is a mortality of from 50 to 90 percent, depending
on a number of factors, including the age of the person.
We have limited experience with treating Ebola with our
developed medical system, and the outcomes are dependent on a
number of factors. A lot have to do with preexisting illness in
the patient, how quickly after onset of symptoms the patient
receives therapy. So I wish we had the assumption that every
person who comes down with Ebola who gets Western-style
medicine would survive, but I do not think that is the case.
Mr. Thompson. Thank you. Mr. Wagner, you talked a little
bit about this enhanced screening that we will start
implementing. I want to give you a scenario, and I want you to
help me with an answer. If someone buys a ticket in West Africa
to Brussels and then buys another ticket from Brussels to the
United States, will that enhanced targeting pick that person
up, or is that still a vulnerability we need to address?
Mr. Wagner. It could be a vulnerability depending on how
the airline has provided us with the information. If it is a
continuous ticket, we will absolutely see it. If it is multiple
tickets, we may not. In that case, we would use our officer
that interviews the person when they arrive in the United
States, and they flip through the passport booklet to look for
stamps to see where they have been.
Everyone goes through a series of questions just about
purpose and intent of travel, so we may ask the person, you
know, how long were they were in Brussels and what were they
doing there. When the answer is, well, I was transiting there,
we could ask from where. So from our questioning we should be
able to determine where that travel originated. Also on the
customs declaration, we ask people what countries they are
traveling from and where they have been to. So there are a few
different ways we would find that out.
Mr. Thompson. Thank you. Yield back, Mr. Chairman.
Chairman McCaul. The Chairman now recognizes Mr. Chaffetz.
Mr. Chaffetz. Thank you. I thank the Chairman and the
Ranking Member for holding this hearing on such an important
topic. Mr. Wagner, I would like to start with you by first
recognizing the people in Customs and Border Protection, the
men and women who do a very difficult job, very demanding job
day in and day out. We appreciate, love them, and care for
them. They have our thoughts and prayers as they have a very
tough duty, and then to add this on top of it is obviously----
I want to talk about the legal authority and what you are
able to do. Being sick is not illegal, but if they are coming
here and they are from a suspected region, a suspected country,
and they do appear to be sick, and they do not want to be
detained, if they do want to, what can you do and not do?
Mr. Wagner. So if they are not a U.S. citizen or permanent
resident, some of our immigration authorities allow us to
declare someone inadmissible to the United States if they have
certain communicable diseases. Other than that, you know, we do
screening of all the people just for overt signs of illness in
general, and then we can work with CDC on some of their
authorities to detain and quarantine or isolate sick travelers
that would have it.
Mr. Chaffetz. So if somebody is appearing to be sick and
they are a United States citizen, but they have been in, say,
Liberia, what can you do or not do at that point?
Mr. Wagner. We would closely with CDC then and use some of
their authorities to get----
Mr. Chaffetz. But what is that authority? I am just
wondering how far you can take this, what you can do or not do.
Dr. Merlin. I am not a person at CDC who is familiar with
all of CDC's quarantine authorities. But CDC has statutory
authority to quarantine people who are suspected of having
infectious diseases that are a risk to the public health. We
can do that through any of our quarantine stations, and we can
work with CBP so that----
Mr. Chaffetz. So can you help me understand what the
standard is? Is it going to be if you have traveled to those
countries, if you have the sniffles? What is the standard?
Dr. Merlin. No. I will have to get back to you on the exact
details of that. It certainly is more than you say. It would
have to be, you know, a reasonable suspicion that the person
could cause harm and infect other individuals by entering the
country, and the person needs to be placed in isolation.
Mr. Chaffetz. So if they are a United States citizen, not a
United States citizen, does that come into play?
Dr. Merlin. Not from our perspective. If they are a threat
to the public health and they need to be in isolation, we will
exercise our legal authority.
Mr. Chaffetz. So what determines the threat to public
health?
Dr. Merlin. That is an area that I am afraid I do not know,
and I----
Mr. Chaffetz. But if you do not know, how are the men and
women are supposed to, you know, be screening somebody in 2
minutes and they have got a line of 12 people behind them, they
are pressured. If you, Dr. Merlin, do not know that, how are
Mr. Wagner's people supposed to figure it out?
Dr. Merlin. I wish I knew all of these things in detail,
but we actually a division of people who focus on quarantine
and migration.
Mr. Chaffetz. I guess my concern is we are starting this
new process. You have articulated the need, and if you do not
know it, how is Mr. Wagner's--by the thousands we have to train
and teach people how to identify this and then pull the right
people out of a line. So when will you have that?
Dr. Merlin. Well, fortunately Mr. Wagner works with people
at CDC who do know this.
Mr. Chaffetz. Okay. So, Mr. Wagner, what is the answer to
this question?
Mr. Wagner. So, we will identify the travelers with the
overt symptoms. We then contact CDC for the medical
professionals to make that determination as to what meets that
standard and what the follow-up care is going to be.
Mr. Chaffetz. Is that only going to happen at the five
ports? What if it happens in Salt Lake City, and they are
coming out?
Mr. Wagner. We do that at all our locations now.
Mr. Chaffetz. There is a CDC representative at every port
of entry.
Mr. Wagner. No, we have 20 locations where they are located
at. But we have contact information for them at all of our
ports of entry, and if we encounter a traveler that has overt
signs of illness, we will contact CDC and coordinate with them.
Mr. Chaffetz. So you are going to hold those people until
CDC shows up?
Mr. Wagner. We potentially could depending on the nature of
what it is. That----
Mr. Chaffetz. So if they have got a high fever, they are
from Liberia, and they are showing up, they are trying to walk
through the port at Nogales, what are you going to do?
Mr. Wagner. I would think we would stop them and call CDC
and contact them until we could get some medical guidance about
what they wanted to do with that person. But at the end of the
day, that is going to be the medical professionals that make
those determinations, not CBP.
Mr. Chaffetz. Mr. Chairman, I guess the encouragement here
is somehow we need to CDC to come up with some really, good
teachable standards so that the people in Mr. Wagner's Customs
and Border Protection actually know what to look for and then
what to actually do. If we do not have that information, we are
going to make this job impossible. So, again, I thank you for
holding this hearing, and I yield back.
Chairman McCaul. Yes, and for clarification, though, Dr.
Merlin, you said there is a division devoted to this legally.
Dr. Merlin. Yes. There is an entire division at CDC that is
devoted to quarantine and migration.
Chairman McCaul. Do they coordinate with CBP?
Dr. Merlin. They coordinate with CBP. What I would do if
the question were asked of me by someone in the CBP section, I
would immediately get in touch with someone who knows the
answer to this question.
Chairman McCaul. The Chairman now recognizes the gentlelady
from Texas, Ms. Jackson Lee.
Ms. Jackson Lee. Mr. Chairman and Ranking Member, let me
thank you very much for this vital hearing and the expression
of the concern of the Members of the United States Congress. I
thank my colleagues for their presence. I particularly, again,
as I note thank my Chairman and Ranking Member, and I thank
several Members that are from this region. I thank them so very
much for their engagement and participation in this on-going
challenge.
I know that we will see some of our local officials on the
second panel, but I want to acknowledge them now and appreciate
all the work that the county and all of the first responders
have done in this community. We need to express our
appreciation to them. Certainly I thank all of you for your
presence here today and the very valiant work that you have
done.
Ten days ago I was at Bush Intercontinental Airport, and I
raised the red flag, not the historical flag, as I was able to
be escorted by Customs and Border Protection to look at the
very fine men and women who work there. I visited the
containment unit by CDC. We were told on the day that I visited
that my CDC team was here in Dallas. I saw the equipment that
was there. I went down to the sub-basement to look at the
amount of equipment. When I say ``equipment,'' I think it is
the Tyvek suits that are there to ensure that both CDC and
others have it. So I think that it is important for the
American public to know that stocked in many of the airports is
this kind of equipment, but I raised the red flag to ensure
that there was this kind of screening.
Publicly today I am going to make a request and think there
was an error made by not designating Bush Intercontinental
Airport as one of the sites to have this enhanced screening. I
have made a request to the President, and to the Secretary, and
to the Centers for Disease Control, and I hope that this will
be responded to. Again, this is a red flag. This is not
hysteria. It is based upon the travel that comes into Bush
Intercontinental Airport.
Let me also say that it is not West Africa, and all of us
must be restrained in how we define it. It is particular
countries such as Guinea, Liberia at this time, and Sierra
Leone. In fact, I offer this headline that says ``Sierra Leone
Leader Pleads for Ebola Aid,'' which means that we are
interrelated.
The President has done a remarkable job, and I want to
thank him for the 130 civilians, the ETU units. These are the
containment units that have been set up. The 50 site burial
teams, and of course, $350 million and another $700 million, I
believe, that I hope that the Congress and all of us will
convince the Congress to support. I especially want to thank
the men and women of the United States military, particularly
from Fort Bliss and Fort Hood that are now on their way or soon
to be on their way.
But let me raise this question. I took the time to talk to
some of our medical professionals at Baylor and the Harris
Health System, which is our county health system. They
indicated that--let me stop for a moment and join my colleague
by expressing my sympathy to Mr. Duncan's family, and, again,
pray for them as they mourn his passing, and take a moment to
do that.
But I want to just relate to you where I think
infrastructure and practical implementation may be two distinct
things. We have the greatest health system in the world, but
are we practically prepared? I do not think that we are
practically prepared, and that is why we are having this
oversight hearing.
If you have any indication of an Ebola patient, I would
think with not any condemnation, you clear out any hospital.
Patients are not going to come. So the question is: Do we need
to--Dr. Merlin, I just need a yes or no--do we need to put
contagion units together?
I hear from my health professionals in this flu season that
hospitals are saying when persons have those similar symptoms
and they are just an average citizen, that they are getting
pushback on the ambulances to bring people with those kinds of
symptoms. You have already indicated it is vomiting. It is
quite different, but they are alike, similar. Do you think it
would be appropriate to have those kinds of units? I know you
are seeing them in the hospitals. Do you think they need to be
separately placed?
Dr. Merlin. I understand the question, and, no, I think
that all facilities need to be able to care for people who
present to those facilities for care. We cannot rely on
individuals to present to selected facilities. All facilities
need----
Ms. Jackson Lee. Let me go on----
Dr. Merlin. Sure.
Ms. Jackson Lee [continuing]. To the next question, and I
want to ask one to Mr. Wagner before my runs out. This question
goes to the two medical persons. I am told that in a survey by
nurses that they are telling me across the country, 80 percent
are saying that the hospitals have not communicated to them any
policy regarding potential admission of patients infected by
Ebola. Eighty-five percent say their hospital has not provided
education on Ebola with the ability for the nurses to interact.
I am going to ask to put this into record. One-third say their
hospital has insufficient supplies of eye protection, face
shields, et cetera.
Chairman McCaul. Without objection.
[The information follows:]
Press Release Submitted For the Record by Honorable Jackson Lee
even after dallas, hospitals still lagging in preparation for u.s.
ebola patients
National Nurses United Press Release, 10/6/14
85% say their hospital has not provided proper training,
education in response to possible Ebola infection
News of the first confirmed patient in the U.S. infected with the
Ebola virus still has not led to effective communication with
registered nurses who would be among the first to respond and interact
with patients possibly infected, according to survey responses from at
least 1,400 registered nurses across the U.S.
National Nurses United is stepping up the call on U.S. hospitals to
immediately upgrade emergency preparations for Ebola in this country.
``Nurses know that what is critical now in the face of this deadly
disease is to spread readiness, not fear. It is Ebola today, but other
infectious diseases are not far away. All hospitals need to take steps
now to protect patients, frontline caregivers, and public safety,''
said Bonnie Castillo, RN, who directs NNU's disaster relief program,
Registered Nurse Response Network.
Several weeks ago, National Nurses United began surveying
registered nurses across the U.S. about emergency preparedness. Most of
the nurses are telling NNU that they remain unaware of proper
preparation for the Ebola virus.
As of Monday morning, about 1,400 RNs at more than 250 hospitals in
31 states have responded to the NNU national survey. Notably, the
number of RNs responding has more than tripled since the news of the
Dallas case--and yet the overwhelming number of RNs voicing concern
over lack of preparedness at their hospitals has showed virtually no
improvement.
Current findings show:
Nearly 80 percent say their hospital has not communicated to
them any policy regarding potential admission of patients
infected by Ebola.
85 percent say their hospital has not provided education on
Ebola with the ability for the nurses to interact and ask
questions.
One-third say their hospital has insufficient supplies of
eye protection (face shields or side shields with goggles) and
fluid resistant/impermeable gowns.
Nearly 40 percent say their hospital does not have plans to
equip isolation rooms with plastic covered mattresses and
pillows and discard all linens after use, fewer than 10 percent
said they were aware their hospital does have such a plan in
place.
NNU is calling for all U.S. hospitals to immediately implement a
full emergency preparedness plan for Ebola, or other disease outbreaks.
That includes:
Full training of hospital personnel, along with proper
protocols and training materials for responding to outbreaks,
with the ability for nurses to interact and ask questions.
Adequate supplies of Hazmat suits and other personal
protective equipment.
Properly equipped isolation rooms to assure patient,
visitor, and staff safety.
Proper procedures for disposal of medical waste and linens
after use.
``Handing out a piece of paper with a link to the Centers for
Disease Control, or telling nurses just to look at the CDC website--as
we have heard some hospitals are doing--is not preparedness. Hospitals
can and must do better, and we should have uniform national standards
and readiness,'' Castillo said.
The Dallas case, where the infected patient was sent home after
arriving at the hospital, hardly provides any reassurance, said NNU.
Media reports have indicated that the Dallas patient's exposure was
not properly communicated to hospital staff. But, Castillo added, it's
not just a failure to communicate, but also a reminder that hospitals
should not just rely on automated protocols with computerized scripts
for interacting with patients.
``It's time to move from the electronic computer plan to a national
healthcare action plan,'' said Castillo. ``We have the expert nurses
and physicians, we have to train and drill with the whole team, from
triage to treatment to waste disposal.''
``As we have been saying for many months, electronic health records
systems can, and do, fail. That's why we must continue to rely on the
professional, clinical judgment and expertise of registered nurses and
physicians to interact with patients, as well as uniform systems
throughout the U.S. that are essential for responding to pandemics, or
potential pandemics, like Ebola,'' Castillo said.
Finally, Castillo said criminalizing the patient in Dallas or
elsewhere is ``exactly the wrong approach and will do nothing to stop
Ebola or any other pandemic.''
NNU is also calling for significant increases in provision of aid,
financial, personnel, and protective equipment, from the U.S., other
governments, and private corporate interests to the nations in West
Africa directly affected to contain and stop the spread of Ebola.
Ms. Jackson Lee. Your answer to how you are going to get
all hospitals prepared, and, Mr. Wagner, your answer on
airports that are not in this scheme of several airports, what
are your men and women doing, and where do they take these
patients if they find they are infected? Dr. Merlin, you can
answer about this survey by nurses who say that they are
actually not prepared.
Dr. Merlin. That is concerning, and we will reach out to
our State and local health departments and medical and hospital
associations to see that those things are addressed. Nurses
need to feel that they practice in a safe environment and that
they can deal with patients who are potentially infectious,
whether it is something like Ebola or something as simple as
influenza. They need to have the needed personal protective
equipment, and we will follow up on that.
Ms. Jackson Lee. Mr. Wagner, if he is able to answer the
question. What are you doing in airports that are not in this
five-member----
Chairman McCaul. If the gentleman would answer the
question. We do need to keep to the 5-minute rule. We have 16
Members of Congress. Go ahead and answer.
Mr. Wagner. Okay. So any location outside of the five, what
we will do is we will identify their travel as originating from
one of those areas, and we will provide them with an
information notice about the symptoms of Ebola and where to go
for help and assistance if they start to develop these symptoms
and where they can go get additional information.
Chairman McCaul. Thank you. The Chairman now recognizes Mr.
Sanford.
Mr. Sanford. Thank you, Mr. Chairman, and, again, thank you
for holding this hearing. Thank the Ranking Member as well.
What I am hearing back home is that people are really
concerned about the disconnect between what they see and what
they hear. So, what they are hearing is it is not communicable.
People are relatively safe. But meanwhile they are seeing
pictures of people coming out of buildings wearing space suits,
and what people are telling me back home is, I do not have a
space suit, how am I safe? So there is a real disconnect
between what they are seeing in terms of the imagery and what
they are hearing.
I would also, though, follow up on the Chairman's point. It
was your words, Mr. Merlin, just a few moments ago that this
disease was ``ferocious.'' Your words were that it was
spreading exponentially, and it was the largest outbreak ever
of Ebola. I asked our staff to look at, you know, how we
treated some of these things in the past. One of the big
benchmarks they used was the Spanish flu of 1918 which killed
millions around the world, and the different protocols between
New York City and at that time Pittsburgh, which were two of
the bigger cities on the East Coast. New York immediately
implemented quarantine. Pittsburgh waited a month, and as a
result, very, very different results in terms of death in those
respective cities, New York faring quite well relative to
Pittsburgh.
So, what people have been saying to me back home is that,
well, wait a minute, if this thing is as virulent as some folks
suggest, why in the world of quarantine are we going to let
people fly from that part of the world--and this is following
up on the Chairman's question that he is getting from his
constituents as well--to this part of the world? What you said
just a moment ago was we need uninhibited travel, but last time
I checked, the 101st Airborne, they do not fly on Delta. I
mean, military air can get resources, people, health
professionals in without having civilians going in and out.
Then the second thing you said was we want to prevent these
countries from collapsing economically. I think that that
overstates the case. I mean, from a U.S. standpoint, certainly
what happens economically in Guinea or Sierra Leone is not
going to drive the American economy and vice versa. From the
opposite end, we have had a travel embargo with Cuba for about
50 years now. It has not crippled the country.
So, it seems to me, again, what a lot of people back home
are saying to the Chairman's point and question is, why would
you not just, you know, if you are over there, we are not going
to issue a travel issue coming over here until we get this
thing sorted out? Because going back to my colleague from
Utah's question just a moment ago, it seems to me that there is
a real mismatch between, well, CDC is saying, well, you know,
Border Patrol folks have got it, and they are pointing to
health care professionals. Until we get all that sorted out,
why would you not just say let us just wait on travel right
now?
Dr. Merlin. Congressman, those are very good questions, and
they are understandable questions. I have to admit that I wince
every time I see the TV images with people in space suits
because it gives an impression about the infectivity of the
virus that is not realistic. It is an overreaction, and I think
it flames people's fears about Ebola and how Ebola is spread.
Doctors Without Borders has taken care of Ebola patients for
years by using established personal protective equipment that
does not include those sort of space suits that you see on
television without acquiring infection in their workers. So,
some of this is unfortunately media-driven.
As to the difference between the influenza epidemic of 1918
and Ebola, there are really major differences----
Mr. Sanford. Understood, but I see we have gone to a yellow
light, and we have a couple of seconds left. But why not,
again, prohibition on civilian travel from this part of the
world, that part of the world? If you are over there, do not
come here. Why not?
Mr. Wagner. We feel that that would cause the disease to
grow in that area and to spill over into other countries, and
then spill over more into the United States, and the real
opportunity now is to put out that disease there. Every travel
restriction that has been placed on travel into that area has
interfered with people who are trying to help not being able to
get there, either travel restrictions or reduction in air
travel.
It is not just the U.S. military, you know. It is people
from Europe. It is people from China. It is people from Cuba
who are trying to get there to help. It would make doing what
we need to do harder, and that is why we ask the American
people's understanding of that.
Mr. Sanford. I hear you. I have questions on that, but my
time has expired. Thank you, Mr. Chairman.
Chairman McCaul. I thank the gentleman, and Mr. Barber is
recognized.
Mr. Barber. Thank you, Mr. Chairman, and thank you, Ranking
Member Thompson, for convening this very important hearing
today. People back home are concerned, and I came here to ask
questions on their behalf as well as to get answers.
But before I do that, I just want to extend my condolences
to Mr. Duncan's family and to all of the people in the
countries that are affected. I think the video we have seen on
television of the suffering in Africa just touches our hearts,
and I know the United States is mobilizing to help. So, I
commend our men and women in uniform for taking this mission
on. I know they will do an incredible job building facilities
to help care for those who are sick. I also, Commissioner
Wagner, want to commend your men and women because you are
really on the front line when it comes to how do we make sure
that we control people coming in who might be bringing this
disease to our country.
I appreciate what the Chairman said earlier about this not
being a political issue, and we have to make sure we avoid
making it one. This is an American issue for the safety of the
people we represent, and it is an American issue for what we
always do so well, and that is help other countries who are not
able to do what they need to do for themselves.
I do hope, Mr. Chairman, as we look at what is needed here
today that we as Members of Congress will return after the
election fully committed to providing the funding that is
necessary, to provide the resources that are necessary, for CDC
and for our men and women who are trying to protect the Nation
and address this disease.
I want to go to the question that has come up now a couple
of times, Commissioner Wagner, about how it is that we control
or manage travelers coming from the countries that are most
affected today. I understand the concerns about stopping
flights, but let me suggest another possible measure to you and
get your reaction. Would it be helpful to require individuals
who are not U.S. citizens or permanent residents traveling from
the countries that are affected, to require them to go to the
local American consulate or embassy in their respective
countries to get a visa, and perhaps we could implement some
screening at that location before people actually embark for
the United States. Could you comment?
Mr. Wagner. Well, they have to have a visa already to come
here, part of that process. It does make a person inadmissible
to the United States if you have any number of communicable
diseases. Once they get that visa, if they develop that disease
or that illness, upon entry into the United States, as part of
our immigration authorities and admissibility questioning and
inspection process, we will be alert for overt signs of illness
of a person.
Mr. Barber. Well, can I just interject, though? I
appreciate that people have to have a visa. I guess what I was
going at, and maybe this is a question for the State
Department. Could we not implement at our consulates or
embassies the same kind of screening procedures that you are
implementing and perhaps even beyond what you are implementing
at people coming into our country? It seems to me if we could
catch the disease before it actually embarks, we would be in a
much better place to protect the United States and the citizens
of the United States.
Mr. Wagner. Yes. I would have to defer to the Department of
State on that one if everyone had to, say, reapply for a new
visa subject to that level of condition.
Mr. Barber. Well, let me turn next to Dr. Merlin. I just
want to commend the CDC for taking on this incredible
challenge. I have a lot of confidence in what the CDC does for
our country. But I am also cognizant that unfortunately the CDC
has been impacted heavily by budget cuts over the last several
years, and I hope when we return, as I said earlier, we will
take a look at what you need to make sure that this job is done
with the resources that are needed.
You mentioned earlier, Dr. Merlin, that we have known about
this disease for 30 years. I have one question as my time is
running out. Is it not possible, and perhaps it is already
underway, for us to develop a test that would understand the
nature of the illness in an individual before we have to wait
21 days? Can we not examine that person in another way rather
than waiting for the disease to be apparent?
Dr. Merlin. Congressman Barber, that is an excellent
question, and it comes up repeatedly. We have currently no
diagnostic test that will detect Ebola before an individual
develops symptoms. In fact, our current testing may not detect
Ebola in the first 3 days of illness. If there is a patient who
is suspected of having Ebola and the first test is negative, we
often recommend a second test at 72 hours.
I think that is a good challenge, and it would be very
helpful to have a test like that. Developing tests to perform
on asymptomatic individuals is very difficult because you need
to find a target. You need to find something that is
distinctive and present enough in the infected individual and
the non-infected individual. That is very hard to do.
Mr. Barber. I appreciate it. Mr. Chairman, my time is up.
Let me just close by saying I think we ought to redouble our
efforts to do just such testing. I think it would be very
useful to our efforts to control this disease. Thank you, Dr.
Merlin.
Dr. Merlin. I will take that back. Thank you.
Mr. Barber. Thank you, Mr. Chairman.
Chairman McCaul. The Chairman now recognizes the gentleman
from Florida, Mr. Clawson.
Mr. Clawson. Thank you for coming here today. Appreciate
your service to our country, and I know how hard you all are
working now to keep us safe. Thank you to the Ranking Member
and Chairman for doing this committee meeting, particularly
here in Dallas. Good job. We have great first responders in our
country. Having lived large parts of my life overseas, I just
think it is not comparable to anywhere else that I have seen. I
want to congratulate you all on that, those of you involved in
that, first of all, and really say it is a good job.
I am worried now about our first responders that are going
to Africa, so my first question is to Dr. Merlin. You know, we
are going to have 3,200 troops that are not medical experts in
these mobile labs, as I understand it, doing testing and so
forth. So my first question is to you all regarding that. Are
our Good Samaritans going to be okay here? Are our Good
Samaritans going to be safe? That is the first thing that
popped in my mind. I have so many veterans in my district. Are
our first responders going to be okay to go to Africa?
The second thing I wanted to ask is how long until we do
have a vaccine? What will it take to get there? If I understood
this morning you all saying this a highly infectious disease,
Dr. Merlin, is that right? Fatal up to 90 percent? If I heard
you right, not necessarily contagious like influenza. Okay. It
sounds still pretty deadly. So, how far out is a vaccine?
Then my question to Mr. Wagner, you talked about the
enhanced efforts, and you are going to get us more information
on exactly procedurally what that means. How long until you are
there? I remember after 9/11, it took us a while for TSA really
to get up to speed, and they are a lot better at what they now
than right after the disaster, and a similar analogy. How long
until you think that you are confident that there are no holes
in the security wall that is your force? If you all would
answer these questions for me, I would really appreciate it.
Dr. Merlin. Thank you, Congressman Clawson. The safety of
anyone who we deploy in an epidemic like this is of utmost
concern. We are putting people in harm's way by having them go
to someplace where they might get infected. We, working with
our partner organizations and DoD, do training and provide
personal protective equipment or coordinate the use of personal
protective equipment to keep people from getting infected. Our
military forces are going to be not on a treatment mission.
They are not going to be providing direct care, but they are
going to be doing logistical work, but still it is a concern.
We will do everything possible to prevent people who are trying
to help from getting infected.
Mr. Clawson. I think the goal here is zero.
Dr. Merlin. I agree. I agree completely. Now I am
forgetting your second question.
Mr. Clawson. Vaccine.
Dr. Merlin. Vaccine. You know, I would prefer that the
National Institutes of Health, which is responsible for
overseeing the vaccine development, and BARDA speak to the
actual time tables for development. Fortunately, there are
candidate vaccines available that have shown efficacy in non-
human primates, but before administering those vaccines to
people, you need to be absolutely sure that they do no harm to
people when you administer them to people. Those trials are
going on now. Then you have to know the right dose to
administer, and you have to have the manufacturing capability.
I know that the agencies are working simultaneously to do
those trials and ramp up the manufacturing capability. But both
BARDA and NIH are better to testify on that than I am.
Mr. Clawson. Do those trials in these sorts of days of
crisis, do those trials go to the top of the heap?
Dr. Merlin. Yes.
Mr. Clawson. Because there is quite a backlog, as you know.
Dr. Merlin. They have gone to the top of the heap. I can
assure you of that.
Mr. Clawson. Thank you. Mr. Wagner.
Mr. Wagner. Today we screen all travelers for any over
signs of illness for a host of communicable diseases, from
measles, to tuberculosis, to H1N1, to MERS, to SARS, you know,
including, you know, symptoms of Ebola. What we are kicking off
Saturday at JFK is some extended procedures about taking
people's temperatures and asking them very specific questions
about contact with people who have Ebola and then working
closely with the CDC to get those people that answer
affirmative or have a temperature in getting them into some
professional medical care to address that.
All the other locations will continue to--I think we have
four other locations--I am sorry--that will kick off following
Saturday at some point next week. That will cover about 94
percent of all of the travelers to the United States coming
from those three regions. All our other locations will continue
to identify any travelers that go to those locations.
Mr. Clawson. Can I butt in real quick?
Mr. Wagner. Yes.
Mr. Clawson. That means you are doing face-to-face training
right now in those airports with those officers so that we will
have an upgraded procedure starting almost immediately.
Mr. Wagner. We have on-going training. We have an annual
certification for all officers about blood-borne pathogens and
diseases. Our Basic Training Academy covers a lot of the work
with CDC and recognizing signs of illness and the protocols for
handing that person off to CDC for the medical care. That is
on-going and continuous. We have done that for a number of
years going back to a lot of our pandemic planning with SARS,
and MERS, and a lot of the other contagious illnesses out
there.
Mr. Clawson. Thank you all three.
Chairman McCaul. The Chairman recognizes Mr. O'Rourke.
Mr. O'Rourke. Thank you, Mr. Chairman. For Dr. Merlin, my
understanding is that there are experimental treatments for
Ebola, and that Mr. Duncan was diagnosed on the 30th of
September, but did not receive treatment until the 4th of
October. Give me your thoughts on that and whether or not that
might have contributed to his death; in other words, the delay
in his receiving that treatment.
Dr. Merlin. Yes. The people who understand best the
decision-making process around whether and when to administer
experimental therapies to the patient are really the care team
providing care for the patient, and the patient, and the
patient's family. We at CDC, our job is to make the public
health officials and the team aware of what experimental
therapies are available and how to go about acquiring them.
Sometimes we facilitate that, but we do not actually----
Mr. O'Rourke. You do not have authority to order a specific
treatment, so that would be a question better asked to the care
team.
Dr. Merlin. Exactly.
Mr. O'Rourke. Let me then move on to my next question. We
have talked a lot about airports and what we are doing to
screen their capacity, training, protocols. What--from a public
health perspective, and then I am going to ask Mr. Wagner from
an operational perspective. What are the threats at our other
ports of entry, sea ports and land ports, from a public health
perspective?
Dr. Merlin. We have had already a number of cargo ships
that come in all the time with people who are sick on the
ships. Often, you know, the Coast Guard is the sort-of first
line of defense on that. They engage with the Coast Guard, and
then usually with, I believe, with CBP and with us to determine
what the best course of action is with the person on a ship.
This is more complicated because often there is a question
of how long the person has been on the ship, and where the ship
has been, and what the person's nature of exposure was. So
these are harder cases to deal with, and they are also harder
because often the person who is sick on the ship is gravely
ill. It is a more difficult situation to deal with.
Mr. O'Rourke. Mr. Wagner, what capacity do we have at these
other ports to handle potentially infected travelers?
Mr. Wagner. The land border is a lot more challenging
because we do not have the advanced notice of the travelers'
itinerary or their arrival. So, again, we would be alert for
any overt signs of illness, and through our routine
questioning----
Mr. O'Rourke. CBP Officers at land ports are receiving that
training to know now to look that?
Mr. Wagner. Yes. Absolutely, yes, all our officers get
that. So during their normal processing of a traveler, if they
see these signs of illness, they have the contacts with CDC to
get the medical professional advice on what to do and for
follow-up for the traveler. But tuberculosis, measles, other
communicable-type diseases, you know, we do see coming across
the border.
Mr. O'Rourke. My last question, again, for Dr. Merlin, CDC
administers public health emergency preparedness grants, $640
million that go to all States. What concerns or questions do
you have or answers for us about accountability for how that
money is spent and used, especially given some of the mistakes
made in Dallas with the handling of Mr. Duncan's case? What
recommendations, if any, do you have going forward in terms of
additional accountability and potentially additional resources
if you feel that those are needed?
Dr. Merlin. That is a very good question, Congressman. I
think we need to assure that, and steps have already been taken
in this, that the PHEP grant and the hospital preparedness
grant programs are well-coordinated. That both grants assure
that not only health departments, but facilities are well-
prepared for potential and infectious disease emergencies, and
that we sort-of have a seamless system.
You know, prior to about 2 years ago, the grants were
administered independently, and now they are better-
coordinated. But we need to be sure that the guidance is
reaching the people in the facilities who will encounter the
patient for the first time and they know how to respond, and
that they are exercised. They are not simply protocols that are
put away, that they are things that people know how to do.
Mr. O'Rourke. We will submit for the record some questions
that try to get to the root of this, whether that money is
being well-spent right now or whether we have the appropriate
accountability to ensure that we have the training in place,
especially given some of the mistakes that were made. I would
love to get your answers to those in a little more specificity.
Thank you. With that, I yield back to the Chairman.
Chairman McCaul. The Chairman recognizes the former
Chairman of the Energy and Commerce Committee, Mr. Barton.
Mr. Barton. I am glad to be recognized, Mr. Chairman, and I
am glad to be a junior member ad hoc of your committee today.
[Laughter.]
Chairman McCaul. We are glad to have you.
Mr. Barton. You and Mr. Thompson are holding a good
hearing, and I am glad to be a small part of it.
Mr. Chairman, I want to feed off of the very first question
that you asked in your question period. I think this is a
serious issue. It is obvious that people are affected by it. It
is very obvious that people are concerned by it. Here in the
North Texas region, it is real. We have had an Ebola case. An
individual not from the area who was traveling to the area has
contracted the disease and has died, so it is not academic.
But first and foremost, this should be treated, I think, as
a public health issue. It is not an international diplomacy
issue. It is not a foreign policy. It is not a civil rights
issue. It is a public health issue. In the community that I
actually live in, Ennis, Texas, about 3 years ago a teacher
contracted tuberculosis, was teaching his class. One of his
students contracted the disease.
When that became known, the Texas Department of Public
Health, which is going to testify on the next panel, came into
the school district, interviewed all of the students
immediately in the class, quarantined some, monitored some,
came down, held a public hearing that I helped facilitate. But
that was treated immediately as a public health issue and dealt
with in such a way that there were no other cases contracted of
TB.
It really does not appear to me right now that we are
treating this primarily as a public health issue. Dr. Merlin,
in a direct response to Chairman McCaul about why we do not
stop flights from these countries in Africa, your response was
because we need to send people and supplies over there to
combat the disease. Well, obviously that is something that
needs to be done. But as Governor Sanford pointed out, you do
not have to have commercial flights to send flights into a
country.
If we were really treating this as a public health issue,
why would we not immediately stop these flights, and then on a
case-by-case basis send equipment and people as necessary, and
on a case-by-case basis allow people to come out? Why do we
have to have commercial flights that under the best of
screening procedures that you have talked about, you are almost
guaranteed mathematically to miss some people?
So with due respect, I do not accept that answer that we
cannot stop flights simply because we need to get people in. Do
you have a response to that--or maybe Dr. Brinsfield might want
to respond, too.
Dr. Merlin. Well, Mr. Barton, I understand, and our
experience has been that when there are interruptions in air
travel, it impedes the public health response. Although there
might be work-arounds, like military transport, that is
difficult, and right now, time is of the essence in what we do.
Mr. Barton. Well, who makes that decision? Is that a
Presidential decision? Is that a Secretary of State decision?
Is that a Secretary of Homeland Security decision? Who makes
that decision about banning flights?
Dr. Brinsfield. So, sir, I would just like to point out,
and I will defer to Chief Wagner here, that there are no direct
flights from those areas, so that it is more an issue of what
people are on flights coming from the intermediate airports.
Mr. Wagner. Correct. So there are no direct flights from
those three affected regions. These travelers are going to
Brussels, Ghana, London, Paris, and Morocco to come here, and
it may just be a couple of people on a single flight of 300 or
350 people. You may have----
Mr. Barton. Well, you could still ban it. I mean, you could
still. The gentleman who came from Liberia through, I believe,
Brussels, he could have been stopped in Brussels or not even
allowed a visa to leave to go to Brussels.
Dr. Brinsfield. I think that is the most important point,
sir. At that point we defer to our colleagues at State, and
there is a good coordination process around those questions.
Mr. Barton. But my question on the table is: Who makes the
decision? Is it the President, or the Secretary of State, or
the Homeland Security, or who makes that decision?
Dr. Brinsfield. Sir, I would defer to the interagency
process that is on-going under the President on this one.
Mr. Barton. So it is the President?
Dr. Brinsfield. I would say that there are many different
actions that you have discussed here, one related to visas, one
related to flights landing. Those are different authorities. If
the Department of State or Department----
Mr. Barton. I know my time is expired, Mr. Chairman. Could
a Governor of a State or could an airport authority ban flights
from a particular region, or that has to be done at the Federal
level?
Mr. Wagner. Sir, most of the airports are landing rights
airports, and they request permission from Customs and Border
Protection to land. So I think it is a question more for the
airlines and the airport authorities on what business they
choose to do or not do.
Mr. Barton. So theoretically DFW Airport could ban a flight
from a passenger coming----
Mr. Wagner. I would have to defer to them on what business
decisions they make and where to fly to and which airlines they
go to.
Mr. Barton. Thank you, Mr. Chairman, for your courtesy.
Chairman McCaul. Thank you. The Chairman recognizes Mr.
Vela from Texas.
Mr. Vela. Thank you, Mr. Chairman. Dr. Merlin, I am trying
to understand, what is the scientific explanation for the
response that a travel ban would actually make things worse?
Dr. Merlin. Mr. Vela, thank you for asking that question.
We have a disease now that we understand the range of how many
people are infected. We know how many people would be infected
next month if nothing is done, and how many people will be
infected by the end of the year if nothing is done. We know the
size and the scale of the international effort. It is a
remarkable international effort that is required to stop it.
We have good projections on how many deaths will be caused
by delay, and we are very afraid that things that are done that
impede travel will delay the interventions that prevent the
progression of the disease. If the disease progresses to the
point that it cannot be stopped, it is going to spill over into
other countries and create a greater threat for the United
States.
So we feel that understandably the notion of stopping
travelers now might prevent a traveler from arriving in the
United States, though we know we can prevent an outbreak from
that. But the greater risk is that by delaying stopping the
epidemic in Guinea, Sierra Leone, and Liberia, you create a
much larger epidemic that is impossible to control. That
disease becomes endemic in Africa, and that we are dealing with
this for the foreseeable future, that we cannot stop it. What
we want to do is stop it right now. We know how to do it. We
just need to get the resources there to do it. We do not want
to do things that would impede that.
Mr. Vela. It also seems to me that there are two great
risks, and that is the spread of the disease outside those
three countries, and then following up a point Mr. Wagner was
making from the flight standpoint, from people who are
traveling from those three countries anywhere else.
What kind of international coordination are we seeing, and
I was wondering if you could maybe give us an idea. I mean, who
is helping us? What is the international community doing to
stop the spread of the virus into the other adjacent countries,
and from going to airports, like Brussels and any other point
in between?
Dr. Merlin. I can tell you from a public health
perspective, CDC regards this as a very high priority. We have
over 140 individuals deployed to not only Sierra Leone, Guinea,
and Liberia, but neighboring countries where they are involved
in working with the ministries of health and training
individuals so that they know how to detect disease early and
engage in contact tracing and break the transmission of
disease.
So what we want to happen in those countries is when an
ember of the disease lands in their country and starts a fire,
for them to be able to quench the disease as quickly as
possible, and that is the sort of public health approach. I do
not know about the air travel issue, and I would defer to my
colleagues. They may know about the coordination of air travel.
Dr. Brinsfield. I would just say that the response is well-
coordinated under the United Nations and has been for several
weeks. I would defer questions on follow-up on the
international response to them and their Department of State
partners.
Mr. Vela. Let me ask you this question. Aside from the
hemorrhaging, the symptoms of the virus appear very similar to
any severe flu. Are there any other distinctions?
Dr. Merlin. In clinical presentation, early clinical
presentation, no. It is unfortunate that it has the name of
viral hemorrhagic fever because only a minority of patients
develop bleeding symptoms, and that is late in the course of
the disease. So early in the course of the disease, the first 3
days, it is a flu-like illness. It is fever, malaise. There is
nothing about the clinical presentation that would make you
know it was Ebola. After about 3 days, there is usually
profound nausea, vomiting, and diarrhea, and that is what my
colleagues and I, when we hear stories about people presenting,
that what really raises the flag that this might be Ebola.
So the travel history and exposure history are very
important to include with the early symptoms to understand
where someone might actually have Ebola. You cannot tell just
on the symptoms alone. You need more information.
Mr. Vela. Is my time up? Thank you.
Chairman McCaul. The Chairman recognizes Dr. Burgess, who
actually practiced at Dallas Presbyterian Hospital.
Mr. Burgess. Thank you, Mr. Chairman, and I thank our panel
for being here. Dr. Brinsfield, Mr. Wagner, appreciate you all
spending time with me on the telephone earlier this week. It
was very helpful, and I am sure we will continue to have
discussions as this story evolves.
We are appropriately respectful of the passing of Mr.
Duncan. I think we also ought to acknowledge the passing of
Patrick Sawyer at the end of July. Mr. Sawyer was an individual
who worked in Liberia, commuted to there from his home in
Minneapolis. After attending his ill sister in Liberia, flew on
to Lagos. Before he could board the plane back to Minneapolis
died of Ebola, and could have been Patient Zero 2 months before
we had the experience here.
So, Dr. Merlin, I guess my question is, I am sure there
will be after-action reports on the case that occurred here in
Dallas. Did you do any study of what might have happened had
Patient Zero arrived in Minneapolis on July 30?
Dr. Merlin. Congressman Burgess, I am not aware of that,
and I will have to get back to you on that. I do not know.
Mr. Burgess. Well, the reason I asked the question, and Ms.
Jackson Lee, I think, put it pretty clearly, you have a
situation at Presbyterian. A nurse does an intake evaluation,
and apparently some travel history is given that perhaps
provided a really important clue that was subsequently lost in
all of the activities involved with treating the individual.
From the CDC standpoint, are you concerned at all with the
directives and missives and action alerts that you have putting
out for months that somehow they were not getting through to
the front line, to the people at the triage desk? Because
really there was only one response: I am here for a fever and a
stomach ache. I have traveled from Africa. Put down the iPad.
Go through that door with the two men in moon suits. We will
meet you and walk you into an isolation unit. Really that is
the only response; is that not correct?
Dr. Merlin. Congressman Burgess, I agree with you. As
someone who has worked in a hospital and in an emergency room,
I am sure you know that things in retrospect are often a lot
clearer than they are when present.
Mr. Burgess. But from a CDC perspective, you have put out
these directives to the hospitals, to the people on the front
lines. You know, this is not the flu as usual. You have got to
be thinking about this. If I am at CDC, I have to be concerned
that that message did not get down to the front line. Not to be
critical of anyone. Not to be accusatory of anyone. But the
message did not get to the front line. What are you going to do
now differently to make sure that message does get to the
people on the front line, because that is really the critical
part that was missed?
Dr. Merlin. I think what we need to do is to work with the
regulatory organizations, like the Joint Commission, to be sure
that compliance with preparedness is a higher priority, and
that when facilities are accredited, that it is something that
is looked at critically, and they look at whether the front
line is trained on these things.
Mr. Burgess. I would just offer that business as usual may
not get it because this is not an ordinary time with what we
are dealing with.
Now, two airlines, Air France and British Airways, stopped
going to Monrovia in the summer, I think in August. So they
just simply on their own decided they were going to stop
service there. I know people have asked me. The President
actually suspended air operations through the FAA into the
airport in Israel for a while this summer while there was some
bombing going on, so we know that authority exists.
Okay. Mr. Thompson provided this nice graph, and Dr.
Brinsfield, you will recognize this graph. This is a classic
growth curve. You have got a lag phase. You have got a log
phase, the log phase, the phase of logarithmic growth, the
exponential phase. In two countries at least it appears--Sierra
Leone and Liberia--they are in the logarithmic phase. Dr.
Fouts, he said in another hearing that I was at in Washington a
few weeks ago that when you get to logarithmic, when you get to
exponential growth, exponential always wins.
So my question is: Where on this line is the threat matrix
such that you would recommend to the President we have got to
do something different, and we have got to stop this disease,
and not allow it to be imported to our country, but this does
not come in through a migratory flyway? It is not like pandemic
flu. You can only get Ebola if you go get it and then bring it
home. So where is the point on this graph where that would
occur?
Dr. Merlin. We are already at the point where we believe
that all stops needs to be pulled out in preventing the growth
of the disease in Africa, and that is what we need to focus on
because the risk in this country will not be eliminated until
we eliminate the spread of disease in Africa.
I think that comes down to the crucial point is that we
will not be safe until we stop the growth of that disease
because it has now infected so many people, and it is
reproducing so quickly that unless we stop it, it will
inevitably become endemic, and it will inevitably be a greater
threat. So I think the President has already taken the message
out to the American people and to the United Nations that this
is the time. The opportunity space is right now.
Mr. Burgess. Dr. Merlin, I know my time is up. With all due
respect, I disagree with you. I do not think the President has
put a significant amount of importance on this. I have not
heard the President say this is the time of zero defects. We
have got to do everything perfectly. Doctors Without Borders,
that has been their experience over in those countries. They
have a low infection rate even though health care workers have
a high infection rate because they do everything by the book
every time, and we need to adopt that same attitude here.
Thank you, Mr. Chairman. You are very kind.
Chairman McCaul. The gentleman's time has expired. The
Chairman recognizes Mr. Swalwell form California.
Mr. Swalwell. Thank you, Mr. Chairman, and thank you to our
panelists. What I have taken away from this hearing and what we
have learned over the past month is we have to fight this
aggressively, and, most importantly, over in the countries
involved in West Africa. To that, we have to be prepared here
locally, whether it is the airport screens that take place or
the hospitals that are ready. Also, No. 3, that we have to bust
some of the myths out there that are creating, I think,
unnecessary hysteria.
So I want to first start with what we can do here locally
with the airport screens. Mr. Wagner, we know that every day
about 1.75 million people are in the air in the United States.
We have about 100,000 pilots, 95,000 flight attendants who are
on the front lines who could be exposed to this. I think some
good questions are rightfully being asked.
So, one of my concerns, although we have five airports that
are now going to have intensified screenings, what would happen
if somebody were to fly from, say, Brussels to Dallas-Fort
Worth Airport, and then, like many foreign travelers, stuck
around in the United States for 2 to 3 weeks and went from
Dallas-Fort Worth to, say, San Francisco International Airport?
That is not one of the five designated airports. Would that
person who perhaps did not present symptoms at DFW, but started
to present symptoms as they went into San Francisco, is there
anything there that would allow us to screen that individual?
Mr. Wagner. Well, Customs and Border Protection is only
going to screen them on their initial entry into the United
States. So when we see them coming into DFW, we would identify
that travel as having originated in one of those three areas.
We would have provided them the information notice about
symptoms to watch out for and where to go and seek help. The
information notice also has a message to the doctor that they
can provide. But then we are relying on that person wherever
they travel within the United States, if they start to develop
those symptoms, they need to go get the proper medical care and
get the medical authorities to make that determination that is
it Ebola or is the flu or is it something else.
Mr. Swalwell. Sure. Dr. Merlin, as far as our local
hospitals, I am having a conference call with all of our
hospital officials on Tuesday. What are we doing to reach out
to them to make sure that they know what to look for if a
patient comes in and has been traveling to some of these West
Africa countries and is presenting symptoms?
Dr. Merlin. We have been communicating with hospitals
through a variety of mechanisms. We have an established email
electronic communication, a health alert network, that goes to
thousands of facilities and providers in the country. We have
been working with our State and local partners to reach out to
facilities and physicians. We have a regular conference call
called the COCA call, which is a clinical outreach call, where
I believe one of the ones recently on Ebola had about 6,000
participants on it.
We have been working through the medical societies. There
were a lot of presentations. This is Infectious Disease Week,
and the Infectious Disease Society of America just had its
meetings, and there were a lot of presentations on Ebola. We
have a large group in our Emergency Operations Center that
regularly now is having outreach calls to either individual
hospitals that want questions answered or professional groups
that want to have questions answered. We have had conference
calls from, you know, single facilities to large groups of
facilities trying to help them with their preparations.
Mr. Swalwell. Dr. Merlin, my colleague, Mr. Barber from
Arizona, alluded to the CDC budget, and budgets reflect
priorities and values. I think the numbers around the CDC
budget over the past few years reflect that prioritizing public
health and addressing world-wide health emergencies have not
been our top priority when it comes to the numbers.
From 2010 to 2014, the CDC budget has steadily gone down.
From 2012 to 2013, the program level for the CDC was cut by
$293 million, which included $13 million in cuts to our efforts
to prevent and respond to outbreaks of emerging infectious
diseases. Is today's funding level for the CDC adequate to
address the world-wide threat and what could happen here in the
United States? Would you like more, and if you had more, what
would you do with it?
Dr. Merlin. The response to that I would defer to the CDC
director and HHS. I am not in the position at CDC where I
really understand and participate in the full budget
formulation.
Mr. Swalwell. Has your budget been cut, though, since
sequestration?
Dr. Merlin. I will have to get back to you on that. My
budget comes from multiple different sources, and I would have
to get back to you on that.
Mr. Swalwell. Sure. Thank you, Mr. Chairman, and I yield
back.
Chairman McCaul. The Chairman now recognizes the gentleman
from Texas, Mr. Marchant.
Mr. Marchant. I would like to thank the Chairman today for
holding this hearing and welcome all the Congressmen to my
district. This is the heart of my Congressional district. It is
the economic hub. Thousands of my constituents come to work
every day in this district, and as you know, 5 million
international travelers come through this airport every year.
So in response to that, I would like to submit for the
record a letter to the Honorable Jeh Johnson that I made this
morning asking for Dallas-Fort Worth International Airport to
be included or added to the list of five airports that are
going to have the increased screening and a letter from the
Dallas-Fort Worth International Airport.
Chairman McCaul. Without objection, so ordered.
[The information follows:]
Letter Submitted for the Record by Honorable Kenny Marchant
October 9, 2014.
The Honorable Jeh Johnson,
Secretary, Department of Homeland Security, Washington, DC 20528.
Dear Secretary Johnson: I am writing to strongly call for the
immediate inclusion of Dallas/Fort Worth (DFW) International Airport--
which I represent in Congress--in the list of other major U.S. airports
at which the administration has announced it will implement heightened
Ebola-related security screening protocols. DFW Airport is the third
busiest airport in the world, hosting over 1,800 flights per day and
serving more than 62 million passengers each year. As you are aware, it
was also the final U.S. arrival destination of Thomas Eric Duncan, the
first individual diagnosed with Ebola inside the United States. Action
must be taken to ensure that the people of North Texas do not suffer
greater exposure to this deadly virus.
The White House has said that five U.S. airports receive roughly
94% of the roughly 150 passengers from the three affected countries
that arrive in the U.S. each day. What risk do the remaining 6% of
passengers have on major airports, such as DFW, that have not been
selected for additional screening? How difficult would be it for
Customs to review the additional 6% of passengers, which amounts to
approximately 9 people per day? The administration should execute every
defense against persons and materials entering the U.S. to guard
against any new Ebola cases arriving in the United States.
Thank you for your review of this correspondence. Should you have
any questions regarding this letter, please feel free to contact me or
my Legislative Director.
Sincerely,
Kenny Marchant,
Member of Congress.
______
Letter From the Dallas/Fort Worth International Airport Submitted for
the Record by Honorable Kenny Marchant
October 7, 2014.
The Honorable Kenny Marchant,
Member of Congress, 24th District, Texas, 1110 Longworth House Office
Building, Washington, DC 20515.
Dear Congressman Marchant: Dallas/Fort Worth International Airport
(DFW) appreciates your concern and your leadership on behalf of our
country and your constituents. In response to your recent letter, I
want to assure you that the Airport takes our responsibility for the
safety and security of customers, passengers and employees very
seriously. DFW's role in response to infectious disease is that of
first responder to any report of anyone at the Airport who exhibits
signs or symptoms consistent with any communicable disease. DFW has in
place a robust and exercised pandemic response plan that has been
reviewed by all relevant agencies.
With regard to infectious disease control and our country's
pandemic response, DFW is part of an integrated response system under
the direction of the Centers for Disease Control and Prevention (CDC)
and local public health authorities.
We rigorously adhere to the guidelines of the CDC which has
jurisdiction in the matter of infectious disease control. As such,
procedures and protocols are in place to ensure that DFW effectively
responds to reports of infectious disease by U.S. Customs and Border
Protection (CBP) as individuals are entering the country, by airlines
for passengers or employees who show symptoms of infectious diseases of
many types, as well as reports from other segments of the travel
industry and public health community.
In addition to the CDC, in the case of our terminals, we follow the
direction of the Tarrant County Department of Public Health, which is
also responsible for public communication.
DFW will continue to take direction and guidance from the CDC and
our federal government with regard to any additional safety and
security measures deemed necessary to protect the safety and security
of our country and the traveling public.
Sincerely,
Sean Donohue,
Chief Executive Officer, DFW International Airport.
Mr. Marchant. Thank you. Mr. Wagner, there are
approximately 13,500 people from the affected areas that have
travel visas that are active at this point. What Federal agency
is responsible for knowing who those 13,500 people are and the
status of their travel?
Mr. Wagner. Well, the Department of State issues that visa,
so they would be responsible for who has them and under what
conditions. Customs and Border Protection would encounter that
individual when they arrive to the United States. Part of what
we determine in that inspection process is does that person
intend to comply with the terms of that visa, and then are
there any grounds for inadmissibility, such as a communicable
illness, that would prevent them from coming in?
Mr. Marchant. So if we indeed are at a critical point in
containing this disease, do you not think it is important or
would you not think that it is important that there be some
identifiable base of people that have come through Customs and
Border Protection that are in the United States or have
traveled in the United States that have presented their
passport, have been questioned, have been screened, and so that
we have some idea of what the number is? I mean, how many
people could this possibly have affected?
Mr. Wagner. Well, we would know how many people came into
the United States from those affected regions over the course
of, you know, any period of time. You know, where they are in
the United States, or who they have had contact with, or what
has, you know, transpired since then is a much more complex
issue.
Mr. Marchant. So DFW Airport is not usually the primary
point of entry for these countries, but as most people across
the country know, if you go anywhere in the United States, you
are probably going to have to go through DFW Airport. I think
it is very critical at this point that we understand that
people are coming into JFK and they are coming into Newark and
these other five entry points and staying 1 or 2 or 3 weeks or
4 weeks, and then they are coming through DFW Airport, and they
are going all over the country.
So I think this is a key place where we need to have an
active program of screening going on. Do we have a CDC facility
that is close? Are we are one of the 20 areas where the CDC has
a center?
Dr. Merlin. No, we do not have a staffed facility at DFW.
We may have a physical space, but it is not currently staffed.
Mr. Marchant. Mr. Chairman, I would like to request that
the CDC strongly consider DFW Airport, as well as George Bush
International in Texas, and fully staffing those. Our Governor
has just recently asked questions about whether our CDC
facilities--where they were located and how well they are
staffed.
Chairman McCaul. Without objection. Just for the record, I
submitted a letter along with Senator Cornyn to the Secretary
asking the same request. I'll include it also. So ordered.
[The information follows:]
Letter From Chairman Michael T. McCaul and Senator John Cornyn
October 10, 2014.
R. Gill Kerlikowske,
Commissioner, U.S. Customs and Border Protection, Washington, D.C.
Dear Commissioner Kerlikowske: We are writing about the decision by the
Department of Homeland Security to provide enhanced screening to
passengers from the Ebola-affected nations of Guinea, Liberia, and
Sierra Leone.
As you may know, Texas is home to both Houston George Bush
Intercontinental Airport (IAH) and Dallas-Fort Worth International
Airport (DFW) where a combined 15.6 million international passengers
visited in 2013. Neither airport has been designated for enhanced
screening. Because those traveling from Guinea, Sierra Leone, and
Liberia can transit to the United States from many other countries, we
have concerns that the current decision to screen only at five airports
may not adequately protect Americans and others traveling to America
from the Ebola virus.
Therefore, we request that you provide answers to the following
questions:
(1) According the Administration, the enhanced screening will take
place at five airports that receive 94 percent of the
passengers from the three affected countries. Where do the
other 6 percent arrive? Will other major international airports
be designated for enhanced screening procedures and additional
resources if this limited initiative does not effectively
mitigate against entry of potentially infected passengers?
(2) How many from those Ebola-affected countries enter the United
States through other ports of entry, such as sea ports and land
border stations?
(3) What other Ebola-related measures are being taken at other
vulnerable port environments, particularly at high traffic land
border ports of entry along the Texas-Mexico border? If none,
why? Will U.S. Border Patrol apply enhanced screening
procedures to those apprehended between land border ports of
entry?
(4) Please explain the tracking system in place for those traveling
from Liberia, Guinea, and Sierra Leone to the U.S. How are you
working with other countries that have connecting flights from
West Africa to the U.S. to ensure an adequate screening
process?
(5) What passenger travel documentation do Customs and Border
Protection Officers inspect when a passenger arrives in the
U.S.? Is documentation other than the origin and connection of
the passenger available for inspection?
We ask that you consider adding IAH and DFW to the list of airports
performing enhanced screening.
Thank you for your attention to this matter. We look forward to a
prompt reply.
Sincerely,
John Cornyn,
United States Senator.
Michael T. McCaul,
United States Representative.
Mr. Marchant. Thank you, sir.
Ms. Jackson Lee. Mr. Chairman, does that include Bush
Intercontinental?
Chairman McCaul. I would have to look at the letter again,
but I would concur with that as well.
Ms. Jackson Lee. Thank you, Mr. Chairman.
Mr. Marchant. Mr. Chairman, I yield back my time.
Chairman McCaul. The Chairman now recognizes Mr. Veasey
from Texas. I am sorry, Ms. Johnson, Eddie Bernice Johnson.
Ms. Johnson. Thank you very much, Mr. Chairman. My usual
appreciation for all of the people that are here, and all of
the respondees to this particular crisis.
Being a nurse, my concern really will center on the details
of why we are in this position. It would seem to me, and I know
that CDC had put protocols in every major hospital in this
country for a number of weeks prior to this happening. So, no
matter what else we do, we have got to depend on people that we
question and whether or not they give the correct information.
I know we are talking about taking temperatures, and I do
not know what other type of interrogation that they will have.
But it would seem to me that we could not sit here and plan for
the expenditure of a whole lot money that we are not going to
do when we get back to Washington, but look very closely at
what we have in place already, and to make sure that is given
the kind of attention it demands to make it work.
Now, I do not know what questions were asked when this man
went to the hospital the first time, nor do I know what
temperature he had. But it would seem to me that much of what
we are worried about right now could have been eliminated
because the protocols were in place. Now, I do not know what
happened with the protocols. But no matter how much we do to
look at every person coming in this country, we have also got
to carry out our own written protocols when they get here.
So, I am concerned about us sitting here and thinking about
all the elaborate things we can do to make things better when
we know we are not going to pay for it when we go back to
Washington. We have not yet. We do not have the money. We do
not have any more now than we did before we did it. So, I am
concerned that we not get too much pie-in-the-sky in planning,
but rather utilize what we have in place. Was there any
faltering in the protocols that were in place?
Dr. Merlin. Ms. Johnson, in terms of the adherence to
protocols and what would have happened at Presbyterian
Hospital, I really defer to the hospital itself and the local
health department, the local and State Health Department. They
are the ones who are responsible for reviewing that. I would
not want to say things because I do not know the details.
Ms. Johnson. Yes.
Dr. Merlin. But I do want to say to your point I think it
is important to move from things like protocols to things like
checklists where every patient in order to process through the
facility, there has to be a checklist and they have to check
off and sign whether they have done this, because that takes
the protocol and makes it a firm responsibility. For things
important like this, we really need to do it. That is one
approach that I do not think adds much in the way of burden and
assures better compliance with recommendations.
Ms. Johnson. Thank you very much. Mr. Wagner, what are we
going to be doing differently than what we did when the patient
entered this country? Was he not asked questions?
Mr. Wagner. So if he were to enter through Dulles next week
at some point, we will set up some enhanced level of screening.
So we will have identified him as traveling from one of the
affected regions. We would have given him a questionnaire to
fill out that we work with CDC that talks about their contact
information, their health status, do they have any symptoms in
place, and, most importantly probably in this case, have they
had any contact with anyone that has had Ebola. We would then
also refer them to a medical professional on site to have their
temperature taken.
If there any indications through that information that they
need additional medical professional review, we would then
coordinate with CDC on site to be able to have that.
Ms. Johnson. Can it not be assumed that someone comes in
from Liberia that they have been in contact?
Dr. Merlin. No. Our questions about contact really have to
do not with being around or in an area that is infected, but
really particularly whether someone has had contact exposure to
body fluids. Have they had a splash of body fluids, with their
unprotected hands touched body fluids? Have they have known a
person who was known to have Ebola? Have they been for an
extended period of time around someone who was known to have
Ebola?
One of the things that we know about the disease in places
like Liberia is it is actually patchy. There are places where
there is a lot of disease, and there are places where there is
very little disease. Our strategy out there, you know, is to
actually prevent it from beginning to spread all over the
place. We would not say in our public health line people from
those countries have had contact with the disease.
Ms. Johnson. Well then, how would you determine an origin?
If you cannot assume or at least act as if it is a possibility
coming from those areas where it is very prominent, how would
you draw the line from wherever they are coming from?
Dr. Merlin. You know, your question is excellent and I
think it ties into the question earlier about the test for a
symptomatic disease. There is no objective test. We rely on
examination, a visual, looking at the person, trying to tell
whether the person might be ill, and a person's answering a
series of questions to see whether the answers to the questions
make sense. But that is the nature of the examination. Mr.
Wagner, do you----
Ms. Johnson. Thank you--excuse me. Did I miss something?
Chairman McCaul. If we can make it brief, yes.
Mr. Wagner. No, that is correct. It depends on how the
people answer the questions and what they say to any follow-up
questions we would ask.
Ms. Johnson. Thank you, Mr. Chairman. My time has expired.
Chairman McCaul. Of course, Mr. Duncan did not reveal that
he had been in contact with the Ebola virus in Liberia, is that
correct?
Mr. Wagner. I believe so. I am not sure if he was aware----
Chairman McCaul. Dr. Merlin.
Dr. Merlin. He did not truthfully answer the questions on
the exit screening where he was asked whether he had an
exposure. It turned out subsequently that he had a known
exposure.
Chairman McCaul. The Chairman now recognizes Mr.
Farenthold.
Mr. Farenthold. Thank you very much. I am going to clean up
here. I am going to have a bunch of quick questions, and if you
could keep your answers relatively short. A lot of this is
follow-ups on other questions.
I do want to say we have got to be real careful here. I do
not think we are doing enough. If this disease gets a foothold
in the United States, we take away the diagnostic question of
have you been in these affected countries, so I think it is
absolutely critical. I do not think we are doing enough.
Let me start with you, Mr. Wagner. We picked five airports
to do. We learned that Mr. Duncan was less than truthful on his
screening. We have just announced to the world what airports
not to go through if you want to come to the United States
because we have got better treatment. Could we maybe do
something like funneling everybody who has a visa from one of
these countries or who has traveled from one of these countries
through one of the airports? Is that a step at least in the
right direction? I think maybe banning all the flights is a
right step, but is an intermediate step funneling everybody
through the airport and screening?
Mr. Wagner. I do not know that we can do that. I think it,
again, relies on who the airlines choose to bring to us from
different parts of the world.
Mr. Farenthold. So we do not have the authority to say if
you are coming from this country you can only enter through
this port?
Mr. Wagner. I do not believe so. I will have to look at
that.
Mr. Farenthold. If not, that is something we might be able
to fix. Let me ask you another question, Mr. Wagner. You talked
about how you all have the authority to stop people for health
reasons. How often does that happen? Do you stop one person a
day? I mean, it seems to me I do not ever hear about it on the
news. Is it a frequent occurrence that you stop people?
Mr. Wagner. We have a million people coming into the United
States every day, so I would say it is not frequent, but it
happens several times a week. You know, we have----
Mr. Farenthold. All right. So you have less than a 1 in a
million chance of getting----
Mr. Wagner. No, I think it is who we have been advised that
have a communicable disease, and we do get information about
that and put it in our computer systems and are able to
recognize that, I mean, and stop them from coming in.
Mr. Farenthold. Right. But even now somebody that is not
showing any symptoms is going to get through.
Mr. Wagner. Well, if they are not showing any overt
symptoms, it is tough for us to be able to recognize that they
would be sick or have a disease that is, you know, to emerge in
them. So I am not sure how----
Mr. Farenthold. I understand. Listen, I do not want to shed
all my rights to international travel any more than anyone else
does, but we have got the obvious countries that we really need
to be suspect of. Short of an absolute travel ban on these
countries or canceling commercial flights, you know, an interim
step is substantially enhanced screening and maybe follow-up
screening every few days after they arrive.
I see, Mr. Merlin, you are nodding your head, but I have a
couple of questions for you. I am sorry if I am skeptical of
you and some of the things that you are saying. The American
people and my constituents have lost trust in the Government
for a variety of reasons, and I do not want to bring politics
into public health. But we have the lowest level of trust in
the Government, I think, in my memory. Add to that, every
outbreak novel or zombie movie you see starts with somebody
from the Government sitting in front of a panel like this
saying there is nothing to worry about.
So you have got to remember the first two Ebola patients
that came back to the United States were American doctors who
became infected, who had all the training in the world and were
Ebola experts. So my constituents, and to some degree I am, a
little skeptical of the statement, oh, actually if you take the
precautions it is very difficult to get. How did these two
doctors get it, American-trained doctors? How did they come up
with it in the first place if it is that difficult to get it,
if our health care workers and the American public is safe?
Dr. Merlin. Let me clarify for you what I said. For people
who are health care workers who are putting themselves in
environments where there are patients known to be infected with
Ebola who have copious body fluids in the environment that
carry the virus, the people have to practice scrupulously-known
procedures for preventing acquisition of the virus. It is a
dangerous environment in which to work, and it can only be done
by scrupulous adherence to those precautions and caretaking
measures.
Outside of those environments, when you are talking about a
situation like the United States where we have a very
sophisticated health care system and a sophisticated public
health system, when we identify a case, we are capable of
doing, what we have done with Mr. Duncan and we do with any
future case, is assuring in collaboration with local and State
health officials and the hospital community that the case is
isolated and treated, that all contacts are quickly identified,
and aggressively identified. If contacts are not reliable, that
steps are taken to be sure that the contacts can be followed,
that their temperatures are monitored. If they should become
symptomatic, they are immediately hospitalized.
We know this works. It works in the United States, and it
worked in Nigeria, and it worked in Senegal, so we can stop
cases like that. Hopefully the difference between the zombie
films and this testimony is this is real.
Mr. Farenthold. I hope so. I see my time has expired, and I
wish you the best of success in your efforts to contain this
both in Africa and here in America.
Chairman McCaul. The Chairman now recognizes Mr. Veasey.
Mr. Veasey. Thank you, Mr. Chairman. I want to ask Dr.
Merlin a question. A second ago you said that it appeared that
Mr. Duncan may have, you know, deceived the screeners at the
airport. But I am looking at this memo that was prepared for
the committee, and let me read you this and maybe see, is there
something that needs to be clarified. ``Although it is now
believed that Mr. Duncan contracted the virus while helping a
pregnant woman to the hospital, reports indicate that the
woman's family told neighbors she was suffering from malaria, a
disease with similar symptoms, not Ebola. Accordingly, there is
no proof that Mr. Duncan intended to deceive airport screener
on his questionnaire.''
Dr. Merlin. That is a fair question, and maybe we need to
re-look at the questionnaire to see what the language is. I am
skeptical myself, and there is no way to know. There is no way
to ask Mr. Duncan. I am skeptical that with Ebola well-
established in Monrovia. I believe this woman he assisted was
being taken to an Ebola hospital for treatment of Ebola, and
she was turned away, and this is my understanding, and we can
probably try to find out the facts on this. I am skeptical that
he actually thought she had malaria.
But, you know, to your point, if we are asking whether you
have been exposed to Ebola, it may have to be have you been
exposed to anyone who has died of an infectious disease in the
last period of time, because we need to be sure that we are not
overly permissive in the questions.
Mr. Veasey. Also let me get your opinion, again, on how the
disease is spread. Is it your opinion that it would be highly
unlikely that the disease would be spread through spit or
sputum, or if someone sneezed or coughed, or, you know, for
instance, in airline travel, bodily fluids inside of a
lavatory?
Dr. Merlin. In advanced Ebola disease, all bodily fluids
are highly infectious. For someone with advanced disease, I
think all of those materials would be highly infectious.
Mr. Veasey. Including coughing and sneezing?
Dr. Merlin. Well, you know, coughing, I mean, you would
basically have to get the splatter into your face or into your
eyes for it to be infectious. But I want to emphasize that
people who are traveling, on exit screening, they have had
their temperatures taken, so they are asymptomatic when they
board the airlines. They are not going to do develop advanced
disease on the 8- to 12-hour or 18-hour flight, so there is no
risk that there is going to be an exposure on aircraft to
someone with highly-infectious bodily fluids like that. That is
just not going to happen.
Mr. Veasey. But if someone could transmit Ebola through a
conversation, and you do not have on a hazmat suit, if there is
spit or sputum that is put in someone's eye through a
conversation, which happens in normal conversations. So are you
telling us that that would be a way to----
Dr. Merlin. Yes, but, you know, people who are in close
contact with someone with advanced disease are at risk. I want
to emphasize that people who have no symptoms pose no risk to
anyone. So the asymptomatic individual who coughs and speaks
poses no risk. Someone who develops symptoms early in disease,
which is the fever and fluid, they are not highly infectious.
It is only late in disease. Now, if you are caring for someone
who has advanced disease, and they cough on you, and they get
the fluid in your face, yes, that is a risk.
Mr. Veasey. Okay. One more question before my time expires
here. Should we be concerned about other strands of the Ebola
virus? I know you talked earlier about different strands.
Should we be concerned about other strands of Ebola?
Dr. Merlin. There are several species of Ebola virus. We
are now dealing with Ebola Zaire. Yes, we do need to be
concerned in Africa about all of the other species where they
are and other outbreaks of Ebola Zaire to be sure that they are
contained because most of them can cause very severe disease.
So, yes, we do need to be concerned about the other strains.
Mr. Veasey. Thank you, Mr. Chairman.
Chairman McCaul. I thank the witnesses for their testimony.
This has been very valuable to the American people, and we
support you and wish you all the best in your efforts to
control and contain this horrific virus.
This panel is now dismissed. The clerk will prepare the
witness table for our second panel.
[Recess.]
Chairman McCaul. We are ready to begin our second panel.
First, we have Dr. David Lakey. He served as the commissioner
of the Texas Department of State Health Services, leading one
of the State's largest agencies with a staff of 11,500. He
oversees programs such as disease prevention and bioterrorism
preparedness, family and community health services, and many
others.
Next, we have Dr. Brett Giroir. He assumed leadership of
the Texas A&M Science Center in October 2013. I was just there
a couple of days ago. The center is a premiere assembly of
colleges devoted to educating health professionals and
investigators through innovative teaching and research in
dentistry, medicine, nursing, and biomedical sciences, and the
list goes on and on. You served as vice chancellor for the
Center of Innovation and Advanced Development. Your resume is
very lengthy and very illustrative. Thank you for being here.
Next, we have the Honorable Clay Lewis Jenkins, county
judge for Dallas County. He is responsible for the truancy
court system. In addition, as the chief elected official of the
county, Judge Jenkins is responsible for the county's disaster
and emergency preparedness. He appointed a director of homeland
security and emergency preparedness person to manage the
county's 24-hour operation. Thank you for being here, sir.
Last, we have Dr. Troisi, who is an associate professor,
Division of Management Policy and Community Health with the
Center for Infectious Diseases at the University of Texas. She
has expertise in infectious diseases, including influenza,
hepatitis, sexually transmitted diseases, as well as outbreaks,
including Ebola as well. Thank you so much for being here.
The Chairman now recognizes Dr. Lakey for his testimony.
STATEMENT OF DAVID LAKEY, M.D., COMMISSIONER OF HEALTH, TEXAS
DEPARTMENT OF STATE HEALTH SERVICES
Dr. Lakey. Good afternoon, and thank you, Chairman McCaul,
and thank you, Ranking Member Sheila Jackson Lee, and thank you
to all the Members that are here today. I thank you for this
opportunity to discuss our efforts here in Dallas to prevent
the spread of Ebola.
I want to start by saying that I know the people in Dallas
and the rest of the State, and I know also in the rest of the
Nation, are scared. Ebola is a frightening disease with grave
health consequences. It is an unknown, something that we have
never diagnosed here within the borders before, and the specter
of the heartbreaking outbreak in West Africa reminds of how
serious this situation could be.
But fortunately, Ebola is also a disease that we can fight
through simple preventative public health measures, measures
that we have in the United States and have long experience
with, measures that have had success in that we can depend on
their effectiveness.
Regretfully, as you know, Mr. Duncan lost his fight with
Ebola on Wednesday, and my condolences really go out to the
family right now. It is hard to image what he and his family
have endured in the last 2 weeks, and the struggle for Mr.
Duncan's family is not over yet. Our goal, however, is to
minimize the possibility that other Texans will be exposed to
Ebola and, thus, reduce the possibility of another case,
another death, and another grieving family.
I know that for all of us our minds weigh heavy on the
thought of Mr. Duncan's family right now and the 48 individuals
and their loved ones who must wait another 2 weeks to feel
confident in their health, uncertain of their future. As Texas
State's health official, responsibility weighs heavy on me,
that we identify every possible contact, that we take every
precaution to prevent the spread of the disease, that we
monitor individuals closely, and that we are earning the
Texans' trust in public health prevention and control.
For decades, public health has taken the role of responding
to infectious disease events. Public health response includes
identification of individuals who have been exposed to a
disease, monitoring people identified as having risk for
exposure, and immediate care and public health follow-up should
symptoms become apparent.
Every infectious disease event is different based on the
nature of the disease and the scope of the event. Despite these
differences, the response structure remains the same. In Texas,
local authorities who best know their affected community lead
response efforts. That is not to say, however, that local
officials are alone in this response. Effective disease
investigation also involves support by the State and by the
Federal Government.
We at the Department of State Health Services are always
prepared to offer local governments our knowledge and our
experience as they respond to infectious disease events. When
an event oustrips local capabilities, the State is ready as
appropriate to take a leadership role. Similarly, the Centers
for Disease Control and Prevention offers Federal expertise and
advice, and can provide additional help for large-scale events
and multi-jurisdictional events.
The norm in public health is for all three levels of
government to work in tandem--local, State, and Federal
government working together in what I call the public health
enterprise, providing each other support and filling in gaps,
to provide a cohesive response. I do want to take a second to
thank the Centers for Disease Control for their on-going work
here in the State of Texas, for their expertise, the help in
our laboratory, the epidemiologists that are here in the State
of Texas, here in Dallas right now.
This cooperative effort is not always easy, and it is not
always executed perfectly, but this partnership will provide
the best results and serve to best protect the public's health.
In this particular incident, Dallas County Health and Human
Services is the lead of the investigation and the response
effort.
The Department of State Health Services and the Centers for
Disease Control became very deeply involved early on given the
significance of this deadly disease. In fact, our State
laboratory at the Department of State Health Services recently
qualified to test for Ebola in Austin and is one of 13 State
laboratories able to do so. For this reason, we were involved
very quickly, providing consultation about the possibility of
testing and diagnosis and diagnosing the case in our
laboratory.
As you know, we are still in the midst of this response.
Forty-eight individuals are being monitored for symptoms of
Ebola due to the risk of exposure. Ten of those individuals are
considered high-risk. Our response won't be over until we can
confidently rule out Ebola infection in each of these
individuals. I want to reassure Texans and the folks in Dallas
right now that none of these individuals are sick at this
point, but keep in mind that the symptoms can become evident
anywhere from 2 to 21 days after exposure.
As with all response efforts here in Texas, we are learning
new lessons for improving our preparedness for outbreaks and
for future disasters. At the end of each event, the Department
of State Health Services immediately initiates an after-action
review to determine what went well, what could be improved, and
how those improvements should be made. The after-action process
will include local, State, and Federal responders to ensure
that we are looking at all aspects of this response.
In the mean time, two themes are apparent. First, we know
that disease reporting systems work and is key to public health
workers quickly stopping the spread of disease. Providers and
facilities must be aware of the responsibility. We as an agency
must do our part to reinforce this responsibility through
reminders, through updates, and to easy-to-use reporting
systems.
Second, providers must be aware of outbreaks world-wide so
that they know what diagnoses are possible based on that very
important travel history. Until the West Africa outbreak is
over, Ebola must be in the differential diagnosis of those
individuals who recently arrived from one of the outbreak
countries. Again, as an agency we must do our part to remind
providers and facilities about outbreaks in other countries
through our current communication chains, by harnessing Federal
reminders, and by keeping health care providers armed with up-
to-date procedures and guidance.
The importance of taking a travel history cannot be
understated given the interconnected world in which we live.
After the Ebola response ends and there has been time to
thoroughly evaluate the entire event, we will complete an
analysis of the event in our plan to improve response efforts
going forward.
In support of this effort and to improve the response in
Texas, our Governor, Rick Perry, has announced the formation of
the Texas Task Force for Infectious Disease Preparedness and
Response to assist and enhance the State's capabilities to
respond to outbreaks such as we are in right now. I am a member
of this task force, and I look forward to working on this
important effort with others who have expertise in fields like
epidemiology, preparedness, and response.
For now, we are focusing on our immediate job, ensuring
that there are no more exposures related to this case in
Dallas. We know that we can complete this job successfully. We
know this because the science is sound. Ebola spreads through
the direct contact with bodily fluids, and there is very little
risk otherwise. Individuals are not contagious until they have
symptoms.
Ebola does not thrive in the environment, and it is easily
killed. Infection control is prevalent in United States
hospitals. We have the supplies, the equipment, and the
protocols to minimize the chance of disease spread within our
hospitals. Prevention in the community is simple: Maintaining
hand-washing hygiene and to avoid direct contact with people
who are medically suspected or known to have Ebola. Most
importantly, we know that we can and will successfully complete
this job because we have done so in the past.
The dependable results of sound public health measures have
been proven on diseases like tuberculosis, measles, and Middle
East Respiratory Syndrome. We have a history in public health
of successfully containing the spread of disease and protecting
the public, and I am confident we will do the same here with
this case of Ebola. Thank you, sir.
[The prepared statement of Dr. Lakey follows:]
Prepared Statement of David Lakey
On October 8, 2014, Thomas Eric Duncan passed away as a result of
contracting the Ebola virus in Liberia. Mr. Duncan was provided
therapeutic care at Texas Health Presbyterian Hospital in Dallas,
Texas, but he was unfortunately unable to recover from this often fatal
disease.
Mr. Duncan's death is a reminder of the importance of disease
prevention and control, and provides additional meaning to efforts in
Texas to prevent further exposure to the disease. The goal in Texas is
to continue to minimize risk, thus reducing the likelihood of another
Ebola death within the State.
Every sympathy and concern is extended to Mr. Duncan's family, as
they both grieve for their loved one and worry for their own health.
background: ebola case in dallas
On September 30, 2014, the Department of State Health Services
(DSHS) Laboratory and Centers for Disease Control and Prevention (CDC)
tested a specimen for Ebola virus, and found it positive. This is the
first Ebola patient to be diagnosed in the country.
The patient contracted Ebola in Liberia, and was not symptomatic
when travelling into the United States. Ebola is only communicable when
an infected person is ill with symptoms. During the incubation period,
when no symptoms are present, a person is not infectious.
Texas Presbyterian Hospital received the patient, and contacted the
Dallas County Health and Human Services on September 28, 2014, after
the patient was transported to the emergency room by ambulance. He had
previously presented at the hospital on September 26, was evaluated,
provided medications, and discharged. Dallas County contacted DSHS and
the CDC, to allow for coordination. Texas Health and Safety Code,
Chapter 81, requires that Viral Hemorrhagic Fever (Ebola) be
immediately reported to the local health department, which in turn
notifies State and Federal partners, as warranted.
Once Ebola was suspected as a possible diagnosis on the 28th,
Dallas County began a public health investigation to determine if
others were exposed to the virus while the patient was symptomatic.
After the patient's diagnosis, DSHS and CDC staff were on-site to
provide assistance in the epidemiological investigation. The initial
investigation identified 114 individuals who may have had contact with
the patient. Additional investigation narrowed this number down, and a
total of 48 contacts of varying risk were identified for monitoring.
The investigation is on-going.
Ebola symptoms can become evident between 2 and 21 days after the
initial infection. However, 8 to 10 days is the most common time frame
for Ebola symptoms to become apparent. Ebola is only transmittable
through direct contact with blood or body fluid, or exposure through
contaminated objects, such as needles. Direct contact requires exposure
through broken skin or unprotected mucous membranes.
By determining whether contact with the patient occurred, and
whether possible contact was direct or indirect, investigating
epidemiologists concluded that 10 individuals should be considered
high-risk exposures. All 48 identified contacts were placed under
monitoring for symptoms, with regular visits from local, State, and CDC
health department officials.
The 48 individuals will be monitored until they have passed the 21-
day threshold for presentation of symptoms.
infectious disease surveillance in texas
The State of Texas is divided into eight DSHS health service
regions. In areas where a local health department exists, DSHS health
service regional offices provide supplemental or supporting public
health services. In areas where there is no local health department,
DSHS health service regional offices act as the local health authority.
Local health departments are of varying size, resources, and
capacities. While some health departments, like Dallas County, support
a full array of services, others have more limited functions.
Approximately 60 health departments in Texas are ``full service,''
while 80 offer fewer services. DSHS' role is to fill in, as needed,
core public health services not offered at the local level.
For infectious disease, DSHS health service regions ensure that
disease surveillance occurs in every Texas county through the continual
and systematic collection, analysis, and interpretation of health data.
This effort is dependent on disease reporting by providers, which is
required by law. Currently, in Texas, over 60 conditions are subject to
mandatory reporting, including: Food-borne, vector-borne, respiratory,
and sexually transmitted diseases. Viral Hemorrhagic Fever, or Ebola,
is an immediately-reportable disease in Texas.
In order to allow real-time monitoring of disease surveillance
data, the CDC provides and maintains the National Electronic Disease
Surveillance Network (NEDSS) for use by local, regional, and State
health departments. NEDSS is used by nearly every local health
department in the State, and allows DSHS to identify unusual increases
or pattern shifts in disease numbers.
In concert with NEDSS, Electronic Laboratory Reporting (ELR) has
improved the timeliness and comprehensiveness of diseases reporting.
ELR electronically links laboratory test reports to NEDSS, allowing
immediate access by DSHS or the local health department with legal
jurisdiction.
infectious disease investigation and response in texas
Timely disease reporting to the public health system is imperative
for quick mobilization of public health investigation and response
efforts. Since Texas is a home-rule State, epidemiological
investigations begin at the local level, unless there is no local
health department. This local responsibility aids in effective
epidemiological investigations by ensuring that investigations are
based on close understanding of the community and its residents. While
local entities have the statutory responsibility to lead infectious
disease investigations, State and CDC guidance is available and widely-
used.
More complicated or wide-spread events can increase the State and
Federal roles. If an outbreak involves multiple jurisdictions, the
State role becomes more prominent. If, at any time, an investigation
goes beyond local capabilities, the State may take the lead. In turn,
if an investigation exceeds State resources, the State may ask the CDC
for assistance. Additionally, the CDC leads multi-State investigations.
No matter the level of outbreak, the norm is for all three levels of
Government to work in cooperation, with varying levels of State and
Federal involvement depending on the size and type of infectious
disease event, and the resources and expertise of the local entity.
Throughout the event in Dallas, the State and local authorities have
been supported by CDC, both in the field and by home office staff.
Support provided by the State and CDC can include a number of
options, depending on the scope of an investigation and local needs.
This support might consist of subject-matter expertise and on-site
assistance; State or CDC laboratory testing; provision of personal
protection equipment; or mobilizing of DSHS Rapid Assessment Teams or
CDC Epi-Aids. The State and CDC can also assist with administering
questionnaires and interviews to cases and potential contacts,
inspecting relevant hospital facilities or restaurants, and helping
examine pertinent records.
In cases of large-scale outbreaks, the State Medical Operations
Center (SMOC) at DSHS may be activated. The SMOC is staffed by DSHS
Community Preparedness, Infectious Disease, and Communications staff.
Its function is to ease the flow of information among multiple
jurisdictions, provide dependable tracking of events, and facilitate
requests for resources and supplies from local jurisdictions. For the
Ebola case and investigation in Dallas, the SMOC has been activated.
successful infectious disease response in texas
The public health response system in Texas, led by local entities
and supported by State and Federal government, has a long history of
successful outbreak responses. Texas has effectively contained events
involving disease like Tuberculosis, measles, hepatitis, and Middle
East Respiratory Syndrome (MERS).
As an example, DSHS disease investigators are currently assisting
the local health authority in El Paso, Texas, to track a number of
exposures to Tuberculosis (TB) that occurred through a health care
worker in the labor and delivery unit of a local hospital. This
situation is a prime example of how, under the current system, all
levels of government successfully work together to respond to an
infectious disease event.
Once the index case was identified, local and State health
department investigators meticulously examined hospital records to
determine infants, parents, coworkers, and volunteers who were at risk
of exposure. This investigation identified an initial 3,227
potentially-exposed newborns, and 69 potentially-exposed health care
workers. Together, public health workers evaluated the index case's
history to determine where exposure may have actually occurred. Then,
they prioritized potential contacts by level of risk, decided on a
contact investigation protocol specific to this incident, and executed
the contact investigation. The CDC has been on-site to provide
assistance, and home office CDC staff has provided expertise and
advice. International coordination took place due to the city's
proximity to the U.S.-Mexico Border; interstate coordination with New
Mexico was also necessary.
While the investigation is not yet complete, its results are
already evident. Public health investigators were able to narrow down
the initial 3,227 number to 757 infants who had some level of risk of
exposure. Follow-up with parents occurred, and testing was recommended,
as appropriate, for potentially-exposed children. Additionally, DSHS
gave providers guidance on treatment algorithms for possible cases. Of
the 503 infants tested, six have tested positive for TB infection, and
are being treated to ensure they do not develop active TB. Of the 58
health care workers tested, four tested positive for TB infection, and
public health follow-up will ensure that these positive cases do not
develop into a risk for further community exposure.
initial lessons learned: ebola case and investigation in dallas, texas
The Ebola investigation is on-going, but events like the TB
exposure in El Paso and past infectious disease events reveal key
themes to successful prevention and control of disease outbreaks in
Texas and in the country.
The crux of infectious disease response is reporting. Providers
must be aware of what diseases are reportable to their local health
department, and promptly report contagious disease through the
reporting system. Provider awareness of this responsibility allows for
more effective disease surveillance, and more timely response to
developing infectious disease events. DSHS works to reinforce this
requirement through reminders, updates, and by making the reporting
system user-friendly.
Secondly, the Ebola case in Dallas highlights the need for
providers to vigilantly take travel histories, and streamline sharing
of this information while a patient is being diagnosed. Providers must
be aware of outbreaks worldwide, to inform their consideration of
patient travel history. Until the Ebola outbreak in West Africa is
over, Ebola must be a differential diagnosis for those who have
recently traveled from one of the outbreak countries. At the same time,
moving forward, providers must be aware of what other outbreaks are
occurring internationally. Electronic notifications from the CDC help
providers stay informed, and these messages can be strengthened through
State and local-level communications.
after-action assessments
After the response to the Ebola case and investigation comes to a
close, DSHS will perform an after-action review of the response to this
situation. Throughout the event, responders keep in mind how the
response flows, what difficulties are encountered, and what successes
are achieved. After the response, a thoughtful assessment brings all
these experiences into one evaluation. An after-action review is
essential to close out any response effort, in order to improve future
responses. The assessment will include input from local, State, and
Federal responders who were part of the effort, and will analyze each
part of the response. The assessment will determine what worked, what
can be improved, and how those improvements can be made. The final
result will be enhanced preparedness plans for future infectious
disease events.
In addition, Texas Governor Rick Perry has formed a Texas Task
Force on Infectious Disease Preparedness and Response, the purpose of
which is to assess and enhance the State's capabilities to respond to
outbreak situations. The task force is composed of 17 members, headed
by infectious disease and Ebola experts, and will be supported by DSHS
and other State agencies. The Task Force will evaluate infectious
disease response in Texas, and determine what recommendations can be
made for improvements, either through agency or legislative action. The
Task Force will make its report to the Texas State Legislature in
December 2014.
conclusion
The response to the Ebola case in Dallas is on-going. Conclusion of
this event will allow a systematic review of the response efforts, and
the Governor's Task Force on Infectious Disease Preparedness and
Response will facilitate an evaluation of the public health response
system as a whole. It is evident from a long history of success that
public health interventions work, and that infectious disease
investigation and follow-up can stop the spread of disease. However,
each infectious disease event provides a new opportunity to make
improvements to disease investigation response and coordination among
public health entities. The current focus is on ensuring that no more
Texans are exposed to the Ebola virus. When that mission is complete,
the focus will shift to recommending and implementing improved plans
for future infectious disease response in Texas.
Chairman McCaul. Thank you, Dr. Lakey.
The Chairman recognizes Dr. Giroir.
STATEMENT OF BRETT P. GIROIR, M.D., EXECUTIVE VICE PRESIDENT
AND CEO, TEXAS A&M HEALTH SCIENCE CENTER, AND DIRECTOR, TEXAS
TASK FORCE ON INFECTIOUS DISEASE PREPAREDNESS AND RESPONSE
Dr. Giroir. Mr. Chairman, Members of the committee, thank
you for inviting me to testify before you today. By training I
am a critical care physician and formerly served in the Federal
Government as director of the Science Office at DARPA and also
on the Defense Threat Reduction Advisory Committee where I
chaired the biological and chemical panel.
On Monday, October 6, Governor Perry named me as the
director of the Texas Task Force on Infectious Disease
Preparedness and Response. The task force includes
internationally-recognized biomedical experts joined by State
agency CEOs, not only from Health and Human Services, but also
from transportation, environmental regulation, public
education, and diverse other areas.
Why such diversity? Because the Dallas case proves that an
effective response requires much more than public health
professionals alone. For example, waste disposal was
complicated by broad challenges, including decontamination
decisions, temporary housing, availability of containers,
vehicle logistics and availabilities, and permitting for
transportation and disposal spanning multiple jurisdictions.
Cleaning a single apartment generated 140 55-gallon containers
of Class A hazardous waste, each of which then needed to be
transported to an incinerator licensed for such disposal.
We believe that the response and coordination of local,
State, and Federal resources in Dallas has been very good, but
there will be areas for improvement and lessons learned. Our
task force has already been very active and has identified
seven major areas for assessment and recommendation. These
include hospital preparedness for patient identification and
isolation; command and control, including education and
activation of the incident command structures, implementation
of epidemiological investigations and patient monitoring;
decontamination and waste disposal; complexities of patient
care, including use of experimental therapies; care of contacts
being monitored by public health officials; and as highlighted
in the Spanish case, we have also added management of domestic
animal exposures.
Now, I would like to respectfully offer three suggestions
for consideration by Congress and the President on how to
improve our preparedness and response. The first is to
reestablish the special assistant to the President for
biodefense. Doing so would restore leadership, accountability,
and consistent prioritization at the highest level of
Government. This position had existed both under the President
Clinton and President Bush administrations, and I would refer
you to Congressman Thornberry and Congressman Langeven's letter
to the President on April 22, 2014 about this very subject.
Point No. 2, restore funding to hospital preparedness
programs. Our Nation's public health infrastructure has been
significantly impeded by cuts to the Federal Hospital
Preparedness Program, which has been reduced from approximately
$500 million per year in fiscal year 2007 and 2008 to $230
million today. There should also, however, be clear metrics for
success, accountability for that success, and close integration
with FEMA emergency management programs.
Point No. 3, set clear deliverables and accountability for
new vaccines and therapies. In terms of the availability of
medical countermeasures against Ebola and many other threats,
our country is woefully deficient. This relates both to
scientific and technical obstacles, but also a lack of
prioritization, accountability, and funding that is based on
outcomes. As the Government is now prioritizing Ebola, it is
critical that we backfill all funding that has been redirected
from other biodefense priorities. We should not fight the
battle against Ebola at the cost of forfeiting the broader war
against other menacing diseases, such as pandemic influenza or
Middle Eastern Respiratory Syndrome.
On a final note is that the Texas A&M Health Science Center
is home to one of three BARTA-funded National centers to
develop and manufacture vaccines and medical countermeasures
against chemical, biological, radiological, and nuclear
threats. Each center, including our own, will be responsible
for producing 50 million pandemic vaccine doses within 4 months
of receipt of the referenced strain. Our center and the others
are also fully capable of supporting development and
manufacture of vaccines and therapeutics against Ebola if
requested by the Federal Government.
In closing, thank you, Chairman McCaul, and the Members of
the committee for your leadership and for engaging on this
critical aspect of National security.
[The prepared statement of Dr. Giroir follows:]
Prepared Statement of Brett P. Giroir
Chairman McCaul and Members of the committee: I am Dr. Brett
Giroir, chief executive officer of Texas A&M Health Science Center, and
professor in the Colleges of Medicine and Engineering. By training, I
am a critical care physician-scientist with specific experience in
treating life-threatening infectious diseases. I also have experience
in the Federal Government as director of the Defense Sciences Office at
the Defense Advanced Research Projects Agency (DARPA) and chair of the
Chemical and Biological Defense Panel of the Department of Defense
Threat Reduction Advisory Committee. In addition, earlier this week,
Governor Perry named me director of the Texas Task Force on Infectious
Disease Preparedness and Response.
The risk of infectious disease outbreaks is real, and these
outbreaks are inevitable given the interconnected nature of the world
we live in. An outbreak anywhere becomes a threat everywhere. Given our
location along the U.S. border, our experience with major natural
disasters, and our unique assets such as the Galveston National
Laboratory and the Texas A&M Center for Innovation in Advanced
Development and Manufacturing (CIADM), Texas is on the front lines of
public health preparedness and protection.
In response to the first case of Ebola diagnosed in the United
States, Governor Perry swiftly established the Task Force on Infectious
Disease Preparedness and Response to assess and manage the risk in
Texas and to prospectively plan for future infectious disease threats--
whether natural or the result of bioterrorist attacks. The Task Force
includes internationally-recognized infectious disease and public
health experts, seasoned biodefense leaders, and State agency
professionals across major areas including health and human services,
emergency management, public safety, transportation, environmental
quality, public education, and housing and community affairs. The
members of this task force volunteered in order to serve the people of
Texas, and as a result, the Nation, and each of us has accepted this
call to duty from the Governor for that sole purpose.
There is no question that there will be opportunities for increased
performance across many of the complex elements that have been brought
together to effectively contain Ebola within Texas. Remember, this was
the first Ebola patient to be diagnosed in the United States. If there
is room for improvement, we will work to assure that Texas learns,
documents, disseminates information, and implements optimal changes to
further protect our citizens--and that the United States, as a whole,
benefits from the process. The Texas Task Force took action right away,
meeting for the first time immediately after the Governor issued the
executive order, and we have been actively engaged in assessments and
discussion since that time. We have preliminarily identified six areas
of focus that have been prominent in the current Ebola response, and we
believe that these areas will have implications for many potential
disease outbreaks should they arrive in the United States. These areas
include:
1. Hospital Preparedness and the Potential Role of Improved Rapid
Diagnostics.--The Task Force will focus on the initial
identification of a patient, or potential patient, and the
education and preparedness of diverse health care professionals
essential for this key step in the containment process.
2. Command and Control Issues.--The Task Force will focus on
processes related to the initial activation of the Incident
Command Structure, integration of local, State, and Federal
resources, development of a common operating picture, and the
unique differences of a public health challenge, such as an
Ebola patient, compared to the challenges experienced in
natural disasters such as hurricanes.
3. Organization and Implementation of Epidemiologic Investigations
and Monitoring.--The Task Force will assess opportunities for
improved integration of disease tracking, data and information
synthesis, and potential opportunities for automated
technologies and scalable common data platforms that could be
shared at the local, State, and Federal levels.
4. Decontamination and Waste Disposal.--The Task Force will review
and assess a plethora of issues faced in this area, including
but not limited to: Determining what could be decontaminated,
versus contained-hauled-incinerated, availability of
appropriate containers, logistics of transport, and complex
permitting issues across multiple levels of jurisdiction.
5. Patient Care Issues.--The Task Force will examine how to improve
information flow to front-line care providers, including
information on new drugs, their risks and potential benefits,
and how they might be accessed under investigational protocols.
6. Care of Patients Being Monitored.--The Task Force will examine
the diverse needs of individuals under monitoring or controlled
monitoring, including the needs for basic necessities, such as
food, clothing, and housing, as well as potential needs for
social services and/or counseling. Due to the rich diversity of
the Texas population, cultural competency in communication and
interactions are important aspects of this area.
The Task Force will submit initial draft assessments and
recommendations by December 1 for consideration by the Office of the
Governor and Texas Legislature, so that actions requiring statutory
changes could be proposed in the 2015 legislative session. In the mean
time, the Task Force is committed to insuring that the teams on the
ground have all necessary expertise and resources at their disposal to
respond to the potential for additional Ebola cases in Texas, and to
begin the process of developing an infectious disease preparedness and
response plan to complement the State Emergency Management Plan already
in place and proven highly effective in response to natural disasters.
Regarding the current situation here in Dallas, the response and
coordination of local, State, and Federal resources has generally been
very good, but the Task Force will seek opportunities for improvement
at all levels of collaboration and integration. Looking forward, the
issues at hand are highly dependent on the larger security and
preparedness system. State and local planning is critical, but so is
clear and defined support to local and State authorities from the
Federal Government, including the Centers for Disease Control (CDC) and
Office of the Assistant Secretary for Preparedness and Response (ASPR).
While there have been lessons learned, the successes in controlling
this potentially dangerous situation are a testament to the incredible
skill and dedication of all those on the ground in Dallas, who in my
mind are nothing less than National heroes.
gaps in hospital preparedness and public health infrastructure
It is important to understand that our State's and the Nation's
public health infrastructure has been subject to significant funding
reductions in the Federal Hospital Preparedness Program (HPP), which is
intended to provide funding and support to improve surge capacity and
enhance community and hospital preparedness for public health
emergencies. These funds are expressly for enhanced planning at the
State and local level, for increased integration across the public and
private health care sectors, including hospitals, and other health care
organizations and providers, and for improving infrastructure for
public health emergencies. It should come as no surprise that hospitals
require public funding to train and prepare for what are low-
probability yet high-consequence, and potentially catastrophic, events.
HPP is meant to provide the foundation and core for exercises and
ability to respond and get information out so that the nurse or
physician on the front line would contemplate Ebola or anthrax in their
differential diagnosis. HPP has been cut significantly in recent years
by the Federal Government, and these actions have had clear,
identifiable consequences here in Dallas. In fact, during the Federal
Budget compromise last year, HPP funds were diverted to fund the
Biomedical Advanced Research and Development Authority (BARDA) rather
than use another funding source that was suggested by Congressional
leaders. While we are very thankful this action allowed BARDA to
continue operations (especially since the importance of its mission has
been made abundantly clear during this Ebola response) robbing Peter to
pay Paul has left us less far less prepared than we could have been,
and indeed should have been. This must change if we are to be prepared
for public health emergencies, now and in the future.
guidelines for health preparedness and technological field support
In January 2012, ASPR issued ``Healthcare Preparedness
Capabilities,'' providing National guidelines for health care system
preparedness. Unfortunately, several of the critical capabilities
identified in the report remain problematic areas in our public health
preparedness and response infrastructure.
For instance, ASPR recommendations address the ability to
coordinate multiple agencies and their decision making, to provide
incident information sharing, to manage resource implementation, to
provide an inventory management system, and to notify stakeholders of
health care delivery status. In reality, the incident command team does
not have the necessary technology in place to provide data tracking and
analysis that would support the prescribed common operating picture
across the multiple layers necessary to coordinate an effective and
integrated response. Currently, information is housed on individual
laptops and other devices, being reported manually, and compiled once
or twice daily for the Texas Department of State Health Services
Commissioner, Dr. David Lakey, who is leading the response in Dallas,
and to whom we all owe a debt of gratitude, along with his colleagues
in the CDC and other responders, who are working around these
technological coordination challenges to the degree possible.
Another critical capability outlined by the ASPR report,
Information Sharing, is to ``Provide health care situational awareness
that contributes to the incident common operating picture.'' This
critical capability has not been realized in the current Ebola
scenario. In short, our public health infrastructure has not kept pace
with technological and communications breakthroughs that are now wide-
spread, and also has not yet incorporated tools to facilitate data
collection, analysis, communication, and decision making. This reality
must be acknowledged by ASPR leadership, and a strategy to address
these significant challenges should be developed in partnership with
the caregivers at the epicenter of the current Ebola containment
mission.
national inventory of potentially available ebola therapeutics
Another major gap is the lack of any sort of inventory of candidate
therapeutics to treat Ebola patients who are brought to the United
States for treatment or who are diagnosed in our country. The fact of
the matter is that we had a person fighting for his life on American
soil and no easily available information about drugs available to
administer. This is not a new issue; Dr. Keith Brantley received ZMapp
in August by hearing about it from a colleague, not from U.S. Federal
authorities. Unfortunately, because of a number of issues as further
described in this testimony, ZMapp was not available to be given to Mr.
Duncan.
The Federal Government should provide a timely and frequently-
updated list of all possible medical countermeasures to treating
physicians or to appropriate State public health officials. This list
should include a concise summary of risks and potential benefits,
instructions for how to obtain these therapies, and also should insure
that there are specific research protocols in place to capture the
meaningful data that will be generated through the use of these drugs.
Today, physicians and patients often must track down the companies
directly and ask for the drug candidates, or officials such as myself
use personal contacts within the Government to provide as much
information as possible to the hospital treatment team. This is both
inefficient and time-consuming--and thus leaves patients and doctors
less than optimally equipped in this struggle for life and death of a
critically-ill patient. This is completely unacceptable given the more
than decade-long effort the Federal Government has undertaken to
evaluate and advance medical countermeasures.
In terms of availability of therapies or vaccines against Ebola,
our country is woefully and indeed frighteningly deficient. While it is
true that the mainstay of Ebola treatment is supportive care, that is
only the case because we have little else to offer. It is my personal
assessment after experiences in both the academic and Federal sectors
that this deficiency relates less to scientific and technical
obstacles, than it does to the lack of Federal prioritization of the
efforts; lack of clear Federal leadership accountability; and
difficult, if not oppressive, contracting procedures that are often at
odds with the iterated National strategy and objectives.
special assistant to the president on biodefense
When Congress created the assistant secretary for preparedness and
response role in 2006 as part of the Pandemics and All Hazards
Preparedness Act, ASPR was intended precisely for the kind of situation
we face today with Ebola. The Nation was to be provided with a Senate-
confirmed assistant secretary to take an all-hazards approach to bring
to bear all necessary resources, regardless of where they belong on the
Federal Government's organizational chart. That resource exists today
in ASPR, but what is critically lacking is a White House Special
Assistant to prepare for and lead such responses. Unfortunately, that
position was eliminated by the current administration in January 2009.
We commend Chairman W. ``Mac'' Thornberry and James Langevin,
Ranking Member, of the House Armed Services Committee Subcommittee on
Intelligence, Emerging Threats, and Capabilities, for their April 22,
2014 letter to the President on this very topic, in which they call for
the appointment of a Special Assistant to the President for Biodefense.
This position has existed under both the Clinton and Bush
administrations but was eliminated early in 2009. The letter notes that
``there are at least 12 separate Government agencies with biodefense
responsibilities.'' As pointed out in a 2001 U.S. Government
Accountability Office report, ``Opportunities to Reduce Potential
Duplication in Government Programs, Save Tax Dollars, and Enhance
Revenue,'' there are more than ``two dozen Presidentially-appointed
individuals with some responsibility for biodefense.''
contracting authority
ASPR, which is housed within the U.S. Department of Health and
Human Services, oversees BARDA and the Office of Acquisitions
Management, Contracts and Grants (AMCG). Several years ago an
administrative decision was made to centralize all contracting under
AMCG, and remove it from under BARDA's responsibility. While this made
sense at the time, in practice, this has significantly slowed BARDA's
efforts to move medical countermeasures through the manufacturing
pipeline. Returning contracting authority to BARDA would certainly
clear the way for the development of medical countermeasures, including
experimental Ebola therapies. I want to specifically state that my
team, and indeed most if not all of the scientific and technical
community, has great respect for the leadership and technical expertise
of BARDA. Without BARDA, the country would be gravely behind the curve
without even the basic National response infrastructure to address this
problem, or ever-present global challenges such as pandemic influenza.
texas a&m ciadm and ebola therapeutics
As you know, the Texas A&M Center for Innovation in Advanced
Development and Manufacturing is a public-public-private partnership
with the U.S. Department of Health and Human Services and 1 of 3
Government-funded biosecurity centers designed to enhance the Nation's
preparedness against pandemic influenza, and chemical, biological,
radiological, and nuclear threats by accelerating the research and
development of vaccines and therapeutics, and rapidly manufacturing
these products at scale in cases of National emergencies. The Texas A&M
CIADM is responsible for producing 50 million vaccine doses within 4
months of a declared influenza pandemic and receipt of the viral
strain. It is also responsible for having the capabilities to
manufacture, at scale, vaccines or biological therapeutics required for
an outbreak, such as Ebola, if requested by the Federal Government. Our
team is made up of leading academic, non-profit, and commercial
partners including GSK.
The Texas A&M CIADM represents a long-term, strategic initiative--
sponsored by BARDA--to assure preparedness by creating indispensable
infrastructure and staff capabilities to rapidly respond against highly
diverse threats. The CIADM will deliver on several critical objectives,
including:
Ensure the United States can develop and manufacture life-
saving vaccines and therapies quickly, flexibly, and cost
effectively at scale;
Improve the ability to protect the health of Americans in
response to emergency situations; and
Train an expert workforce that can fill the needs of
National biosecurity for the next generation.
The Center stands ready, and if called upon, will compete for
manufacturing of a wide range of vaccines or therapeutics required by
the U.S. Government, including products against Ebola. Texas A&M Health
Science Center also has a proprietary vaccine candidate now in
preclinical evaluation that holds promise as one of the weapons against
this growing global threat.
In closing, I thank you Chairman McCaul, and the Members of the
committee for your leadership and for engaging on this important series
of challenges that I have outlined. The members of the Texas Task Force
and Texas A&M Center for Innovation want to be seen as your partners in
solving the current Ebola situation in Texas and building a resilient
and prepared homeland that can overcome threats, regardless of the
source. I am honored and privileged to serve as resource to you now and
going forward.
Chairman McCaul. Thank you, Dr. Giroir. Let me say the
Governor, I believe, made an excellent choice appointing you to
be the head of this task force. Thank you.
Dr. Giroir. Thank you, sir.
Chairman McCaul. Judge Jenkins.
STATEMENT OF HON. CLAY LEWIS JENKINS, JUDGE, DALLAS COUNTY,
TEXAS
Judge Jenkins. Well, thank you, Chairman McCaul,
Congresswoman Sheila Jackson Lee, Members of this committee,
and my friends from the Texas delegation who are here with us
today. Thank you for your support in this challenging response.
Local government has treated everyone involved in the Ebola
with dignity, and compassion, and as fellow human beings, not
merely as disease contacts. In interacting with Louise and
those three young men, it was important that I followed all CDC
protocols to avoid any chance of spreading that virus. But it
was important that I not move that family wearing a hazmat
suit. It was important for them to see me as a fellow human
being face-to-face, and for me to converse with them as equals.
That is a basic tenant of leadership, and it is in keeping with
modern medicine.
Louise Troh and those three young men have been handling an
extraordinarily scary, sad, and difficult situation with grace.
Louise and Eric's 19-year-old son, Karsiah, is a fine young
man, forced to deal with the loss of his father without being
able to hug and hold his mother. The death of Eric Duncan is
the loss of a father, a fiancee, a son, and a person that was
loved by an extended family.
Forty-eight people were found to be potentially exposed,
disease contacts, by the excellent epidemiological and disease
detection work performed by Dallas County, the State of Texas,
and the Federal Government. For these 48 people and their
families, this remains a tense and anxious period. They all
need our thoughts and prayers, thankfully all without symptoms
or fever on this the 12th day of monitoring.
We are one team, one fight, and we are committed to working
together. We activated our Dallas County Emergency Operations
Center, and we are operating under the incident command system
with Federal, State, county, and city assets. Many partners,
but one team, one team and one fight. Simply put, there is no
other way to stop Ebola.
There is a lot of fear out there, and I understand why.
Ebola is a scary, terrible disease. However, there is a 0
percent chance of contracting Ebola without coming into contact
with the bodily fluids of a symptomatic Ebola victim. People
who have been exposed to Ebola but have no fever or symptoms
cannot transmit the virus.
We must not allow fear and panic to weaken our resolve, nor
force us to abandon the values that that have built this great
country. Everybody has a job to do in this outbreak. The
Federal, State, and local governments are doing their job. I
urge Congress to pass the appropriations necessary to fight
Ebola in Africa, which is the best way to stem the epidemic,
protect humankind, and for you to perform your important role
in the strengthening and streamlining of Ebola response in the
United States.
We are doing something that has not been done before, and
we cannot fail. We will contain Ebola in Dallas, Texas. It is
only a matter of time before the next case comes to our shores.
Help us win this fight. We must win now. Work with us to fight
this disease abroad and strengthen our public health security.
Thank you.
[The prepared statement of Judge Jenkins follows:]
Prepared Statement of Clay Lewis Jenkins
October 10, 2014
Local government has treated everyone involved in this Ebola crisis
with dignity and compassion as fellow human beings; not merely as
disease contacts.
In interacting with the family, it was important that I followed
all CDC protocols to avoid any chance of spreading the virus. It was
also important that I not move the family while wearing a hazmat suit;
for them to see me face-to-face and for me to converse with them as
equals.
That is a basic tenet of leadership and in keeping with modern
medicine.
Louise Troh and the three young men have been handling an
extraordinarily scary, sad, and difficult situation with grace. Louise
and Eric's 19-year-old son Karsiah is a fine young man forced to deal
with the loss of his father without being able to hug and hold his
mother.
The death of Eric Duncan is the loss of a father, fianceee, son,
and person loved by an extended family.
Forty-eight people were found to be potentially-exposed disease
contacts by the excellent epidemiological and disease-detection work
performed by Dallas County, the State of Texas and the Federal
Government. For these 48 people and their families, this remains a
tense and anxious period. They need all of our thoughts and prayers.
Thankfully, all are without symptoms or fever on this twelfth day of
monitoring.
We are one team, one fight, and we are committed to working
together.
We activated our Dallas County Emergency Operations Center and are
operating under the Incident Command System with Federal, State,
county, and city assets. Many partners, but one team.
One Team, One Fight! Simply said, there is no other way to stop
Ebola.
There is a lot of fear out there and I understand why. Ebola is a
scary, terrible viral disease. However, there is a 0 percent chance of
contracting Ebola without coming into contact with the bodily fluids of
a symptomatic Ebola victim. People who have been exposed to Ebola but
have no fever or symptoms cannot transmit the virus. We must not allow
fear and panic to weaken our resolve nor abandon the values that built
this great Nation.
Everybody has a job to do in this outbreak. The Federal, State, and
local governments are doing their jobs. I urge Congress to pass the
appropriations necessary to fight Ebola in Africa which is the best way
to stem the epidemic, protect humankind, and for you to perform your
important role in strengthening and streamlining the Ebola response in
the United States.
We are doing something that has not been done before and we cannot
fail. We will contain Ebola in Dallas, Texas. It's only a matter of
time before the next case comes to our shores. Help us, help us win
this fight. We must win now. Work with us to fight this disease abroad
and strengthen our public health security.
Chairman McCaul. Thank you, Judge.
The Chairman recognizes Dr. Troisi.
STATEMENT OF CATHERINE L. TROISI, PH.D., ASSOCIATE PROFESSOR,
DIVISION OF MANAGEMENT, POLICY, AND COMMUNITY HEALTH CENTER FOR
INFECTIOUS DISEASES, THE UNIVERSITY OF TEXAS
Ms. Troisi. Thank you. Chairman McCaul, Ranking Member
Jackson Lee, and Members of the committee, I am Catherine
Troisi, an infectious disease epidemiologist at the University
of Texas School of Public Health, and I have also practiced
public health at the local level. I am a member of the American
Public Health Association and the Texas Public Health
Association. Adequate funding of all levels of public health
system is a top priority for these organizations.
I would like to start with a definition of ``public
health,'' a term that is sometimes confused with ``medical
care.'' ``Public health'' is defined as ``all organized
measures to prevent disease, promote health, and prolong life
among the population as a whole.'' While medical care is
concerned with the individual, public health's patient is the
community.
I would argue that this definition of ``public health''
puts it in the realm of public safety. Just as police and
firefighters protect communities from crime and blazes, public
health protects communities from disease. Indeed, of the 30
years of added life to the U.S. life expectancy during the last
century, 25 of these are due not to medical advances, but to
public health interventions, such as sanitation, immunizations,
workforce safety, tobacco control, et cetera. It has been said
that health care is vital to all of us some of the time, but
public health is vital to all of us all of the time.
I hope that I have convinced you of the importance of
public health efforts in maintaining and promoting the health
of our Nation and the world. This cannot be done without
adequate resources. I am sure that you are much more familiar
than I with the negative effects of spending caps and
sequestration on public health agencies, such as the CDC.
Federal funding for public health has declined in recent years,
and this has affected flow-through funding to States and
locals. Adjusted for inflation, CDC funding has decreased more
than $1 billion since 2005, 15 percent.
At the State level, the Association of State and
Territorial Health Officials reports that budget cuts continue
to affect the health of Americans. Health departments in 48
States have had budgets cut since 2008, with 95 percent of
departments reducing services that they offer. The Trust for
America's Health and the RWJ Foundation released a report
showing that the majority of States reached only half or fewer
of key indicators of policies and capabilities to protect
against infectious disease threats. Texas scored 4 out of 10.
One of the indicators, increased or maintained level of
funding, was not met by 33 States.
The same trends can be found at the local level. The
National Association of County and City Health Officials
reported that over one-quarter of local health departments
experienced a budget cut in the current fiscal year, and this
has been happening over at least the last 6 years. Almost half
of these had reductions in services. Overall, State and local
public health departments, the boots-on-the-ground providers of
public health, have lost over 51,000 jobs since 2008. This
represents 20 percent of public health jobs at the State and
local level.
Ebola is a frightening disease with horrific symptoms, and
concern is naturally high that spread may occur in the United
States. However, this is highly unlikely. To be infected, you
must have physical contact with bodily fluids from someone with
symptoms. We know how to stop transmission by using barrier
nursing practices, such as gloves, disinfectants, and patient
isolation.
Unfortunately, many countries in Africa do not have the
resources to provide for these precautions. Ebola is a major
concern for the affected countries, and the fear and loss of
life are devastating on a humanitarian level. The danger is
that we will be fixated on this virus and not on other
pathogens that have outbreak potential, such as flu, SARS, and
MERS-CoV, among others. Other pathogens, such as measles and
pertussis, periodically cause outbreaks due to lack of immunity
among those not vaccinated. Then there is the on-going
syphilis, food-borne illnesses, HIV, tuberculosis, meningitis,
enterovirus D68 infections that we fight every day in public
health.
So what can we do to prepare for potential pandemics?
Congress must begin to prioritize public health funding and not
just when a crisis occurs. Critical to the capacity to respond
to any type of outbreak, routine or otherwise, are
epidemiologic and laboratory capabilities. These involve
disease surveillance and reporting, case investigation,
outbreak response and control, contact management, and data
analysis synthesis and communication.
The disease-of-the-month type of response limits our
ability to react to threats, and disease-specific funding
streams tie public health hands when prioritizing activities.
While we are appreciative of the increased funding to combat
Ebola, and adequate response to the initial outbreak would have
mitigated spread. The U.S. funding for WHO activities have
decreased one-third from 2010 to 2013.
In summary, public health is on a par with police and fire
protecting the community from disease. In order to provide this
protection, we need on-going adequate funding to make sure our
epidemiologists and laboratories have the resources they need
to quickly identify and stop infectious disease outbreaks.
Thank you for the opportunity to testify about public
health and our ability to deal with public health threats.
[The prepared statement of Ms. Troisi follows:]
Prepared Statement of Catherine L. Troisi
October 10, 2014
Chairman McCaul, Ranking Member Thompson, and Members of the
committee, my name is Catherine Troisi. I am an infectious disease
epidemiologist at the University of Texas School of Public Health and,
in addition to my years in academia, I have practiced public health at
the Houston Department of Health and Human Services. I am also a member
of the American Public Health Association, a diverse community of
public health professionals who champion the health of all people and
communities. Adequate funding at all levels of our public health system
is a top priority for the association
Thank you for this opportunity to talk about public health, its
role in disease outbreak detection, and recent trends in resources for
these important public safety efforts. I'm delighted to remind the
Members from Texas that the University of Texas School of Public Health
has regional campuses in Austin, Brownsville, Dallas, El Paso, and San
Antonio, fulfilling our mission to improve and sustain the health of
people by providing the highest quality graduate education, research,
and community service for Texas, the Nation, and the world; to provide
quality graduate education in the basic disciplines and practices of
public health; to extend the evidence base within those disciplines;
and to assist public health practitioners, locally, Nationally, and
internationally, in solving public health problems.
I'd like to start with a definition of public health, a term that
is sometimes confused with medical care. Public health has been defined
by the U.S. Centers for Disease Control and Prevention (CDC, the
Nation's public health agency) as ``the science of protecting and
improving the health of families and communities through promotion of
healthy lifestyles, research for disease and injury prevention and
detection and control of infectious diseases.'' There are a couple of
concepts in that definition I'd like to emphasize. The first is that
public health is science-based and the corollary of that is that we
should employ techniques that have been proven to be of value. The
second is the idea of protection which implies action before disease
occurs. Public health has two main functions--disease prevention and
health promotion. As our grandmothers said ``an ounce of prevention is
worth a pound of cure''. The last concept in this definition that I
want to emphasize is that of communities. While traditional medical
care is concerned with the individual, public health's ``patient'' is
the community. Individual interventions can be the mandate of public
health, e.g., immunizations, but the overall goal is to protect the
community. One specific function of public health agencies, largely
limited to governmental public health, is detection of outbreaks of
infectious diseases and mitigation of spread.
With these definitions in mind, what are public health tasks? The
Institute of Medicine has broken these into three core functions--
assessment, policy development, and assurance. In simple terms, this
means that public health is responsible for evaluating and responding
to health problems in the community as well as prioritizing these
efforts, developing policies to protect communities' health, and
assuring that all populations have access to appropriate and cost-
effective prevention services. I would argue that this academic and
functional definition of public health puts it in the realm of public
safety. Just as police protect communities from crime and fire fighters
from the devastations of fire, public health protects communities from
disease. Indeed, of the 30 years of life expectancy added to the
average U.S. life expectancy in the 20th Century, 25 of these are due,
not to medical care, but to public health interventions, such as
sanitation, immunizations, control of infectious diseases, tobacco
control, etc. It's important to emphasize that we talk about the
``public health system'' which consists of all organizations involved
in protecting and improving the health of the community, whether
Governmental, medical, non-profit, educational, social services, etc.
However, given the scope of these hearings and the fact that it is
Governmental public health that is largely concerned with detecting and
controlling infectious disease outbreaks, I'm going to be talking about
governmental local, State, and National public health.
I hope that I have convinced you of the importance of public health
efforts in maintaining and promoting the health of our Nation and our
world. Obviously, this cannot be done without adequate resources.
Public health activities occur at the Federal, State, and local level
and are funded as such. However, the CDC and other Federal agencies
provide flow through funding for many public health activities at the
State and local level. I'm sure that you are much more familiar than I
with the negative effects of spending caps and sequestration on public
health agencies such as the CDC over the past few years. However, in a
nutshell, Federal funding for public health has been relatively flat-
funded and has shown a significant decline in recent years (Figure 1).
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Figure 2 shows the declining level of terrorism preparedness and
emergency response funding allotted to CDC for activities at the
National, State, and local levels and for the Strategic National
Stockpile (www.cdc.gov/fmo/topic/Budget%20Information/index.html).
Following infusion of after 9/11, levels have been on the decline.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
This situation is also reflected at the State level. The
Association of State and Territorial Health Officials (ASTHO) reported
in September of this year that budget cuts continue to affect the
health of Americans. Health departments in 48 States, three
territories, and the District of Columbia have had budget cuts since
2008, with 95 percent of State or territorial health departments
experiencing reduced services. Approximately 11,000 public health jobs
have been lost in State health departments (http://www.astho.org/
budget-cuts-Sept-2014/). The Trust for America's Health and Robert Wood
Johnson Foundation released a report last December showing that the
majority of States reached half or fewer of key indicators of policies
and capabilities to protect against infectious disease threats. Texas
scored 4 out of 10. One of the indicators (increased or maintained
level of funding for public health services from fiscal years 2011-12
to fiscal years 2012-2013) was met by only 17 States (Texas was one of
these 17 States), meaning that 33 States had decreased funding. Budgets
in 20 States decreased 2 or more years in a row and 16 States had
decreased budgets 3 or more years in a row (http://
healthyamericans.org/report/114/).
Not unexpectedly, these trends in budget cuts can also be found at
the local level. The National Association of County and City Health
Officials (NACCHO) administers a biannual survey of local health
departments (http://www.naccho.org/topics/infrastructure/lhdbudget/
upload/Survey-Findings-Brief-8-13-13-2.pdf). Over 1 in 4 local health
departments experienced a budget cut in the current fiscal year and, as
shown in Figure 3, this has been an on-going declining trend.
Data from the 2013 survey show that the size of the public health
workforce has decreased since 2008 when best estimates were 190,000
(range of 160,000 to 219,000) to 139,000 (range of 139,000 to 185,000),
representing a total of 48,300 jobs lost. Almost half (41%) of local
health departments Nation-wide experienced some type of reduction in
workforce capacity, with, 48 percent of all local health departments
reducing or eliminating services in at least one program area. Overall,
State and local public health departments, the ``boots on the ground''
purveyors of public health, have lost over 51,000 jobs since 2008,
representing one in five public health jobs.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Now I'd like to put on my infectious disease expertise hat. The
news coming out of West Africa is alarming. Almost 7,500 cases of Ebola
with almost 3,500 deaths have been reported with many more suspected.
Ebola is a frightening disease with horrific symptoms and concern is
naturally high that further spread may occur. Is there a possibility
that the next pandemic (defined as a world-wide epidemic) will be
caused by Ebola? By looking at the characteristics of viruses that can
spread world-wide, we can see that while there are some viruses capable
of causing pandemics, Ebola is not one of them, and our undue anxiety
over spread in the United States is diverting attention from true
public health concerns.
Characteristics of a pandemic virus include:
many people are susceptible to becoming infected;
people can transmit the virus before they have symptoms;
the virus causes severe symptoms and deaths;
the virus is easily transmitted from person to person.
While Ebola has the first characteristic and certainly causes many
deaths, it is lacking the two important ones--spread before symptoms
occur and easy transmission. To become infected with Ebola, you must
have physical contact with blood or bodily fluids from someone with
symptoms. Unlike other viruses like influenza, people with Ebola are
NOT infectious before symptoms appear. We know how to stop transmission
by using barrier nursing practices such as gloves, disinfectants, and
patient isolation. Unfortunately, many countries in Africa do not have
the resources to provide for these precautions in their hospitals and
so spread of Ebola is occurring in the health care setting. Adding to
the problem are cultural practices where families prepare bodies of
Ebola victims for burial, inadvertently becoming exposed to the virus.
The conditions for spread of the Ebola virus in the United States and
other resource-rich countries do not exist and the only danger is that
we may be fixated on this virus and not on ones that could actually
cause world-wide harm.
Given these characteristics, there are viruses that have outbreak
or pandemic potential (or have caused these in the past) that public
health agencies need to be on the look-out for--viruses such as
influenza, SARS (severe acute respiratory syndrome), and MERS-CoV
(Middle East Respiratory Syndrome), among others. Other ``common''
viruses such as measles and pertussis periodically cause outbreaks due
to lack of immunity among those not vaccinated. Influenza is a virus
that has caused pandemics in the past and has the potential to do so
again. The virus can mutate so much that it's like a new virus no one
has experienced before and so no one is immune. The great influenza
pandemic of 1918 killed more people than World War I. There was concern
in 2009 (when a new influenza virus appeared that looked like the 1918
virus) that we would again see a major influenza pandemic. While many
people got infected, we were ``lucky'' that the virus did not kill more
people than we typically see each flu season--although that number can
be very high and the very young, seniors, and those with underlying
illness are particularly susceptible. In Texas alone, over 2,300 people
were hospitalized with 20 deaths in children last year. Many more were
sick with the disease. Indeed, estimates are that up to 49,000 deaths
occur Nation-wide each year due to seasonal influenza. Scientists are
carefully monitoring some new influenza viruses that have been
transmitted from birds to people, killing more than half of those
infected, and although so far these avian flu viruses have not spread
easily from person to person, the viruses could mutate to allow this to
happen. Should this occur, a pandemic, with resultant high number of
deaths, is almost inevitable.
MERS-CoV is caused by a virus currently occurring throughout
countries in the Middle East. Although the disease spread through the
air, as of right now, the virus does not appear to transmit easily from
person to person (camels and/or bats are the most likely source of
infection). While the chances of Ebola becoming airborne are
exceedingly small (no pathogen has changed the way in which it is
spread), it is more likely that small changes in the RNA of MERS-CoV
could allow the virus to spread from person-to-person in a more
efficient manner. Should this happen, the likelihood of a pandemic
increases dramatically.
So what can we do to prepare for potential pandemics? Public health
agencies such as CDC are constantly monitoring infections around the
world to determine if new viruses are appearing. State and local health
departments also are involved. Ebola virus is a major concern for the
affected countries and the fear and loss of life are devastating on a
humanitarian level. But we do not have to fear spread of the virus to
the United States or other resource-rich countries. We would better
spend our time preparing for diseases such as influenza which do have
the potential to cause pandemics around the world, including the United
States.
Congress must begin to prioritize public health funding and not
just when a crisis occurs. Level or reduced funding for public health
activities means that the same or less amount of money must cover
prevention activities for an increased population. As recent outbreaks
of food-borne illnesses, vaccine-preventable diseases, hospital-
acquired infections, and emerging infectious diseases have shown, the
threats remain and we need our public health community adequately
funded to respond to these threats. While we are appreciative of the
increased funding to combat Ebola contained in the recent continuing
resolution signed by President Obama, an adequate response to the
initial outbreak would have mitigated spread within Africa. According
to a report by the Congressional Research Service, U.S. funding for
World Health Organization (WHO) activities have decreased about one-
third from 2010 to 2013. As seen in the U.S. public health system, this
decreased funding resulted in WHO job losses and the ability to respond
to emergencies such as Ebola.
Thank you for the opportunity to testify before you today about
public health and our ability to deal with public health threats. I am
happy to answer any questions you may have.
Chairman McCaul. Thank you, Doctor. The Chairman recognizes
himself for questions.
Judge Jenkins, you mentioned that we have never encountered
this before. I agree, this is new territory. In fact, in this
county we experienced the first fatality due to Ebola in the
United States. There is a lot of fear amongst not only
residents here, but across the State and across America about
this. We in Dallas County witnessed janitors wearing Tyvek
suits in our schools. This really hits home.
So my question to Dr. Lakey and Dr. Giroir, what can you
tell us here today, what can you tell the people of Dallas
County, and the State of Texas, and the United States of
America to alleviate these fears?
Dr. Lakey. Thank you. I think the first thing, and I will
repeat what I have already said, that we know the science. The
CDC knows the science about this virus, that unless somebody is
symptomatic, it is not contagious, that it is not spread in the
air.
We are doing a lot of work right now to make sure that we
do everything we can to prevent another Texan to be exposed to
this virus. I believe this is a safe community. I feel safe
enough. I have talked to the schools, I have talked to the
emergency managers, I have talked to the hospitals, a wide
variety of individuals and systems in Dallas and in Texas. One
of the things that I told the schools, you know, I am a father.
I would very comfortable with my kids going to these schools
right now. They are not going to get Ebola from going to the
schools right now.
We know the 48 individuals that had contact. We are
monitoring them very closely. The kids that had contact, we are
giving them home-based schooling to address this risk. But
unless you have symptoms, you are not going to spread this
disease. So, we take this very seriously. The monitoring is
going very well, again, partners from the local level, the
State level, the Federal level working together. Those 48
individuals that we are monitoring very closely, none of them
are symptomatic.
Chairman McCaul. Dr. Giroir, you have just been appointed
the head of this task force. What are your plans to deal with
this threat and deal with this fear amongst the population?
Dr. Giroir. Well, first of all, I want to reiterate exactly
what Dr. Lakey said, and I agree with every one of his points,
that the transmission is, as he said, only by close contact
with bodily fluids of an infected symptomatic person. Among the
activities of this response, the ones that went very, very well
were the identification of the contacts and institution of the
appropriate monitoring. So we are very comfortable that that
was done in a very effective and efficient way, and we will
find ways to even improve on that even further. So all of these
will be part.
One area that we will focus on in the task force is to make
sure that all our potential notifiers really understand because
a person with Ebola may not just walk into a major tertiary
hospital. They may walk into their pharmacist, or they may walk
into their local nurse, or their public health official.
So one thing we are going to have very, very early is a
quick and rapid understanding to make sure we are educating all
the potential people who could be the first contact with the
patient, because the key to this whole success is
identification of that patient and institution of monitoring,
just like Dr. Lakey and the CDC team have done.
Chairman McCaul. Dr. Giroir, in your testimony you
mentioned there were issues involved in decontaminating the
apartment in question, Mr. Duncan's apartment, including the
needs for permits to transport the waste. Are you confident
these issues have been resolved?
Dr. Giroir. They were resolved. I am confident they have
been resolved. A lot of it was by brute force and by working on
issues as they came from the leadership that was there on the
ground. What we want to do is make that much easier and much
more facile the next time so that the leadership within the EOC
can focus on the specific tasks at hand. Remember, next time it
may not be 1 patient. It may be 5 patients, 10 patients with
hundreds of contacts. So it was resolved effectively, but we
have lessons learned. Maybe Dr. Lakey would want to comment on
that.
Dr. Lakey. I think that is right. This was a challenge, the
first time you had to dispose of 140 55-gallon barrels, and
they had to be put into another type of barrel, and have
special permits from the Department of Transportation. I think
we saw for this issue those barrels were burned today. They are
gone, but I think this is an on-going issue we need to look at
as a Nation. An event like this, how can we transport Class A
medical waste and get rid of it quicker than what we could here
in the State of Texas?
Chairman McCaul. Lastly, Dr. Giroir, you mentioned that
this senior assistant for biodefense existed under both the
Clinton and Bush administrations. I am not quite sure why that
was eliminated under this administration. Is it, again, one of
your recommendations that that position be reinstituted?
Dr. Giroir. Again, I have no idea what are the reasons in
the organization, but it is a strong recommendation that I have
and a number of groups have for this position. You know, there
is talk about Ebola czars or whatever, but this should not be a
one-off. This should be a priority that transcends whatever
disease is coming around the corner.
I know personally when I was at DARPA and the special
assistant to the President called all the agencies in, all of a
sudden it just was not a meeting where everybody had to have
consensus and, you know, kind of figure out what everybody
wanted to do and agree on the lowest common denominator. It was
directives and leadership from someone who was in the White
House.
I personally felt that made an enormous difference to
organize our initial responses, whether that be in Africa or to
write a pandemic flu plan. I personally feel, and I think you
would get a lot of support, that that is the
institutionalization at the highest level of a person
responsible that you could turn to and we could depend on.
Chairman McCaul. So you knew who is in charge.
Dr. Giroir. You knew who was in charge. The other comment
is absolutely Health and Human Services has a huge part of
this, but the Department of Defense also does. There are
parallel programs. Homeland Security, as you know, identifies
what is on the threat list that has to be transmitted. So this
is bigger than one agency. There are 11 agencies funded in the
biosecurity, biodefense areas, and there needs to be someone in
charge. That is what this recommendation really is.
Chairman McCaul. Thank you. The Chairman recognizes the
Ranking Member.
Ms. Jackson Lee. Again, Mr. Chairman, let me thank you for
this very important hearing, and let me thank my fellow Texans
for setting a standard which the world can watch. Even as I
pose these questions, it is at the backdrop of a great deal of
thanks to all of you.
I wanted to just read just an excerpt from this morning's
newspaper, which indicates that 6 U.S. military planes arrived
in the Ebola hot zone. This article is making a statement in an
article that Sierra Leone, as I indicated, they are pleading
for our help. One of the African leaders said, ``It is a
tragedy unforeseen in modern times.''
I do not want to, as I indicated, create hysteria. I want
to be on alert. I think the important point to be made at this
hearing for all of you is that all of those who may have been
exposed will be watched and monitored for the full 21 days and
maybe until the end of the month. Dr. Lakey, is that accurate?
Dr. Lakey. We will be monitoring everyone exposed for the
full 21 days.
Ms. Jackson Lee. There are articles in the paper that
indicate if they have not shown any signs in 10 days, then they
are okay. I think that is a false premise that should be
corrected by those who may perceive that. But you are saying
that everyone will be monitored, is that correct?
Dr. Lakey. All 48 contacts that we identified that have a
risk of being infected with Ebola are being monitored daily.
They have temperature checks twice a day. An epidemiologist
sees them every day. I checked with them this morning. All of
them are asymptomatic, yes.
Ms. Jackson Lee. Let me thank Dr. Giroir. I did not
indicate to you because one of my Baylor doctors and emergency
doctors indicated that panels should be created across the
Nation, so let me thank the State of Texas for creating that.
But let me make this point. As I indicated, six planeloads
of our best and our brightest military personnel, they have to
come home. I frankly do not believe that we are prepared, and I
will tell you why. I ask the Chairman if I could submit into
the record an article, ``Even After Dallas, Hospitals Still
Lagging Preparation for Ebola Patients, Say U.S. Nurses.'' I
ask unanimous consent.
Chairman McCaul. Without objection, so ordered.*
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* The information has been previously included in this document.
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Ms. Jackson Lee. I particularly want to bring to your
attention that one-third say their hospital has insufficient
supplies of eye protection, feel shields, or side shields with
goggles and fluid resistant impenetrable gowns. Dr. Lakey and
Dr. Giroir, this is not condemnation. The CDC has done an
amazing job. They are our theoreticians. They are the ones with
theory and doing the research. But do we have a problem as we
see the fluidness of people moving around the country, around
the world, with making sure that every hospital that can afford
the resources be prepared? Is that something that is necessary?
Dr. Lakey. I will start, and then, Dr. Giroir, you can
finish. I do not think preparedness is something you do and
then you are done. You have to continue to work to be prepared.
You have to continue to educate health care providers about
exotic diseases and how do you respond to a major disaster.
As I tell folks, unfortunately the unthinkable can happen.
We are dealing with Ebola right now. While I have been in this
chair I also responded to Hurricane Ike. We responded to H1N1,
major events, and you have to have a strong public health
system to do that. So, hospital preparedness funds and the
other----
Ms. Jackson Lee. So it would be important for us to make an
assessment of whether equipment is in places where this may
happen. I say that, Mr. Chairman, because an airplane was
quarantined in Las Vegas just a few hours ago thinking there
was an Ebola patient and it happened not to be. But ambulances
and all, which is based upon people's fear, and that is what we
need to do is to quell it, but we need to convince people that
we are prepared.
Let me go quickly to Ms. Troisi on this funding situation.
Do we need to ramp up our funding? Do we need to end the
sequester? Would Medicaid be helpful here?
Ms. Troisi. I personally feel that, yes, we do need more
funding for public health because as Dr. Lakey just said,
public health is there all of the time. We should not be just
be responding to crisis, and if you have a good system in place
when a crisis does occur, you are better prepared.
Ms. Jackson Lee. Medicaid expansion might help as well.
Ms. Troisi. Medicaid expansion would certainly help people
who----
Ms. Jackson Lee. I only have a few minutes. Thank you
very----
Ms. Troisi [continuing]. Who do not have insurance.
Ms. Jackson Lee. Thank you for your grace, Judge Jenkins,
and your heart. We know how you lead in this county. Thank you
for treating these individuals with dignity. But let me just
say you expended dollars, 140 55-gallon barrels. What can we do
to prepare for returning military personnel that may be all
over America coming home as heroes, but having been in the hot
spot of Ebola, and may, in fact, themselves be impacted coming
to counties like Dallas County. What do you see that we would
need to do in being prepared if that was to happen?
Judge Jenkins. Well, as far as the disease, the military I
think has a good preparedness as people come home. It is very
important to me that as our military men and women come home--
Dallas County is the third choice in the country by popularity
for them to return to--that we get them good jobs. You are on
the right track that we need health care for people. We need
Medicaid expansion. We need good jobs for our returning
military.
The best thing that we can do to fight Ebola is to fight
Ebola at its source overseas before it gets here.
Ms. Jackson Lee. Thank you, Mr. Chairman. May I just add
this to the record? It shows the kind of attire that should be
used dealing with ``Suiting up for Ebola.'' I ask unanimous
consent to place this in the record.
Chairman McCaul. Without objection.
Ms. Jackson Lee. I ask for these two documents, including
``Ebola Outbreak Preparedness and Management,'' prepared by
Doctors Without Borders*, to be put into the record.
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* The information has been retained in committee files and is
available at: http://www.medbox.org/ebola/ebola-outbreak-preparedness-
management/toolboxes/preview.
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Chairman McCaul. Without objection, so ordered.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Jackson Lee. I thank the gentleman.
Chairman McCaul. The Chairman recognizes the gentleman from
South Carolina, Mr. Sanford.
Mr. Sanford. Thank you, Mr. Chairman. Judge Jenkins, I do
not know your story, but based on what I just heard, if you
walked into an apartment with Ebola was there and somebody just
died, I admire your courage, your humanity, your leadership in
terms of just walking in without glove in hand, and shaking
hands with folks, and giving them a hug as the case might have
been. So I admire that.
But I want to go back to Dr. Lakey's comment. Well, in
fact, everybody said the same thing. Everybody said you cannot
get this disease unless it is from an infected party, a human
contact. You are not going to get it out of the drapery over
here. You are not going to get it out of the floor. You are not
going to get it through the air, right? I mean, everybody has
consistently said that.
Yet what we just heard was 140 55-gallon drums of hazardous
waste were taken out of the apartment, which is to say unless
the guy lived in a mansion, and I do not think he did, they
flat-out stripped that apartment, in essence, down to the
studs. I mean, they took out the carpet. They took out the
drapes. They took out everything, threw it in. You had Class A
hazardous material wherein you are having to fight permits in
terms of getting it out.
Again, the folks back home are saying this does not connect
for me. It is the same disconnect. We are told you are
completely safe, but by the way, we are going to go to this
guy's apartment that died, and we are going to strip it down to
the studs. I mean, 140 55-gallon drums would fill this entire
floor area right here. So which one is it? Is it really more
hazardous than we think, or did they make a mistake in a degree
of overkill, if you will, and drag out 140 55-gallon drums?
Dr. Lakey. I can start, and then if any of the other
panelists want to chime in. That would be great. We feel
confident in the science that this is spread through contact
with bodily fluids.
Mr. Sanford. I understood that. Then why all the 55-gallon
drums?
Dr. Lakey. The challenge was in this apartment, you know,
if he threw up, if there was other bodily fluids on curtains,
et cetera, it had to be taken care of. There is a perception
related to the apartment. You know, no one was going to rent
that apartment unless you had done all you can do in order to
decontaminate it. Because it was a Level A agent----
Mr. Sanford. I mean, you are not in the real estate
business. You are not worried about who is going to rent the
apartment next.
Dr. Lakey. But we needed to decontaminate the apartment, do
everything we could to fully decontaminate----
Mr. Sanford. Okay. But then you are going to the
decontamination side, which is then it takes more than, as I
have written it down, physical contact with an affected party.
That is what is consistently said over and over and over again.
Dr. Giroir. I think most of the leadership was concerned
about blood, bodily fluids, other excretions that could have
been in places in the apartment, such as in the bathroom, or
rugs, or things like that. The data really show that the Ebola
virus is very wimpy on surfaces, that it really goes away very
quickly. It does not live very long at all. But if there is
tissues, bodily fluids----
Mr. Sanford. So, I mean----
Dr. Giroir. So I believe there was a conscious decision to
overly decontaminate and overly do waste removal because this
was the first patient in the country. It was approached with an
abundance of caution. For example, a toilet can be
decontaminated, but do you want to sit there and decontaminate
the toilet and have every question, or do just want to pick the
toilet up, put it in a drum, and get rid of it, and be done? We
had the luxury of only having one apartment to do, and I think
with an abundance of caution----
Mr. Sanford. Understood. Let me just follow up because I
see I am down to a minute.
Dr. Giroir. Yes, sorry.
Mr. Sanford. The same question then in a different light in
terms of the disconnect that I seem to be hearing from folks
back home. A number of you all have talked about public health
and the need to prioritize spending. We are well on our way to
spending about a billion dollars in these three countries and
sending in the military, which is a very expensive way of
dealing with the problem. If, in fact, it is not as lethal and
it could be handled by health care professionals rather than
cranking up C-17s and sending them across the Atlantic, why not
have health care professionals do it rather than $750 million,
because we could then allocate some of the resources that
Sheila Jackson Lee was just alluding or some of the other
resources that are around the world given the crop up in Spain
and other places?
Judge Jenkins. Sir, can I take a stab at that? It is
extremely lethal. Fifty percent of the people in the world who
get this disease die. The disconnect in what the visuals are on
television is this. My contact and other officers' contact were
with people who are being monitored to see if they become
symptomatic. Their bodily fluids cannot transmit Ebola. The men
in hazmat suits----
Mr. Sanford. I understand that. I have run out of time, but
I am still curious as to are we doing overkill then, spending a
billion dollars with the military rather than having health
care professionals. But I see I have run out of time, Mr.
Chairman. Thank you, sir.
Chairman McCaul. Thank you, sir. The Chairman now
recognizes Mr. Swalwell from California.
Mr. Swalwell. Thank you, Chairman, and thank you to the
officials for being here today, and thank you for what you are
doing in this fight to keep Ebola from spreading here in the
United States. I would just have to say just to follow up on my
colleague from South Carolina, I certainly understand what he
is saying, and I certainly understand, Dr. Giroir, the position
that you are in and Dr. Lakey, which is on one hand if you have
the case in America, people are watching it. We are in this
Twitter, Facebook era where everything you do is going to be
exponentially multiplied and told to the rest of the world.
But perhaps if the science is true that it can only be
spread by direct bodily contact by somebody who is presenting
the symptoms, if we are, as you said, Dr. Giroir, overly
decontaminating, we could be our own worst enemy, and that by
overly decontaminating, we are creating this perception that it
is something that perhaps could be airborne.
So, I guess, my first question is, if you could just tell
the public, you know, I will just go down the line, and each of
you could pick one myth that you would like to dispel based on
your expertise to the public, because my colleague from Texas,
Congresswoman Jackson Lee, she is right. There is a plane right
now in Vegas that people are just getting off because someone
was coughing and sneezing, and people started freaking out and
tweeting that they have Ebola. They were tweeting at Delta who
was the carrier, and you can just imagine what that scene was
like. So if I could just go down the line. One myth that you
would like to dispel for the American public.
Dr. Lakey. The first myth would be that the individuals
that have been exposed but have no symptoms, that there is a
risk. That is causing, I think, discrimination related to those
individuals, and that is a myth that needs to be changed.
Mr. Swalwell. Great, thank you. Dr. Giroir.
Dr. Giroir. Again, just to reemphasize what everyone has
said is that you have to be in close contact with the blood and
body fluids of a person who is actively symptomatic. Again, if
there were bodily fluids left on a carpet and you go there in a
couple of hours, you know, there is a concern about that. But--
--
Mr. Swalwell. Dr. Giroir----
Dr. Giroir. Yes?
Mr. Swalwell [continuing]. If Mr. Duncan had, as you said,
perhaps thrown up in the apartment, how long would that bodily
fluid be active, meaning if it was decontaminated, it was left
there for days, weeks, months, how long would it be active?
Dr. Giroir. Do you want to answer that?
Dr. Lakey. I cannot tell you exactly how long it would be
active in carpet. I cannot give you specific----
Ms. Troisi. There was a study just published. It was not
specifically on carpet, but showing it lasts a couple of hours
on surfaces at ambient temperature.
Mr. Swalwell. Okay, thank you. Judge, how about a myth that
you would like to dispel? You were right there on the front
lines.
Judge Jenkins. Well, in the interest of repetition, and if
people from the Dallas-Fort Worth area are watching, there is
zero risk of you becoming infected from anyone who has come in
contact with me or any first responder. We would never put your
family and your children at risk. We follow CDC protocols. When
we follow more than that, it causes panic.
Mr. Swalwell. Ms. Troisi----
Dr. Giroir. The task force does believe that there is
significant opportunity to create less drums of waste moving
forward. When you have an on-going relationship with a specific
decontaminating contractor that you have set this up
prospectively, that we do believe that there are really good
opportunities to do less than was done. But on the first case
in an acute situation, these situations were made by the
incident command structure. I happened to be in the command
post that day, but these were made by the incident commanders,
and I fully support sort of the overabundance of caution in the
first case.
Mr. Swalwell. Thank you, Doctor. Ms. Troisi, if you had a
myth you could dispel.
Ms. Troisi. Yes. Again, as everyone has said, Ebola is hard
to get. You have to have direct contact. Whereas 1 person with
measles typically infects 18 other people, with Ebola it is 2
other people.
Mr. Swalwell. Thank you. So, Mr. Chairman, it sounds like
to me, you know, fighting Ebola in West Africa has to be our
primary goal, but also fighting myths at home just to prevent
hysteria also has to be a priority. I yield back. Thank you.
Chairman McCaul. The Chairman now recognizes Mr. Clawson.
Mr. Clawson. Since I am from Florida, not from Texas, I
would like to defer my time to Mr. Barton. I have got a
question or two, but I will follow the Texans I think is the
right way to go here.
Chairman McCaul. We admire that as Texans. Mr. Barton.
Mr. Barton. Well, I appreciate my colleague from Florida.
Today is my day to pick up my 9-year-old son from daycare, so I
am very appreciative----
Mr. Clawson. That is a priority.
Mr. Barton [continuing]. That I get to go next. Our first
panel we focused on National and international issues, and my
questions were directed primarily to why let people come into
this region from the center of the disease, which is over in
Africa. Well, this panel is a little bit different ball game.
You have to deal with what is on the ground. It is not your
issue how the people that might have the disease get into the
United States. They are here. We have had a case here in
Dallas, Texas, and the State of Texas has responded, Dallas
County has responded. Some of the local hospitals have
responded.
So my first question would be to you, Dr. Lakey. Dr. Merlin
indicated that 114 people had been identified as having some
significant contact with the individual who has since passed
away from Ebola. Are you confident that your agency and CDC has
everybody under observation who needs to be under observation?
Dr. Lakey. Yes. I have talked to the CDC, the director here
on the ground, and the other epidemiologist. They started out
with 114, and then they took histories and talked to
individuals, and they felt that those individuals, that there
were 48. Now, I would say, yes, there are always rumors, and
when there are rumors, we track them down to see if there is
any truth to any of those rumors. That happens in every
response.
But 48 individuals from all the analysis that the
epidemiologists have had, the discussions linked with those
individuals and with Mr. Duncan before he died indicated those
48 individuals, and those were the individuals that continue to
be monitored. At the same time, I would say, yes, we are
confident. We also understand that you always have to have a
little humility when you are in a disaster. We prepare that if
there was somebody else that was unreported, that we are ready
for those individuals, too. So, that is my answer, sir.
Mr. Barton. Do you have all the authority that you need to
have to monitor, if necessary, quarantine and restrict
individuals so that they do not transmit this disease to
somebody else? Are there any restrictions on the State of
Texas' Department of Health Authority to handle this situation?
Dr. Lakey. This is one issue that I have been in the midst
of, and I have the ability to put in a control order, and I put
in three control orders. I do not take that lightly. I only did
that because I had to ensure that we could monitor individuals
effectively. If there was something that made me think that I
could not do that, I put in a control order.
Now, my control order, though, is written documentation to
that individual. It does not give the ability for the police to
deter that individual. If the individual leaves, then you have
to go get an Attorney General's opinion. The Attorney General
Office goes to get a judge's opinion that then can give the
ability for law enforcement to detain that individual.
Mr. Barton. Is that the State of Texas Attorney General?
Dr. Lakey. That is the State of Texas. So as I was
discussing with some folks, I have more ability in my position
to detain somebody for a short period related to mental health
issues than I have with an infectious disease issue, like
Ebola, initially because my order is written documentation, and
only when they break that do I have the ability to get the
police to detain that individual.
Mr. Barton. So if Judge Jenkins, or the mayor of Dallas, or
any other locally-elected official wanted to do something, they
would come to you or your designee, and you would make the
determination unless you felt it took a law enforcement action,
which you would go to a district judge----
Dr. Lakey. Yes, sir.
Mr. Barton [continuing]. Who then would issue the proper
authority for law enforcement to take whatever action you deem
necessary.
Dr. Lakey. The local health authority has that ability.
This is a special situation, so I am here.
Mr. Barton. So you are saying that the Dallas County Health
Department has this authority. Either you have it, or they have
it, or share it?
Dr. Lakey. We both have it because we use it for
tuberculosis, same type of control order. But that does not
give us the power to detain until the individual breaks that
control order. So you always have the possibility, and we have
been doing this with putting the police out there so we do not
lose an individual. But you have the ability that somebody
could break that control order, and then you have to find them
again.
Mr. Barton. Now, how much longer do you have to monitor
these 48 individuals before they are off the watch list and you
can say with 99 percent confidence that there is no threat here
in the DFW area, another 10 days?
Dr. Lakey. We are monitoring them for 21 days. We are at
day number 12 now.
Mr. Barton. So 9 more days. If we do not develop a case, if
they do not become symptomatic in the next 9 days, then we can
safely say there is no danger immediately in the DFW area, is
that correct?
Dr. Lakey. That is correct. It gets a little bit
complicated because the policies for overseas related to Ebola,
they go two incubation periods, so 42 days. It is a little
different situation since we know this one individual, but we
will monitor the contacts for 21 days. If there is anybody that
was exposed, we monitor 21 days after that. So the individual
patient, 21 days.
Mr. Barton. I want to thank you, Mr. Chairman, for letting
me participate. I also want to compliment the DFW Airport
Authority for hosting this and putting it together so quickly.
Finally, much has been made of the 140 barrels of hazardous
waste material that has been collected and was incinerated
today. The company that did that is in my Congressional
district, and I want to commend that private-sector company for
working with the local officials in such a conciliatory and
cooperative fashion. They were willing to cut some of the red
tape and so some things that needed to be done. With that,
thank you for chairing this hearing and having it here in the
DFW area.
Chairman McCaul. It has been a real honor to have you, sir,
and good luck with that 9-year-old boy.
[Laughter.]
Chairman McCaul. The Chairman now recognizes the gentlelady
from Texas, Ms. Eddie Bernice Johnson.
Ms. Johnson. Thank you very much, Mr. Chairman, and let me
thank you for the hearing, and thanks to everyone who took the
time to come today. I especially want to thank the panel. I
cannot tell you how much appreciation I have for the type of
leadership that you put into play when this happened. It could
have been a lot worse. I am not certain it could have been much
better, but I appreciate everything that you have done. I do
not see anything that we left undone. I think that if there is
a question, it might have been related to what happened between
the first contact of the patient in the hospital, and that is
not anything we are discussing today.
But what comes to mind is how well we can respond and how
much we can over-respond sometimes if we do not use education
and common sense and professionalism. Now, we have talked about
stacking up a lot of equipment, goods, and supplies, which I
think it is totally unnecessary. I do think we should be ready,
but I also think we have to be concerned about expiration dates
and how much we are stacking up for something that might not be
necessary. So it does take some professional approach to
determine what is going to be necessary to have a degree of
readiness for any communicable disease.
We all are aware of the cuts. We all are aware that many of
the cuts that we need to address. Sometimes we have overdone
it. But I also want to remind everyone that when you ask for
more airports to be added and more different other things to be
added, that that is also another cost. So I just want you to
know that when you ask for DFW to be included, I want to make
sure that you include the budget for DFW to be included as
well.
It is clear that we have dealt with and are dealing with a
very serious disease that is affecting West Africa. We have
done, I think, the best we could do with all of the anxiety
that people experience with having one in this country. There
are some other communicable diseases that are common in this
country that we have not yet addressed quite as well, but we do
have that ability.
But my caution is not to let our anxiety and the lack of
clear education cause us to spend much more than what we need
to. I went to the Department of Transportation to get
permission for these goods to be disposed of, and I am
delighted to be able to have done that. I do not know, and I
cannot make a judgment at this point, how much was overdone or
under done, but I think that I can be very clear in my
appreciation to say that we did what we thought we needed to do
for safety, for education, and to alleviate anxiety, and we
will probably continue to do that. My caution is that we not
overdo and over spend because we are still trying to address
anxiety rather than the disease itself.
But at this point, I do not have any further questions, but
just to express my appreciation to both the committee, the
persons who came today, and to all of you who are on the front
lines. And to say that I do not know anything else that I would
have expected of our leadership from our Governor, to all of
you who responded, to our local officials. I think that we did
the best we could under the circumstances. It is a very new
thing. I am not saying that we were perfect, but I am not sure
that I can tell you what else you could have done. So thank
you, Mr. Chairman, for having the hearing.
Chairman McCaul. Thank you as well. The Chairman recognizes
Dr. Burgess.
Mr. Burgess. Well, thank you, Mr. Chairman. This has been a
very important afternoon, and I am certainly thankful that you
let me participate. There will be another hearing on this
subject next Thursday in Washington in the Energy and Commerce
Committee. I spent the day yesterday in a field hearing in
Raleigh-Durham on vaccine development. This is for people who
think that we are not paying attention to this. I just want to
underscore that.
I also just want to mention that I realize the CDC was on
the previous panel, and it is easy to be critical of the
Federal agencies. But I would also say that it is the CDC that
goes afield and does the work. Yes, the World Health
Organization is there, but I will tell you the global outreach
and resource network of the World Health Organization would be
nothing without the participation of the CDC. They have borne
the lion's share of this burden overseas and in the United
States. The United States taxpayer has borne the lion's share
of this burden, and I do hope that other global partners will
step up because fighting the disease, you know, on the fronts
in Africa is extremely important.
We were told by all the experts that this would burn itself
out, March/April time frame, and then when it did not, of
course it was so much more established that it is now. As I
pointed out on Mr. Thompson's graph, were are in the
exponential phrase. It is very, very difficult to control a
disease in the exponential phase.
But we have also, I think, lost an opportunity here at home
to provide that public trust or that public confidence, and
that is going to be hard to get back, and that is why so much
of the discussion that you heard with the earlier panel dealt
with how do we deal with people coming in. Okay, no direct
flights. It turns out there are 125, 150 people a day who come
from those countries in Africa to this country. Perhaps we
should increase the surveillance period. Yes, that would cost
some additional money, but, you know, it is the old deal, a
stitch in time saves nine.
We are paying an enormous amount of money for the fact that
someone got through, the problem has happened, and then the
whole cascade. Then as a consequence to that, and, Dr. Lakey,
you and I discussed this, I mean, this problem does not stop at
the county line. One of your employees, Judge Jenkins, one of
my constituents, who had a problem the other day, and once that
threshold is reached again, the entire cascade has to happen
yet again with all of the concern and all of the expense.
Dr. Giroir, I would be interested in your thoughts because
you have participated at the Federal level before. Is there not
something more we can do at the beginning phase of this when
people are coming into this country to hold people a little
longer, to keep a little tighter surveillance, and not have to
bear the expense at Judge Jenkins' level and Dr. Lakey's level?
Dr. Giroir. Again, international travel is really not my
area of expertise, but I do want to underscore as in any
situation like this, the further you push this event to the
left, the better you are going to be. So the earlier you
identify the individual, if that is going to be in the hospital
in the emergency room that first time or when they go to the
pharmacist, that first identification is very important.
The earlier you do that and the further you push that back,
that is where it needs to be done because by the time you close
down a 24-bed ICU, you activate all of the EOCs, that is really
not the way you want to attack this. It would be great----
Mr. Burgess. It is the most expensive way.
Dr. Giroir. It is the most expensive and the least
effective way. So you get it at its origin in Africa, this
disease in Africa. There will be other diseases in other parts
of the world, and maybe we will originate some that the other
parts of the world will deal with as well. It is not an African
issue. It is a world issue. But again, I agree with what you
said. You get it as close to the source as possible. You do not
try to play catch-up once it is here and it is out.
Mr. Burgess. Dr. Lakey, you referenced an after-action
report. I referenced that in my earlier discussion with the
earlier panel. Is there actually a report that is going to be
produced by the State?
Dr. Lakey. We do that after every major event. We did it
after H1N1. We did it after Hurricane Ike. It is part of our
policy. We are a learning agency, and we have to learn from our
experience. So, yes, we do an after-action after every major
event.
Mr. Burgess. Well, I am sure Mr. McCaul would like you to
share that with the Homeland Security Committee. I would just
ask that we just share that with the Energy and Commerce
Committee as well.
Dr. Lakey. Absolutely.
Mr. Burgess. Then, Judge Jenkins, finally, again, your
employee, my constituent, who had a problem the other day, and
not to get into the details or specifics of that. But is there
a contact number that someone has who might have a concern
about this who was in that, not the primary group, the 48
people that you are talking about, but in, say, a secondary or
even a tertiary group where they can talk with someone before
having to pull the lever of going to an urgent care center or
an emergency room. Is there an intake place that they have
available to them?
Judge Jenkins. There is, and your constituent and my
employee, I spoke to him this morning, and I spoke to his wife,
and I spoke to the head of his association. What I told him is
that he has my full support. He and his family acted
appropriately on the information they were given by someone
outside. They were given information that we were unaware of at
the incident command structure, and they acted on that.
The information within the incident command structure would
be different, and we have had a meeting now with all law
enforcement at the agency level, at the association level, to
let them speak to infectious disease doctors from the other
Dallas area hospitals that are unaffiliated with the Government
or Presbyterian Hospital and get their questions answered. We
have set up a location for them to receive care should they
have any sorts of concern.
But let me make something very clear to the public. There
is a 0 percent chance that I or my deputies or my first
responders contracted Ebola because I and my deputies and my
first responders did not come into contact with any bodily
fluids of Mr. Duncan.
Mr. Burgess. I appreciate that. I do hope that this
information will part of that after-action report as it is all
incorporated when you look back at the entire series of events.
Judge Jenkins. Congressman, I also want to stress that we
want a complete after-action. To the extent permitted by law, I
want that to be public.
Mr. Burgess. Yes, I agree. Thank you, Mr. Chairman. Thank
you for holding the hearing.
Chairman McCaul. Thank you, Doctor, for your expertise. The
Chairman recognizes Ms. Jackson Lee for the purpose of
introduction of a document into the record.
Ms. Jackson Lee. Let me thank you, Mr. Chairman. I would
like to add into the record a letter dated October 8, 2014
officially requesting for the enhanced screening and CDC at
Bush Intercontinental, and I would add that I join on DFW as
well. Let me conclude, Mr. Chairman. I know there is one more,
I think, testimony coming. Two more. Just to say that I want to
thank all these gentleman. I am stepping away for an airplane.
I want to give my appreciation and thanks, and I want to thank
Commissioner Jenkins for, again, your grace and humanity.
To the others, I will put into the record, Mr. Chairman, my
question about contagion units as well as my question regarding
the idea of the panels that the Governor was astute in putting
in this State, whether they would be appropriate. Again, this
hearing is not just for Ebola, but to be prepared for any
episode that we might come in contact with, and I thank the
witnesses very, very much. I thank this community very, very
much. I yield back.
Chairman McCaul. Without objection, so ordered with respect
to the document.
[The information follows:]
Letter from Honorable Jackson Lee to Director Frieden
October 8, 2014.
Dr. Tom Frieden,
Director, Centers for Disease Control and Prevention, 1600 Clifton
Road--Mailstop E-92, Atlanta, GA 30329-4027.
Dear Dr. Frieden: As a Senior Member of the House Committee on
Homeland Security and the Ranking Member of the Subcommittee on Border
Security, I am pleased that the Centers for Disease Control, the
Department of Homeland Security's U.S. Customs and Border Protection
Agency, and the United States Coast Guard are coordinating to establish
a new level of screening for international air travelers during the
global Ebola health crisis that is impacting the United States. I
understand this coordinated effort will add new screening protocols
beginning Saturday, October 11, 2014 for passengers with flight
itineraries where travel originated in the countries of Guinea,
Liberia, or Sierra Leone. Additionally, I am aware that the Centers for
Disease Control and the Department of Homeland Security announced new
layers of entry screening at Hartsfield-Jackson Atlanta International
Airport, Newark Liberty International Airport, John F. Kennedy
International Airport, Dulles International Airport, and Chicago O'Hare
International Airport.
As a Member of Congress representing, Houston Texas, the 4th
largest city in the nation, I am requesting that George Bush
Intercontinental Airport be included on the list of airports to receive
the enhanced Ebola screening protocols for those passengers whose
flight itineraries indicate that the air travel originated in the
countries of Guinea, Liberia, or Sierra Leone. The George Bush
Intercontinental Airport serves the Houston area and is a major
originating and connecting hub for international air travelers. From
January to August 2014, there have been 99,452 West African passengers
traveling into and out of the George Bush Intercontinental Airport with
a total of 1,856,421 international travelers. I am requesting that
George Bush Intercontinental Airport be added to the list of airports
receiving new layers of entry screening.
The new layers of entry screening that should be followed at the
George Bush Intercontinental airport include: (1) Customs and Border
Protection agents greeting passengers and escorting them to a
quarantine area where they will answer questions from a detailed
questionnaire; (2) United States Coast Guard trained medical staff
conducting a preliminary health screening by checking temperatures with
a contact free thermometer; and (3) Centers for Disease Control staff
making further health assessments to determine whether a passenger
should go to a hospital. Further, these passengers will be provided
with information on signs of the illness and information on self-
quarantine and who to contact for medical assistance. If a passenger's
answers to the questionnaire indicate that future follow up and
tracking should be done, they will referred to a county health
department for follow up medical assessment.
I am available to speak with you regarding the George Bush
Intercontinental Airport and the status of their level of preparedness
as well as the hospitals and first line health care providers serving
the city of Houston.
Very truly yours,
Sheila Jackson Lee,
Member of Congress.
Chairman McCaul. Mr. Clawson is recognized.
Mr. Clawson. Thank you for your service. Thanks for coming
here today. I am not from Texas, but I can see you all are very
competent in what you do and very knowledgeable, and I am very
appreciative for you coming here today.
A few years ago I got off a plane from India for my
business. It was the monsoon season, and there were big dang
mosquitoes everywhere. About a week later in the United States
I became very ill with a hemorrhagic illness and went to the
hospital, and was ordered tested for malaria and a few other
things, but was not tested for chikungunya for that matter or
any of the other illnesses that, by the way, are getting closer
and closer to our country and to Texas.
So when the incident happened in Texas, I really was not
surprised because just from my own experience, it seemed to me
that this idea that the folks in our emergency rooms could have
enough first-hand knowledge of the different hemorrhagic
infectious diseases around the world and match them with the
travelers. I had told my doctor that I was coming from India,
and it was the monsoon season. It feels like a really hard task
that you are up against because the first line has got to be
100 percent, and it is a complicated world.
So I draw two conclusions or questions from that. How do we
get that knowledge at the hospital level really ingrained, and
second, whatever you all are learning here because you are on a
steep learning curve, right? How do we get it to other States
and areas like mine so that we do not have to re-learn tough
lessons? Will you all respond to that a little bit?
Dr. Lakey. I will start, and then I will hand off. I think
you are right. I think we have to be prepared for the next
event. I would not be surprised if we have something like this
somewhere else in the United States. We were just unfortunate
here in Texas.
I think a lot of the things that you saw happen here could
happen in other places with somebody not fully understanding
the travel history, not making the link of what is going on
halfway around the world, and making the first diagnosis of a
tropical disease here in the United States. So we have to learn
from one another.
So some of those things that we do, there is an
organization of the folks that do my job across the United
States. We have had multiple phone calls related to this
strategic plan issue, chikungunya, et cetera, and we share
information rapidly between each other. There is a Council of
Epidemiologists across the United States. They have had those
types of meetings. We have to educate here in the State of
Texas. We have had multiple phone calls with all the hospitals,
all the EMS providers, all the emergency managers across the
State of Texas. We will share our after-action report and share
that information with our colleagues across the United States.
But we take that very seriously.
I think also to reiterate some of the comments that were
made earlier, I do not think you ever get done with
preparedness. So, those funding streams for hospitals to be
prepared or for public health emergency preparedness really are
essential for hospitals, for clinicians, for public health
individuals across the United States so they know how to
recognize when something like this occurs and have the
expertise to respond quickly. Those funds have been reduced
over the last several years, and they are essential to a health
department like mine to be able to respond effectively to an
event like this.
I guess the other thing I would add is that many years ago
there were dollars that went to academic institutions to
provide disaster education, and those funds have also been
decreased over the last several years.
Dr. Giroir. It is always very difficult for a low-risk,
high-consequence event to have everyone thinking about those
events. After you have the first event, everybody is thinking
about those events. We have done this in the past with the
college meningitis. There was a big outbreak in North Texas,
and the mortality rate went down many-fold just by education,
but it is not just education. It is really getting on the
ground and making sure people understand how to act on that
education.
I can say our task force, we can say all the good things,
but you do not know until you ask the people who are on the
front line. So we have a formal process we will be announcing
to seek information from the Texas Medical Association, Nurses
Association, Pharmacy Association, Public Health Association,
the first responders, the Rural and Community Health
Association, because not everybody lives in an urban area. We
are a rural State.
So we want to seek a lot of input in how we could best
educate the diverse groups and make that on-going. It may be as
simple as, I do not know if this is simple or effective, but we
all have continuing medical education, you know, 24 hours every
2 years. Have 15 minutes, just a 15-minute on-line that it does
not matter whether you are a nurse, a doctor, or a pharmacist,
that says what is circulating--what do you need to worry about?
It takes 15 minutes, and at least you reach everybody during
that basis. But we will be exploring all those efforts.
Mr. Clawson. Well, let us hope that we can get everybody in
the country in those jobs having that 15 minutes, right,
because it seems like a pretty important 15 minutes.
Dr. Giroir. Yes, sir.
Judge Jenkins. Can I answer that from the perspective of
what you could take home to your local governments for them to
do immediately?
Mr. Clawson. It would be very helpful.
Judge Jenkins. Yes, sir. Every county that you represent
needs to have a protocol for identifying people who have
recently traveled to West Africa and have certain symptoms, and
then quarantine them into a private room, and take appropriate
precautions. We had that in Dallas County. It was not followed
in this case.
At some hospitals, the electronic medical records have
artificial intelligence that would trigger that. That would be
a good best practice for large hospitals. The incident command
in a box for Ebola, that is not just a game plan. You have
actually contacted those cleaning guys and those apartment or
home residences you are going to move people to, and they are
actually going to clean up after Ebola, and actually going to
take contact families into their premises. There is going to be
a security perimeter around that to keep out onlookers.
Where we fell down is not that David and I could not white
board what needed to happen. It was the length of time it took
to make it happen, and it took a phone call from me to a member
of the faith community after we exhausted every housing source
in Dallas County, 2.5 million people. It took a call to the
faith community and asking them to clear out an area and do
this for us, and that is not any way to have to do this.
Chairman McCaul. Thank you. The Chairman recognizes Mr.
Farenthold.
Mr. Farenthold. Thank you very much, Mr. Chairman. You did
a great job of getting a bipartisan panel. We have an Aggie and
somebody from The University of Texas here.
[Laughter.]
Mr. Farenthold. So we have a great bipartisan panel.
Chairman McCaul. I am going to stay out of that one.
Mr. Farenthold. Mr. Jenkins, I want to follow up on what
Mr. Clawson was asking. You know, listen, yes, I think you did
a phenomenal job, the humanity that you showed, and I join you
in my sympathy for Mr. Duncan's family. But my question is, you
talked a little bit about what all the counties need to be
doing, actually having the places. Can you take maybe a minute-
and-a-half and just give me your top 5 things that the county
judges and all the other Texas counties ought to be thinking
about and doing?
Judge Jenkins. You need to make sure you have protocols and
that our hospitals have been training with repetition. You need
to activate your medical societies so that they are training
with that repetition and interactions with your hospitals. Then
on your instant command in a box, you need to have that laid
out and ready to go on a moment's notice.
You need to have places for people to move to, people to
clean things up. Your first responders need to know what the
protocols are to handle these situations. You need to have a
messaging plan to keep people calm and have them follow the
science. You need to bring in your schools early and your faith
community early and help them be messengers. You need to
empower all of your school boards, your city councils in your
suburban areas. You need to do that in the first 24 hours.
Mr. Farenthold. All right. Mr. Giroir, we have heard a lot
about the failure of this information to get down to the front-
line folks in the hospital. I mean, that was kind of the big
screw-up here I think. I get hundreds of emails every day. I
used to be a computer guy. I would get somebody from the
Computer Emergency Response Team. I get all sorts of
information like that in my inbox. When I have got a busy day,
that just is the first thing that does not get read are the,
you know, the emails with important updates.
You talk about a 15-minute continuing medical education, 15
minutes every 2 years. Does not this change more than every 2
years? I mean, that probably would not be enough. I mean----
Dr. Giroir. No, it certainly would not.
Mr. Farenthold. How do you get around that? I mean,
everybody knows about Ebola if they have turned on their
television newscasts now. But what happens early on when the
next one comes?
Dr. Giroir. Right, and I think you are exactly right. We do
not know if the information did not get to the people in the
emergency room or they did not act on the information in the
correct way. That will be something in the future.
But you are correct that the best way to approach any
problem, and you do it in hospitals all the time, is to create
processes that you cannot get around. As the judge said, the
Texas Senate heard testimony of one of the large hospitals,
Parkland, where it is an automated record that if you are from
West Africa, it literally lights up on every screen, and it has
to go to a higher-level supervisor in order to make sure that
it is appropriately handled. Those kinds of fail-safe
mechanisms do not rely on individual emails or education, but
it is a multifaceted approach.
Mr. Farenthold. How do you get away from the reluctance?
Again, I am an old computer guy. There is nobody who hates
computers more than doctors. I mean, every doctor I know has
complained about electronic medical records and the expert
systems.
Dr. Giroir. But we do educate providers. We do keep them
up. There are continuing medical educations. There are
conferences. There are meetings. There are other ways to reach
people. But there is no single solution. This is going to be a
comprehensive education solution that spans many, many
disciplines because, again, not everybody goes to a hospital
ER. They may show up at a pharmacist, or a public health
professional, or a nurse, or from promotoras in the colonias.
We have to have this widespread. It is a challenge, there is no
doubt.
Mr. Farenthold. All right. Finally, I think everybody on
the panel has said that funding needs to be restored for a
variety of projects. What else can we do as Congress to help
with this beyond kicking up the budgets? Is there legislation
we need to do? Are there holes? What else is there to do
besides spend some more money? Go ahead, Judge.
Judge Jenkins. Streamline the process for permitting for
waste. Empower public health officials and executives. I serve
as the director of homeland security and emergency management
for Dallas County. Give us the power to do this quicker. We are
working under laws that clearly were not set up for Ebola.
Mr. Farenthold. Anybody else?
Dr. Lakey. I would agree. I talked a little bit about the
ability of a health authority to be able to detain an
individual, understanding that you do not want that to be very
broad, an emergent issue, to be able to do this. We talked
about funding. The health alert networks, the basic abilities
to do surveillance activities, monitor individuals, having
exercises that take place in hospitals, the requirements for
continuing medical education, those types of things.
I guess the other idea that I would have is I was able to
participate this summer with the Institute of Medicine looking
at how we can we improve the ability to do research in the
middle of a disaster. I think you need to think about how can
we facilitate that in an emergent event to rapidly be able to
take investigational drugs, to monitor them appropriately, and
to decrease that time that it took to get research done and
investigational medicines out.
Mr. Farenthold. I see, Ms. Troisi, you look like you want
to answer.
Ms. Troisi. Yes, really.
Mr. Farenthold. I do not have a lot of time, but if the
Chairman will----
Ms. Troisi. No, I will add one thing, is that disease-
specific funding hampers public health's ability to prioritize
what needs to be done. Many times communities that have one
problem have another problem, but the funding streams are such
that you can only deal with problem A, not with problem B with
that specific funding. So non-restricted funds would be good.
Mr. Farenthold. Thank you very much.
Dr. Giroir. Money is important, but accountability for the
funds, money spent right, is equally as important as the amount
of money, and that takes leadership across agencies. I think
there is tremendous duplication even in my area between DoD and
DHHS that could be easily streamlined for less money.
The third thing I would say, and I am on the other side of
this now, is that probably the onerous Government contracting
procedures probably double the time and increase the costs by
30 or 40 percent than what they need to be. Congress has given
special contracting authorities to certain agencies to allow
that to be expedited, and they are not being expedited in their
fullest. We can get more for the money we spend right now.
Mr. Farenthold. Thank you.
Chairman McCaul. We thank the witnesses for this hearing,
for being here. It has been very informative, and not only in
terms of identifying the threat and how to best contain and
control it, but also to debunk some of these myths out there in
terms of Ebola and how it is transmitted. I think that will go
a long way in alleviating some of the panic and the fears out
there in the general population.
So the record will stay open for 10 days. Members may have
additional questions to submit in writing.
With that, Ms. Jackson Lee is recognized.
Ms. Jackson Lee. Thank you so very much. On behalf of Mr.
Thompson, I want to also express my appreciation to the
Chairman and to all of you. I think in addition to debunking, I
think there has been given comfort that health professionals
across America, we cannot have hearings with every county and
State, but that there is a preparedness and a readiness to be
prepared, and the recognition that we may not have rural
hospitals before us.
Texas Presbyterian may be the one in the eye of the storm
and people are looking into how that treatment was. But at
least you have given a pathway for our hospitals and medical
facilities to reach out for information, to determine if they
have the right amount of equipment, and as well, to raise
questions such as the kind of containment units.
Again, I am going to push this idea of regional panels. Dr.
Giroir, I think it is an excellent idea, and we have learned a
lot from hearing what Texas has done. Thank you all so very
much. Thank you, Dr. Lakey----
Chairman McCaul. With that, the committee is adjourned.
[Whereupon, at 4:01 p.m., the committee was adjourned.]
A P P E N D I X
----------
Questions From Honorable Lamar Smith for Toby Merlin
Question 1. In understanding that there may be some accuracy
questions or concerns around reliance on a non-contact thermal
thermometer, what steps will the CDC or other agencies take to achieve
secondary/confirmatory screening to ensure optimal accuracy and quality
and potentially more precision in readings?
Answer. Response was not received at the time of publication.
Question 2. Could you provide the committee with background on the
decision process that went into the choice of the thermometer(s) that
will be utilized?
Answer. Response was not received at the time of publication.
Question 3. Will the temperature screeners be maintaining the
recommended distance barrier (3 ft.) for evaluation and if so, how will
they use the infrared devices effectively?
Answer. Response was not received at the time of publication.
Questions From Honorable Beto O'Rourke for Toby Merlin
Question 1a. The Center for Disease Control and Prevention (CDC)
provides grant funding to ensure that public health departments are
prepared for emergencies. What are the audit and accountability
mechanisms for CDC Public Health Emergency Preparedness (PHEP) grants?
Was any of the PHEP funding spent in Texas and specifically in
Dallas?
Question 1b. If so, how was this funding spent and why did this not
prevent the mistakes that occurred in Mr. Eric Duncan's case?
Question 1c. Given the public health errors made in Dallas with
regards to Mr. Duncan's case, what procedural changes does CDC
recommend?
Answer. Response was not received at the time of publication.
Question 2a. There was a 4-day delay from when Mr. Duncan was
diagnosed and when he received the experimental treatment. What effect
did this have on Mr. Duncan's death?
I understand that CDC cannot mandate the specific type of care, but
what are your thoughts on the efficacy of the treatment Mr. Duncan
received?
Question 2b. Was the hospital adequately prepared?
Answer. Response was not received at the time of publication.
Questions From Honorable Eric Swalwell for Toby Merlin
Question 1. Dr. Merlin, at the October 10 hearing I asked you about
the budget of the Centers for Disease Control and Prevention (CDC). I
inquired if the CDC's budget was adequate or if it needed to be
increased. And, I asked what would be done with this additional funding
if it were needed. You answered that you would defer to the CDC
director and Department of Health and Human Services (HHS). Having had
time now to consult with the director of the CDC and anyone at HHS, how
would you answer my questions about the adequacy of the CDC's budget
and what would be done with extra funds if they were considered needed?
Answer. Response was not received at the time of publication.
Question 2a. I followed up my question about the general CDC budget
with a question about the budget of just your part of CDC, the Division
of Preparedness and Emerging Infection. You said you would have to get
back to me. Please now provide information about the budget of the
Division of Preparedness and Emerging Infections. Specifically, include
the level of funding your division has received between fiscal year
2005 and fiscal year 2015. Please also note the effect of
sequestration.
Do you consider these levels of funding adequate to accomplish your
mission?
Question 2b. If not, what have been the negative effects of these
insufficient amounts?
Answer. Response was not received at the time of publication.
Question 3a. Dr. Francis Collins, head of the National Institutes
of Health (NIH), recently said the following in talking about the
impact of budget cuts on finding a vaccine for Ebola: ``Frankly, if we
had not gone through our 10-year slide in research support, we probably
would have had a vaccine in time for this that would've gone through
clinical trials and would have been ready.''
Do you share Dr. Collins's view?
Question 3b. Why or why not?
Answer. Response was not received at the time of publication.
Question From Honorable Lamar Smith for John P. Wagner
Question. What type of precautions will the involved agencies be
taking to protect the screeners at the airport (i.e. will they all use
personal protective equipment (PPE) to include gloves, surgical masks).
And if so, will that differ from the precautions they plan to take for
the screeners of those passengers who have an elevated temperature?
Answer. U.S. Customs and Border Protection (CBP) Office of Field
Operations (OFO) has received guidance from the Department of Homeland
Security (DHS) Office of Health Affairs (OHA) and Centers for Disease
Control and Prevention (CDC) on Ebola entry screening and the
requirements for the use of Personal Protective Equipment (PPE) for
enhanced Ebola screening. OFO has distributed this guidance to the CBP
employees at the ports of entry (POE) processing international
travelers arriving from or transiting through the countries affected by
the Ebola virus outbreak.
DHS guidance on Ebola entry screening outlines the requirements of
PPE use, including proper procedures for putting on (donning), taking
off (doffing), and wearing PPE. DHS guidance outlines the required PPE
that must be worn when an employee is in close proximity to a traveler
from a country of concern. In addition, the guidance outlines the
additional required PPE to be worn by an employee when working in close
proximity to a traveler from a country of concern who is exhibiting
symptoms consistent with the Ebola virus.
PPE has been made available to all CBP employees at the five
designated POEs where enhanced Ebola screening is being conducted along
with OHA guidance which includes the Job Hazard Analysis and PPE
Assessment. CBP has deployed formal training to CBP employees
conducting enhanced screening on the donning and doffing of PPE and
will be implementing additional training on PPE and enhanced screening
protocols.
CBP is in the process of deploying additional PPE to all POEs, and
all POEs have been instructed to maintain a 60-day supply of PPE at
each location.
[all]