[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]





    EXAMINING THE U.S. PUBLIC HEALTH RESPONSE TO THE EBOLA OUTBREAK

=======================================================================

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                            OCTOBER 16, 2014

                               __________

                           Serial No. 113-179
                           
                           
                           
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


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                    COMMITTEE ON ENERGY AND COMMERCE

                          FRED UPTON, Michigan
                                 Chairman

RALPH M. HALL, Texas                 HENRY A. WAXMAN, California
JOE BARTON, Texas                      Ranking Member
  Chairman Emeritus                  JOHN D. DINGELL, Michigan
ED WHITFIELD, Kentucky               FRANK PALLONE, Jr., New Jersey
JOHN SHIMKUS, Illinois               BOBBY L. RUSH, Illinois
JOSEPH R. PITTS, Pennsylvania        ANNA G. ESHOO, California
GREG WALDEN, Oregon                  ELIOT L. ENGEL, New York
LEE TERRY, Nebraska                  GENE GREEN, Texas
MIKE ROGERS, Michigan                DIANA DeGETTE, Colorado
TIM MURPHY, Pennsylvania             LOIS CAPPS, California
MICHAEL C. BURGESS, Texas            MICHAEL F. DOYLE, Pennsylvania
MARSHA BLACKBURN, Tennessee          JANICE D. SCHAKOWSKY, Illinois
  Vice Chairman                      JIM MATHESON, Utah
PHIL GINGREY, Georgia                G.K. BUTTERFIELD, North Carolina
STEVE SCALISE, Louisiana             JOHN BARROW, Georgia
ROBERT E. LATTA, Ohio                DORIS O. MATSUI, California
CATHY McMORRIS RODGERS, Washington   DONNA M. CHRISTENSEN, Virgin 
GREGG HARPER, Mississippi            Islands
LEONARD LANCE, New Jersey            KATHY CASTOR, Florida
BILL CASSIDY, Louisiana              JOHN P. SARBANES, Maryland
BRETT GUTHRIE, Kentucky              JERRY McNERNEY, California
PETE OLSON, Texas                    BRUCE L. BRALEY, Iowa
DAVID B. McKINLEY, West Virginia     PETER WELCH, Vermont
CORY GARDNER, Colorado               BEN RAY LUJAN, New Mexico
MIKE POMPEO, Kansas                  PAUL TONKO, New York
ADAM KINZINGER, Illinois             JOHN A. YARMUTH, Kentucky
H. MORGAN GRIFFITH, Virginia
GUS M. BILIRAKIS, Florida
BILL JOHNSON, Ohio
BILLY LONG, Missouri
RENEE L. ELLMERS, North Carolina

                                 7_____

              Subcommittee on Oversight and Investigations

                        TIM MURPHY, Pennsylvania
                                 Chairman
MICHAEL C. BURGESS, Texas            DIANA DeGETTE, Colorado
  Vice Chairman                        Ranking Member
MARSHA BLACKBURN, Tennessee          BRUCE L. BRALEY, Iowa
PHIL GINGREY, Georgia                BEN RAY LUJAN, New Mexico
STEVE SCALISE, Louisiana             JANICE D. SCHAKOWSKY, Illinois
GREGG HARPER, Mississippi            G.K. BUTTERFIELD, North Carolina
PETE OLSON, Texas                    KATHY CASTOR, Florida
CORY GARDNER, Colorado               PETER WELCH, Vermont
H. MORGAN GRIFFITH, Virginia         PAUL TONKO, New York
BILL JOHNSON, Ohio                   JOHN A. YARMUTH, Kentucky
BILLY LONG, Missouri                 GENE GREEN, Texas
RENEE L. ELLMERS, North Carolina     JOHN D. DINGELL, Michigan (ex 
JOE BARTON, Texas                        officio)
FRED UPTON, Michigan (ex officio)    HENRY A. WAXMAN, California (ex 
                                         officio)

                                  (ii)
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Tim Murphy, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     2
    Prepared statement...........................................     3
Hon. Diana DeGette, a Representative in Congress from the State 
  of Colorado, opening statement.................................     5
Hon. Bruce L. Braley, a Representative in Congress from the State 
  of Iowa, opening statement.....................................     6
    Prepared statement...........................................     7
Hon. Fred Upton, a Representative in Congress from the State of 
  Michigan, opening statement....................................     7
    Prepared statement...........................................     8
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................     9
    Prepared statement...........................................    10
Hon. Marsha Blackburn, a Representative in Congress from the 
  State of Tennessee, opening statement..........................    10
Hon. Henry A. Waxman, a Representative in Congress from the State 
  of California, opening statement...............................    11
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, prepared statement........................   148
Hon. Gene Green, a Representative in Congress from the State of 
  Texas, prepared statement......................................   150

                               Witnesses

Thomas R. Frieden, Director, Centers for Disease Control and 
  Prevention.....................................................    13
    Prepared statement...........................................    16
    Answers to submitted questions...............................   163
Anthony S. Fauci, Director, National Institute of Allergy and 
  Infectious Diseases, National Institutes of Health, Department 
  of Health and Human Services...................................    29
    Prepared statement...........................................    31
    Answers to submitted questions...............................   195
Robin A. Robinson, Deputy Assistant Secretary and Director, 
  Biomedical Advanced Research and Development Authority, Office 
  of the Assistant Secretary for Preparedness and Response, 
  Department of Health and Human Services........................    43
    Prepared statement...........................................    45
    Answers to submitted questions...............................   207
Luciana Borio, Assistant Commissioner for Counterterrorism Policy 
  and Director, Office of Counterterrorism and Emerging Threats, 
  Food and Drug Administration, Department of Health and Human 
  Services.......................................................    56
    Prepared statement...........................................    58
    Answers to submitted questions...............................   214
John P. Wagner, Acting Assistant Commissioner, Office of Field 
  Operations, U.S. Customs and Border Protection, Department of 
  Homeland Security..............................................    66
    Prepared statement...........................................    68
    Answers to submitted questions...............................   217
Daniel Varga, Chief Clinical Officer and Senior Executive Vice 
  President, Texas Health Resources..............................    72
    Prepared statement...........................................    75
    Answers to submitted questions...............................   228

                           Submitted Material

Photo chart, ``Levels of protective gear,'' New York Times, 
  submitted by Ms. DeGette.......................................    84
Report of October 15, 2014, ``Safe Management of Patients with 
  Ebola Virus Disease (EVD) in U.S. Hospitals,'' Frequently Asked 
  Questions, Centers for Disease Control and Prevention, 
  submitted by Ms. DeGette.......................................    87
Health Advisory of August 1, 2014, ``Guidelines for Evaluation of 
  U.S. Patients Suspected of Having Ebola Virus Disease,'' 
  Centers for Disease Control and Prevention, submitted by Ms. 
  DeGette........................................................    91
Health Advisory of July 28, 2014, ``Ebola Virus Disease Confirmed 
  in a Traveler to Nigeria, Two U.S. Healthcare Workers in 
  Liberia,'' Centers for Disease Control and Prevention, 
  submitted by Ms. DeGette.......................................    94
Letter of October 16, 2014, from Randi Weingarten, President, 
  American Federation of Teachers, to Mr. Upton and Mr. Waxman, 
  submitted by Ms. Schakowsky....................................   105
Article, ``Diary,'' by Paul Farmer, London Review of Books, 
  October 23, 2014 issue, submitted by Ms. Schakowsky............   108
Letter of October 16, 2014, from Delegate Robert G. Marshall, 
  House of Delegates, Commonwealth of Virginia, et al., to Terry 
  McAuliffe, Governor, Commonwealth of Virginia, submitted by Mr. 
  Griffith.......................................................   124
Report of October 2014, ``Will America's Fragmented Public Health 
  System Meet the Ebola Challenge?,'' Scholars Strategy Network, 
  submitted by Mr. Yarmuth.......................................   129
Map, ``Top Passenger Flows: Number of passengers (weekly),'' 
  submitted by Ms. DeGette.......................................   143
Report of August 2014, ``DHS Has Not Effectively Managed Pandemic 
  Personal Protective Equipment and Antiviral Medical 
  Countermeasures,'' Office of Inspector General, Department of 
  Homeland Security, \1\ submitted by Mr. Burgess
Photo showing personal protective equipment, Dallas Morning News, 
  submitted by Mr. Burgess.......................................   146
Subcommittee memorandum..........................................   152

----------
\1\ The report has been retained in committee files and also is 
  available at  http://docs.house.gov/meetings/IF/IF02/20141016/
  102718/HHRG-113-IF02-20141016-SD010.pdf.

 
    EXAMINING THE U.S. PUBLIC HEALTH RESPONSE TO THE EBOLA OUTBREAK

                              ----------                              


                       THURSDAY, OCTOBER 16, 2014

                  House of Representatives,
      Subcommittee on Oversight and Investigations,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 12:02 p.m., in 
room 2123 of the Rayburn House Office Building, Hon. Tim Murphy 
(chairman of the subcommittee) presiding.
    Members present: Representatives Murphy, Burgess, 
Blackburn, Gingrey, Scalise, Gardner, Griffith, Johnson, Long, 
Ellmers, Upton (ex officio), DeGette, Braley, Schakowsky, 
Castor, Welch, Yarmuth, Green, and Waxman (ex officio).
    Also present: Representatives Matheson, Sarbanes, Harris, 
and Meadows.
    Staff present: Gary Andres, Staff Director; Charlotte 
Baker, Deputy Communications Director; Sean Bonyun, 
Communications Director; Leighton Brown, Press Assistant; 
Rebecca Card, Staff Assistant; Karen Christian, General 
Counsel; Noelle Clemente, Press Secretary; Marty Dannenfelser, 
Senior Advisor, Health Policy and Coalitions; Brenda Destro, 
Professional Staff Member, Health; Andy Duberstein, Deputy 
Press Secretary; Brad Grantz, Policy Coordinator, Oversight and 
Investigations; Sydne Harwick, Legislative Clerk; Brittany 
Havens, Legislative Clerk; Sean Hayes, Deputy Chief Counsel, 
Oversight and Investigations; Kirby Howard, Legislative Clerk; 
Charles Ingebretson, Chief Counsel, Oversight and 
Investigations; Emily Newman, Counsel, Oversight and 
Investigations; Krista Rosenthall, Counsel to Chairman 
Emeritus; Macey Sevcik, Press Assistant; Alan Slobodin, Deputy 
Chief Counsel, Oversight and Investigations; Sam Spector, 
Counsel, Oversight and Investigations; Jean Woodrow, Director 
of Information Technology; Ziky Ababiya, Democratic Staff 
Assistant; Peter Bodner, Democratic Counsel; Brian Cohen, 
Democratic Staff Director, Oversight and Investigations, and 
Senior Policy Advisor; Lisa Goldman, Democratic Counsel; 
Elizabeth Letter, Democratic Professional Staff Member; Karen 
Lightfoot, Democratic Communications Director and Senior Policy 
Advisor, and Nick Richter, Democratic Staff Assistant.
    Mr. Murphy. Good afternoon. I convene this hearing of the 
Subcommittee on Oversight and Investigations, Committee on 
Energy and Commerce.
    Ms. DeGette. Mr. Chairman, I can't see the witnesses.
    Mr. Murphy. We will need to make sure that the media is--
when the witnesses speak that we are clear of the center 
section.

   OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Today, the world is fighting the worst Ebola epidemic in 
history. CDC and our public health system are in the middle of 
a fire. Job one is to put it out completely, and we will not 
stop until we do. We must be clear-eyed and singular in purpose 
to protect public health, and to ensure not one additional case 
is contracted here in the United States. We in Congress stand 
ready to serve as a strong and solid partner in solving this 
crisis because there is no greater responsibility for the U.S. 
Government than to protect and defend the safety of the 
American people.
    The stakes of this battle couldn't be any higher. The 
number of Ebola cases in western Africa is doubling about every 
3 weeks. The math still favors the virus, even with the recent 
surge in global response.
    With no vaccine or cure, we are facing down a disease for 
which there is no room for error. We cannot afford to look back 
at this point in history and say we should have done more.
    Errors in judgment have been made, to be sure, and it is 
our immediate responsibility today to learn from those errors, 
correct them rapidly, and move forward effectively as one team, 
one fight.
    Let us candidly review where we stand. When the latest 
Ebola outbreak in West Africa was confirmed months ago, 
authorities thought it would be similar to the 1976 outbreaks 
and quickly contained. That turned out to be wrong. By 
underestimating both the severity of the danger and overstating 
the ability of our healthcare system to handle Ebola cases, 
mistakes have been made. What was adequate practice for the 
past has proven to fall short for the present.
    The trust and credibility of the administration and 
Government are waning as the American public loses confidence 
each day with demonstrated failures of the current strategy, 
but that trust must be restored, but will only be restored with 
honest and thorough action.
    We have been told: ``virtually any hospital in the country 
that can do isolation can do isolation for Ebola.'' The events 
in Dallas have proven otherwise. Current policies and protocols 
for surveillance, containment, and response were not 
sufficient. False assumptions create real mistakes, sometimes 
deadly mistakes.
    We must understand what went wrong so we can get a firm 
handle on this crisis: Why was the CDC slow to deploy a rapid 
response team at Texas Health Presbyterian Hospital? Why 
weren't protocols to protect healthcare and hospital workers 
rapidly communicated? What training have healthcare workers 
received?
    And there are things about Ebola we don't know. How long 
does the virus live on surfaces or on certain substances? How 
do healthcare workers wearing full protective gear still get 
infected? Can it be transmitted from a person who does not yet 
have a high fever? Both CDC and NIH tell us that Ebola patients 
are only contagious when having a fever. However, the largest 
study of the current Ebola outbreak found that nearly 13 
percent of confirmed cases in West Africa did not have 
associated fever.
    Now, I respect the CDC as the gold standard for public 
health, but the need for strong congressional oversight and 
partnership remains paramount. I want to understand why CDC and 
the White House changed course in 2010 on proposals first 
introduced in 2005 that would have strengthened the Federal 
quarantine authority. We are here to work through and fix these 
problems.
    I restate my ongoing concern that administration officials 
still refuse to consider any travel restrictions for the more 
than 1,000 travelers entering the United States each week from 
Ebola hot zones.
    A month ago, the President told us someone with Ebola 
reaching our shores was unlikely and that ``we have taken the 
necessary precautions'' to ``increase screening at airports so 
that someone with the virus does not get on a plane for the 
United States.''
    Screening and self-reporting at airports have been a 
demonstrated failure, yet the administration continues to 
advance a contradictory position for this failed policy that 
frankly doesn't make sense to me, especially if priority one is 
to contain the spread of Ebola and protect public health.
    It troubles me even more when public health policies are 
based upon a stated concern over cutting commercial ties with 
fledgling democracies rather than protecting public health in 
the United States. This should not be presented as an all-or-
none choice. We can and will create the means to transport 
whatever supplies and goods are needed in Africa to win this 
deadly battle. We do not have to leave the door open to all 
travel to and from hot zones in western Africa while Ebola is 
an unwelcome and dangerous stowaway on these flights. I am 
confident we can develop a reasoned and successful strategy to 
meet these needs.
    The current airline passenger screening at five U.S. 
airports through temperature taking and self-reporting is 
troubling. Both CDC and NIH tell us that Ebola patients are 
only contagious when having a fever, but we know this may not 
be totally accurate.
    A determined, infected traveler can evade the screening by 
masking the fever with ibuprofen or avoiding the five airports. 
Further, it is nearly impossible to perform contact tracing of 
all people on multiple international flights across the globe.
    So let me be clear to all the Federal agencies responding 
to the outbreak. If resources or authorization is needed to 
stop Ebola in its tracks, tell us in Congress. I pledge, and I 
believe this committee joins me in pledging, that we will do 
everything in our power to work with you to keep the American 
people safe from the Ebola outbreak in West Africa.
    [The prepared statement of Mr. Murphy follows:]

                 Prepared statement of Hon. Tim Murphy

    Today, the world is fighting the worst Ebola epidemic in 
history. CDC and our public health system are in the middle of 
a fire. Job One is to put it out completely. We will not stop 
until we do.
    We must be clear-eyed and singular in purpose to protect 
public health, and ensure not one additional case is contracted 
here in the U.S. We in Congress stand ready to serve as a 
strong and solid partner in solving this crisis. There is no 
greater responsibility for the U.S. Government than to protect 
and defend the safety of the American people.
    The stakes in this battle couldn't be any higher. The 
number of Ebola cases in West Africa is doubling about every 
three weeks. The math still favors the virus, even with the 
recent surge in global response.
    With no vaccine or cure, we are facing down a disease for 
which there is no room for error. We cannot afford to look back 
at this point in history and say we could have done more.
    Errors in judgment have been made, and it is our immediate 
responsibility today to learn from those errors, correct them 
rapidly and move forward effectively as one team--one fight.
    Let us candidly review where we stand.
    When the latest Ebola outbreak in West Africa was confirmed 
months ago, authorities thought it would be similar to the 1976 
outbreaks and quickly contained. That turned out to be wrong.
    By underestimating both the severity of the danger and 
overstating the ability of our healthcare system to handle 
Ebola cases, mistakes have been made. What was adequate 
practice for the past has proved to fall short for the present.
    The trust and credibility of the administration and 
Government are waning as the American public loses confidence 
each day with demonstrated failures of the current strategy. 
That trust must be restored, but will only be restored with 
honest and thorough action.
    We have been told: ``virtually any hospital in the country 
that can do isolation can do isolation for Ebola.'' The events 
in Dallas have proven otherwise.
    Current policies and protocols for surveillance, 
containment and response were not sufficient. We've learned 
frontline hospital workers were not fully trained in these 
procedures, do not have proper equipment, do not know how to 
properly put on and remove safety gear, so we still have alot 
more work to do because educating, training and assisting our 
public health workforce on the frontlines across the country 
must be a priority.
    We cannot be lulled into a false sense of security. We know 
we have the best healthcare system in the world, but this 
committee well knows from our previous hearings with other 
Federal agencies and notably General Motors, what happens when 
assumptions are made that foster complacency. False assumptions 
create true mistakes. Sometimes, deadly mistakes.
    At the same time we must understand what went wrong so we 
can get a firm handle on this crisis: Why was the CDC slow to 
deploy a rapid response team at Texas Health Presbyterian 
Hospital? Why weren't protocols to protect healthcare and 
hospital workers rapidly communicated? What training have 
healthcare workers received?
    There are things about Ebola we don't know. How long does 
the virus live on surfaces or on certain substances? How do 
healthcare workers wearing full protective gear get infected? 
Can it be transmitted from a person who does not yet have a 
high fever?
    Both CDC and NIH tell us that Ebola patients are only 
contagious when having a fever. However, the largest study of 
the current Ebola outbreak found that nearly 13% of confirmed 
cases in West Africa did not have associated fever. With many 
lives at risk, we should investigate the findings, and take 
proper action.
    I respect the CDC as a gold standard for public health, but 
the need for strong congressional oversight and partnership 
remains paramount given the CDC hasn't had a stellar year. 
There have been high profile mishaps such as transfers of live 
anthrax, some anthrax held in Ziploc bags, and mistaken 
shipments of a deadly strain of Avian flu unknown to CDC 
leadership for weeks. I also want to understand why CDC and the 
White House changed course on in 2010 on proposals first 
introduced in 2005 that would have strengthened Federal 
quarantine authority. We are here to work through and fix these 
problems. I restate my ongoing concern that administration 
officials still refuse to consider any travel restrictions for 
the more than 1,000 travelers a week entering the U.S. from 
Ebola hot zones.
    A month ago, the President told us someone with Ebola 
reaching our shores was ``unlikely'' and that ``we've been 
taking the necessary precautions'' to ``increase screening at 
airports so that someone with the virus doesn't get on a plane 
for the United States.''
    Screening and self-reporting at airports have been a 
demonstrated failure, yet the administration continues to 
advance a contradictory reason for this failed policy that 
frankly doesn't make sense, especially if ``priority one'' is 
to contain the spread of Ebola and protect public health.
    It troubles me even more when public health policies are 
based upon a stated concern over ``cutting commercial ties with 
fledgling democracies'' rather than protecting public health in 
the United States. This should not be presented as an all-or-
none choice. We can and will create the means to transport 
whatever supplies, and goods are needed in Africa to win this 
deadly battle. We do not have to leave the door open to all 
travel to and from hot zones in western Africa while Ebola is 
an unwelcome and dangerous stowaway on these flights. I am 
confident we can develop a reasoned and successful strategy to 
meet these needs.
    We will have a rational, informed discussion about using 
commercial travel restrictions--the same ones being employed by 
British Airways, Air France, and more than a dozen nations--to 
protect Americans while at the same time ensuring aid and 
eradication efforts continue in West Africa.
    The current airline passenger screening at five U.S. 
airports through temperature taking and self-reporting is 
troubling. Both CDC and NIH tell us that Ebola patients are 
only contagious when having a fever. The largest study of the 
current Ebola outbreak found that nearly 13% of confirmed cases 
in West Africa did not have associated fever. With many lives 
at risk, we should investigate the findings, and take proper 
action.
    A determined, infected traveler can evade the screening by 
masking the fever with ibuprofen or avoiding the five airports.
    Further, it is nearly impossible to perform contact tracing 
of all people on multiple international flights across the 
globe, when contact tracing and treatment just within the 
United States will strain public health resources.
    The only way we can dispel the fear and hysteria 
surrounding Ebola is with clear, honest answers teamed with 
swift, effective action. This situation demands leadership from 
the top and by that I mean the White House. The `lead from 
behind' strategy is recipe for disaster when trying to stop the 
transmission of Ebola. The legislative and executive branches 
of this Government are one team, and we will fight this 
together. We stand ready to meet with the administration at 
anytime and anywhere in this cause to help everyone.
    So let me be clear. To all the Federal agencies responding 
to the outbreak: If resources or authorization is needed to 
stop Ebola in its tracks, speak up--tell Congress. I pledge to 
will do everything in my power to work with you to keep the 
American people safe from the Ebola outbreak in West Africa.

    Mr. Murphy. I now recognize the ranking member of the 
subcommittee, Ms. DeGette.

 OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF COLORADO

    Ms. DeGette. Thank you, Mr. Chairman.
    On Monday, the Director General of the World Health 
Organization called the Ebola outbreak ``the most severe, acute 
health emergency seen in modern times.'' She warned that the 
epidemic ``threatens the very survival of societies and 
governments in West Africa.''
    This WHO assessment is no exaggeration. CDC predicts that 
up to 1.4 million West Africans could be infected with Ebola. 
Many more will die from treatable illnesses due to the collapse 
of these countries' public health infrastructures. This is a 
humanitarian crisis, and we have a moral imperative to help in 
West Africa. But ending the West Africa outbreak is also a U.S. 
national security imperative because doing so is the best way 
to keep Ebola out of the United States.
    I was alarmed like all of us were when Thomas Duncan flew 
to the United States while harboring Ebola, and even more 
disturbed to learn of his discharge from the Texas Presbyterian 
ER with a fever after reporting that he had traveled from 
Liberia. Even worse, we learned this week that two nurses 
treating Mr. Duncan, Nina Pham and Amber Vinson, have 
contracted Ebola. I know, Mr. Chairman, we all join in sending 
these women and their families our prayers.
    These new cases raise serious questions. The Washington 
Post wrote yesterday that Texas Presbyterian ``had to learn on 
the fly how to control the deadly virus'' and that the hospital 
was ``not fully prepared for Ebola.'' We need to find out why 
this hospital was unprepared and if others are too, and we need 
to make sure that the CDC is filling these readiness gaps. We 
should be concerned about the appearance of Ebola in the United 
States and the transmission to two health care workers, but we 
should not panic. We know how to stop Ebola outbreaks by 
isolating patients and tracing and monitoring contacts. The 
U.S. health care system can prevent isolated cases from 
becoming broader outbreaks, and that is why I am glad Dr. 
Frieden is here with us and Dr. Varga will be with us by video, 
because it would be an understatement to say that the response 
to the first U.S.-based patient with Ebola has been mismanaged, 
causing risk to scores of additional people. I know both of 
these gentlemen will be transparent and forthright in helping 
me to understand how we can improve our response when yet 
another person, and it will inevitably happen, shows up at the 
emergency room with these kind of symptoms.
    I appreciate the steps taken by CDC and Customs to begin 
airport screenings. These steps are appropriate, and as some 
call for cutting off all travel, as the chairman said, this 
won't be reasonable to be able to stop anybody with Ebola from 
coming into the United States, and we don't want to take steps 
that would endanger Americans by interfering with efforts to 
halt the outbreak in Africa.
    You know, there is no such thing as fortress America when 
it comes to infectious diseases, and the best way to stop Ebola 
is going to be to stop this virus in Africa. Experts from 
Doctors Without Borders have told us that a quarantine on 
travel would have ``catastrophic impacts on West Africa.'' 
Also, earlier this week the Director of NIH, Dr. Francis 
Collins, said had we adequately funded his agency for over a 
decade, we would already have an Ebola vaccine. His words are a 
reminder that key public health agencies have faced stagnant 
funding for several years, hampering our ability to respond to 
this crisis.
    Mr. Chairman, 6 weeks ago when I first sent you a letter to 
ask for this hearing, the scope of the problem in West Africa 
was beginning to come into focus. Now the situation is dire. 
Let us work together to make sure that we stop it as quickly as 
we can.
    With that, I yield the balance of my time to the gentleman 
from Iowa, Mr. Braley.

OPENING STATEMENT OF HON. BRUCE L. BRALEY, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF IOWA

    Mr. Braley. Thank you.
    Our duty today is to make sure the administration is doing 
everything possible to prevent the spread of Ebola within the 
United States. Our number one priority in combating this 
disease must be the protection of Americans, and we have to 
figure out the best way to do that.
    My heart goes out to all those suffering from this horrible 
epidemic, and I am very proud of the hard work done by American 
troops, doctors, nurses, and other volunteers to combat this 
disease. Congress must come together, put aside partisan 
differences and help stop this outbreak.
    Today I hope to hear what steps the administration is 
taking to prevent the spread of Ebola and respond to the 
outbreak. I am greatly concerned, as Congresswoman DeGette has 
expressed, that the administration did not act fast enough in 
responding in Texas. We need to look at all the options 
available to keep our families safe and move quickly and 
responsibly to make any necessary changes at airports.
    [The prepared statement of Mr. Braley follows:]

               Prepared statement of Hon. Bruce L. Braley

    Thank you. Today, we must make sure the administration is 
doing everything possible to prevent the spread of Ebola within 
the United States. Our number one priority in combating this 
disease must be the protection of Americans.
    My heart goes out to those suffering from this epidemic, 
and I'm very proud of the hard work done by American troops, 
doctors, nurses, and volunteers to combat the disease. Congress 
must come together, put aside partisan differences, and help 
stop this outbreak.
    Today, I hope to hear what steps the administration is 
taking to prevent the spread of Ebola and respond to the 
outbreak. I'm greatly concerned that the administration did not 
act fast enough. The administration needs to look at all 
options available to keep our families safe, and they need to 
move quickly and responsibly to make any necessary changes at 
our airports and hospitals that would prevent this disease from 
spreading further. And I'm going to ask specific questions on 
their plans for that.
    One of the most important allies we have is a company in 
Ames, Iowa, called NewLink Genetics, with 120 employees working 
around the clock. NewLink has an Ebola vaccine that could help 
stop this disease, and they are currently trying to secure a 
contract with HHS to expand their manufacturing, so I hope to 
hear how HHS is moving forward as quickly as possible.
    Thank you to the witnesses for being here today, and I look 
forward to a thoughtful and productive conversation.

    Mr. Murphy. The gentleman's time is expired. I now 
recognize the chairman of the full committee, Mr. Upton, for 5 
minutes.

   OPENING STATEMENT OF HON. FRED UPTON, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF MICHIGAN

    Mr. Upton. Well, thank you.
    Let me first begin by thanking our witnesses and all of the 
Members, Republicans and Democrats, for being here today.
    You know, it is unusual to convene a hearing in DC during a 
district work period, but on this issue, there is no time to 
wait. I was likewise glad to see the President get off the 
campaign trail yesterday to finally focus on the crisis.
    People are scared. We need all hands on deck. We need a 
strategy, and we need to protect the American people, first and 
foremost. It is not a drill. People's lives are at stake, and 
the response so far has been unacceptable.
    As chairman of this committee, I want to assure the 
witnesses that we stand ready to support you in any way to keep 
Americans safe, but we are going to hold your feet to the fire 
on getting the job done, and getting it done right.
     Both the United States and the global health community 
have so far failed to put in place an effective strategy fast 
enough to combat the current outbreak. The CDC admitted more 
could have been done in Texas. Two health care workers have 
become infected with Ebola even as nurses and other medical 
personnel suggest that protocols are being developed on the 
fly. And none of us can understand how a nurse who treated an 
Ebola-infected patient, and who herself had developed a fever, 
was permitted to board a commercial airline and fly across the 
country.
    It is no wonder the public's confidence is shaken. Over a 
month ago, before Ebola reached our shores, we wrote to Health 
and Human Services Secretary Burwell seeking details for the 
preparedness and response plan here at home and abroad, and it 
is clear whatever plan was in place was insufficient, but I 
believe that we can and must do better now.
    We need a plan to treat those who are sick, to train health 
care workers to safely provide care, and to stop the spread of 
this disease here at home and at its source in Africa. This 
includes travel restrictions or bans from that region beginning 
today. Surely we can find other ways to get the aid workers and 
supplies in to these countries. From terrorist watch lists to 
quarantines, there are tools used to manage air travel to 
assure public safety. Why not here? We can no longer be 
reacting to each day's crisis. We need to be aggressive and 
finally get ahead of this terrible outbreak.
    The American people also want to know about our troops and 
medical personnel who are courageously headed to Africa to 
treat the sick. How will they be protected? We want to know 
that health care workers here in America have the training and 
resources necessary to safely combat that threat as well.
    So it is not just the responsibility of the United States. 
The global health community bears the charge to finally get 
ahead of the threat, develop a clear strategy, train all those 
who are involved in combating this disease, and eradicate this 
threat.
    We have all heard the grave warnings that this will get 
worse before it gets better. People are scared. It is our 
responsibility to ensure that the Government is doing whatever 
it can to keep the public safe.
    Diana DeGette and I have partnered together on the 21st 
Century Cures initiative to help improve the research and speed 
the approval of life-saving medicines and treatments, and while 
much attention has been paid to how this effort can help with 
diseases like cancer and diabetes, these same reforms can also 
help in the development of treatments for deadly infections 
like Ebola. We are all partners in this effort to save lives.
    [The prepared statement of Mr. Upton follows:]

                 Prepared statement of Hon. Fred Upton

    Let me begin by thanking our witnesses and all of the 
Members, Republicans and Democrats, for being here today. It's 
unusual to convene a hearing in Washington during a district 
work period, but on this issue, there's no time to wait. I was 
likewise glad to see President Obama get off the campaign trail 
to finally focus on this crisis.
    People are scared. We need all hands on deck. We need a 
strategy. We need to protect the American people, first and 
foremost. This is not a drill--a fact that the doctors and 
nurses working on the front lines understand. People's lives 
are at stake, and the response so far has been unacceptable.
    As chairman of this committee, I want to assure the 
witnesses that we stand ready to support you in any way to keep 
Americans safe, but we are going to hold your feet to the fire 
on getting the job done, and getting it done right. Both the 
United States and the global health community have so far 
failed to put in place an effective strategy fast enough to 
combat the current outbreak.
    Just the other day, the CDC admitted more could have been 
done in Texas. Two health care workers have become infected 
with Ebola even as nurses and other medical personnel suggest 
that protocols are being ``developed on the fly.'' And none of 
us can understand how a nurse who treated an Ebola-infected 
patient, and who herself had developed a fever, was permitted 
to board a commercial airline and fly across the country.
    It's no wonder the public's confidence is shaken. Over a 
month ago, before Ebola reached our shores, we wrote to Health 
and Human Services Secretary Sylvia Burwell seeking details for 
the preparedness and response plan here at home and abroad. 
It's clear whatever plan was in place was insufficient, but I 
believe we can and must do better now.
    We need a plan to treat those who are sick, to train health 
workers to safely provide care, and to stop the spread of this 
disease here at home and at its source in Africa. This includes 
travel restrictions from that region beginning today. Surely we 
can find other ways to get the aid workers and supplies in to 
these countries. From terrorist watch lists to quarantines, 
there are tools used to manage air travel to assure public 
safety. Why not here? We can no longer be reacting to each 
day's crisis. We need to be aggressive and finally get ahead of 
this outbreak.
    The American people also want to know that our troops and 
medical personnel who are courageously headed to Africa to 
treat the sick will be protected. We want to know that health 
care workers here in America have the training and resources 
necessary to safely combat this threat.
    This is not just the responsibility of the United States. 
The global health community bears the charge to finally get 
ahead of this threat, develop a clear strategy, train all those 
who are involved in combating this disease, and eradicate this 
threat.
    We have all heard the grave warnings that this will get 
worse before it gets better, and folks are scared. It is our 
responsibility to ensure that the Government is doing whatever 
it takes to keep the public safe. Diana DeGette and I have 
partnered together on the 21st Century Cures initiative to help 
improve the research and speed the approval of life-saving 
medicines and treatments, and while much attention has been 
paid to how this effort can help with diseases like cancer and 
diabetes, these same reforms can also help in the development 
of treatments for deadly infections like Ebola. We are all 
partners in this effort to save lives.

    Mr. Upton. I yield the balance of my time to Dr. Burgess.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE 
              IN CONGRESS FROM THE STATE OF TEXAS

    Mr. Burgess. Thank you, Mr. Chairman, and my thanks to the 
panel for being here today, and I think everyone here agrees, 
we must fix this.
    America's response to the Evola Virus Disease outbreak is 
not a political issue, it is a public health crisis and a very 
dire one at that.
    The frightening truth is that we cannot guarantee the 
safety of our health care workers on the front lines. It has 
been known for some time that health care workers have an 
outsized risk in western Africa. They have a 56 percent 
mortality rate of those health care workers who catch this 
disease. Two nurses have contracted Ebola in the United States, 
and indeed, we have to learn from the current situation in 
Texas and use any information we can gather to better help 
prepare hospitals and protect our health care workers on the 
front line. We are here today because we need answers to these 
questions.
    This past August, the Inspector General of the Department 
of Homeland Security issued a report on personal protective 
equipment and antiviral countermeasures. They found that, and I 
am quoting here, ``The Department of Homeland Security did not 
adequately conduct a needs assessment prior to purchasing 
pandemic preparedness supplies and then did not effectively 
manage its stockpile of personal protective equipment and 
antiviral medical countermeasures.'' This just illustrates how 
unprepared we are. We have to get this right.
    [The prepared statement of Mr. Burgess follows:]

             Prepared statement of Hon. Michael C. Burgess

    America's response to the Evola virus disease is not a 
political issue. This is a public health crisis and a dire one 
at that. The frightening truth is that we cannot guarantee the 
safety of our health care workers on the front lines of 
response.
    In West Africa, there have been 416 healthcare workers who 
have contracted Ebola. 233 of them have died. That is a 56% 
mortality rate.
    As of today, two health care workers contracted Ebola in 
the United States. According to the CDC, they were exposed to 
the virus before Mr. Duncan, Patient Zero, was diagnosed. In 
turn, the focus must now be on preparedness for hospitals 
around the country.
    Indeed, we must learn from the current situation at Texas 
Presbyterian and use any information we can gather to help 
better prepare other hospitals around the country.
    We are here today because we need answers to our questions 
about both the CDC's and the administration's flawed responses. 
While I believe the CDC had protocols in place, it seems to me 
there was a breakdown in the communication between the CDC and 
hospitals around the country.
    This past August, the Inspector General at the Department 
of Homeland Security issued a report on personal protective 
equipment and antiviral medical countermeasures.
    They found that, and I quote, ``The Department of Homeland 
Security did not adequately conduct a needs assessment prior to 
purchasing pandemic preparedness supplies and then did not 
effectively manage its stockpile of pandemic PPE and antiviral 
medical countermeasures.'' This illustrates just how unprepared 
we may still be.
    Drugs companies are stating that they will have basic 
information on the efficacy of their drugs and vaccines by the 
end of the year. The end of the year is too late. We have been 
actively funding research on vaccinations and drug treatments 
for over a decade, but now the time to perform is now. When 
will these protocols be expedited?
    Relevant agencies have the statutory authority to 
quarantine and isolate individuals who are infected with or 
carrying an infectious communicable disease.
    Secretary Burwell has this authority which is enumerated in 
the Public Health Service Act. When will this authority be 
used?
    Numerous laws have been passed in the past decade to better 
prepare us for an outbreak of infectious illness, to increase 
coordination, and to fast- track drug development. The 
Assistant Secretary for Preparedness and Response, Dr. Lurie, 
has been notably absent.
    I have a long-standing relationship with Texas 
Presbyterian. This crisis is in my back yard. I want to make 
sure we are doing everything in our power to stop Ebola.

    Mr. Burgess I would like to yield the balance of my time to 
Ms. Blackburn from Tennessee.

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF TENNESSEE

    Mrs. Blackburn. Thank you, Dr. Burgess, and yes, indeed, 
welcome to all of our witnesses.
    Everyone has mentioned we are here to work with you to 
protect Americans, and that includes the caregivers, and by 
that I mean the men and women working on the front lines, the 
Screaming Eagles of the 101st from Fort Campbell.
    I will yield back my time and have further questions later. 
Thank you.
    Mr. Murphy. The gentlelady yields back and time is expired. 
I would now like to introduce the witnesses--I am sorry. No, 
first I go to Mr. Waxman. I apologize.

OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Mr. Waxman. Thank you, Mr. Chairman. I am pleased to have 
this opportunity to make an opening statement before we hear 
from the witnesses.
    I think we have to put all of this in perspective and not 
panic. Everybody said not to panic, and then they made 
statements like ``We are going to get tough. We are going to do 
something about it.'' Well, what do we need to do?
    First of all, we have got a problem in Africa, and this is 
a serious outbreak that could spiral beyond our control. On 
Tuesday, the World Health Organization estimated that soon 
there could be up to 10,000 new Ebola cases each week in West 
Africa, and CDC has warned that the outbreak could infect as 
many as 1.4 million people by the end of January. So this is a 
humanitarian crisis in Africa, and we have a responsibility to 
help because if we don't help there, that outbreak is going to 
continue to spiral out to other places, and sealing people off 
in Africa is not going to keep them from traveling. They will 
travel to Brussels, as one of the people did, and then into the 
United States.
    We can stop the epidemic from spreading in Africa or in the 
United States if we isolate the patient and monitor the 
contacts of that patient, and if we do that, we can stop it 
there and we can stop it here.
    So in Africa, we need to know: Are we moving fast enough, 
do responders have adequate resources, are we effectively 
coordinating our response with other countries in international 
organizations?
    But here, people are scared, and we shouldn't make them 
even more frightened. Put this in perspective. We have had 
three recent cases of Ebola in this country: Thomas Duncan, who 
entered the United States while harboring Ebola and who flew 
through Brussels to get here; Nina Pham and Amber Vinson, the 
nurses who became ill while caring for Mr. Duncan. We should be 
concerned about these cases, and we need to act urgently, but 
we need not to panic. What we have to do is learn what we need 
to do, what mistakes we have made and not repeat them. We want 
to find out what happened at Texas Health Presbyterian 
Hospital, how CDC, State and local health officials and 
hospitals can improve procedures moving forward.
    We should also use this as a wakeup call to ensure the 
adequacy of our own public health and preparedness safety net. 
We need to be prepared before a crisis hits, not scrambling to 
respond after the crisis.
    In the past decade, the ability to fund research and public 
health programs has declined here in the United States. Since 
2006, CDC's budget adjusted for inflation has dropped by 12 
percent. Funding for the Public Health Emergency Preparedness 
Cooperative Agreement, which supports State and local health 
department preparedness activities, has been cut from $1 
billion in its first year of funding in 2002 to $612 million in 
2014. All of these were also subject to the sequestration, and 
those who allowed that sequestration to happen by closing the 
Government have to answer to the American people as well.
    We need to commit adequate funding to public health 
infrastructure. We need to hold public health systems 
accountable to standards of preparedness. Based on what we 
know, it appears that Texas Presbyterian would have not met 
those standards, though in fairness, I suspect that many 
hospitals all over the country would also have struggled to 
respond. This is a problem we have to solve.
    Mr. Chairman, before I run out of time, I want to 
acknowledge the health care workers and volunteers, those 
treating Ebola victims in the United States and those who have 
traveled to West Africa to help during this outbreak. It is 
dangerous work that they are doing. They are putting themselves 
in danger to save lives. They deserve our thanks and our 
praise.
    I also want to thank all of our witnesses. You have my 
confidence, and I appreciate you joining us today to provide 
answers about how to stop the current Ebola outbreak in Africa 
and how to improve our public health systems to avoid the next 
crisis.
    I am ending my career at the end of this year, but I have 
been through so many hearings where, when there is a crisis, we 
have Congressmen sit and point fingers. Well, let us point 
fingers at all of those responsible. We have our share of 
responsibility by not funding the infrastructure. In Africa, 
they have no infrastructure. We have to help them develop it to 
deal with this crisis, but we shouldn't leave ourselves 
vulnerable by these irrational budget cuts.
    Mr. Murphy. The gentleman's time is expired. Thank you.
    I would now like to introduce the witnesses on the panel 
for today's hearing. Dr. Thomas R. Frieden is the Director of 
the Centers for Disease Control and Prevention. Dr. Anthony 
Fauci is the Director of the National Institute of Allergy and 
Infectious Diseases within the National Institutes of Health. 
Dr. Robin Robinson is the Director of Biomedical Advanced 
Research and Development Authority within the Office of the 
Assistant Secretary for Preparedness and Response at the United 
States Department of Health and Human Services. Dr. Luciana 
Borio is the Assistant Commissioner for Counterterrorism Policy 
at the U.S. Food and Drug Administration. Mr. John P. Wagner is 
the Acting Assistant Commissioner of the Office of Field 
Operations within U.S. Customs and Border Protection at the 
U.S. Department of Homeland Security. And joining us today on 
videoconference from Texas will be Dr. Daniel Varga, who is the 
Chief Clinical Officer and Senior Vice President at Texas 
Health Resources.
    I will now swear in the witnesses. You are all aware that 
the committee is holding an investigative hearing, and when 
doing so has had the practice of taking testimony under oath. 
Do any of you object to taking testimony under oath? None of 
the witnesses say so, and Dr. Varga?
    Mr. Varga. No.
    Mr. Murphy. Thank you. The Chair then advises you that 
under the rules of the House and the rules of the committee, 
you are entitled to be advised by counsel. Do any you desire to 
be advised by counsel during your testimony today? Thank you. 
Everyone answers no. In that case, would you all please rise 
and raise your right hand and I will swear you in.
    [Witnesses sworn.]
    Mr. Murphy. You are now under oath and subject to the 
penalties set forth in Title XVIII, section 1001 of the United 
States Code. We will call upon you each to give a 5-minute 
opening summary of your written statement.
    Dr. Frieden, you are recognized for 5 minutes.

STATEMENTS OF THOMAS R. FRIEDEN, DIRECTOR, CENTERS FOR DISEASE 
 CONTROL AND PREVENTION; ANTHONY S. FAUCI, DIRECTOR, NATIONAL 
    INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES, NATIONAL 
INSTITUTES OF HEALTH, DEPARTMENT OF HEALTH AND HUMAN SERVICES; 
  ROBIN A. ROBINSON, DEPUTY ASSISTANT SECRETARY AND DIRECTOR, 
BIOMEDICAL ADVANCED RESEARCH AND DEVELOPMENT AUTHORITY, OFFICE 
   OF THE ASSISTANT SECRETARY FOR PREPAREDNESS AND RESPONSE, 
    DEPARTMENT OF HEALTH AND HUMAN SERVICES; LUCIANA BORIO, 
    ASSISTANT COMMISSIONER FOR COUNTERTERRORISM POLICY AND 
DIRECTOR, OFFICE OF COUNTERTERRORISM AND EMERGING THREATS, FOOD 
    AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN 
SERVICES; JOHN P. WAGNER, ACTING ASSISTANT COMMISSIONER, OFFICE 
   OF FIELD OPERATIONS, U.S. CUSTOMS AND BORDER PROTECTION, 
   DEPARTMENT OF HOMELAND SECURITY; AND DANIEL VARGA, CHIEF 
  CLINICAL OFFICER AND SENIOR EXECUTIVE VICE PRESIDENT, TEXAS 
                        HEALTH RESOURCES

                 STATEMENT OF THOMAS R. FRIEDEN

    Mr. Frieden. Thank you very much, Chairman Murphy, Ranking 
Member DeGette, Chairman Upton, and Ranking Member Waxman. I 
very much appreciate the opportunity to come before you to 
discuss the Ebola epidemic and our response to it to protect 
Americans.
    My name is Dr. Tom Frieden. I am trained as a physician. I 
am trained in internal medicine, in infectious diseases. I 
completed the CDC Epidemic Intelligence Service training, and I 
have worked in the control of diseases, communicable diseases 
and others, since 1990.
    Ebola spreads only by direct contact with a patient who is 
sick with the disease or has died from it, or with their body 
fluids. Ebola is not new, although it is new to the United 
States. We know how to control Ebola, even in this period. Even 
in Lagos, Nigeria, we have been able to contain the outbreak. 
We do that by tried-and-true measures of finding the patients 
promptly, isolating them effectively, identifying their 
contacts, ensuring that if any contact becomes ill, they are 
rapidly identified, isolated, and their contacts are 
identified.
    But there are no shortcuts in the control of Ebola, and it 
is not easy to control it. To protect the United States, we 
have to stop it at the source.
    There is a lot of fear of Ebola, and I will tell you as the 
Director of CDC, one of the things I fear about Ebola is that 
it could spread more widely in Africa. If this were to happen, 
it could become a threat to our health system and the health 
care we give for a long time to come.
    Our top priority, our focus is to work 24/7 to protect 
Americans. That is our mission. We protect Americans from 
threats, and in the case of Ebola, we do that by a system at 
multiple levels. In addition to our efforts to control the 
disease at the source, we have helped each of the affected 
countries establish exit screening so that every person leaving 
has their temperature taken. In a two-month period of August 
and September, we identified 74 people with fever. None of them 
entered the airport or boarded the plane. As far as we know, 
none of them were diagnosed with Ebola, but that was one level 
of safety.
    Recently, we have added another level of screening people 
on arrival to the United States. That identifies anyone with 
fever here, and we have worked very closely with the Department 
of Homeland Security and Customs and Border Protection to 
implement that program, and I would be happy to provide further 
details of it later.
    We have also increased awareness among physicians 
throughout the United States to think Ebola in anyone who has 
fever and/or other symptoms of infection and who has been to 
West Africa in the previous 21 days. We have established 
laboratory services throughout the country so that not all 
laboratory tests have to come to the specialized laboratory at 
CDC. In fact, one of those laboratories in Austin, Texas, 
identified the first case here.
    We also have fielded calls from concerned doctors and 
public health officials throughout the country. We found more 
than 300 calls and only one patient, Mr. Duncan, had Ebola, but 
that is one too many, and we are open to ideas for what we can 
do to keep Americans as safe as possible as long as the 
outbreak is continuing.
    We also have established emergency response teams from CDC 
that will go within hours to any hospital that has an Ebola 
case to help them provide effective care safety.
    [Slide.]
    There is a lot of understandable concern about the cases in 
Dallas. I have one slide, if we can show it, of the contact 
tracing activities there, and I think we provided copies for 
the members. The two core activities in Dallas are to ensure 
that there is effective infection control and to trace 
contacts. Here you see a timeline of exactly what has happened 
in the identification of contacts. We have followed each of the 
contacts. When any become ill or if any become ill, we 
immediately isolate them so that we can break the chain of 
transmission. That is how you stop Ebola. I can go through the 
details when you wish.
    We also are working to ensure that there is effective 
infection control there, and I can go through the details of 
that.
    In sum, CDC works 24/7 to protect Americans. There are no 
shortcuts. Everyone has to do their part. There are more than 
5,000 hospitals in this country. There are more than 2,500 
health departments at the local level. We are there to support. 
We are there with world-class expertise, and we are there to 
respond to threats so that we can help protect Americans, and 
we are always open to new ideas. We are always open to data 
because our bottom line is using the most accurate data and 
information to inform our actions and protect health.
    Thank you.
    [The prepared statement of Mr. Frieden follows:]
    
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    
    
    Mr. Murphy. Thank you, Dr. Frieden. I now recognize Dr. 
Fauci for a 5-minute summary of your statement.

                 STATEMENT OF ANTHONY S. FAUCI

    Mr. Fauci. Thank you, Chairman Murphy, Ranking Member 
DeGette, Chairman Upton, and Ranking Member Waxman. You have 
just heard about the public health aspects of Evola Virus 
Disease from Dr. Frieden. I appreciate the opportunity to speak 
with you this morning for a few minutes on the role of the 
National Institute of Allergy and Infectious Diseases in 
research addressing Evola Virus Disease.
    Of note is that our activities actually started with the 
tragic events of 9/11/2001, which were followed closely by the 
anthrax attacks, which many of the members remember, against 
the Congress of the United States and the press. It was in that 
environment that a multifaceted approach towards bioterrorism 
was actually mounted by the Federal Government, one of which 
was the research endeavor to develop countermeasures. We soon 
became very aware that naturally occurring outbreaks of disease 
are just as much of a terror to the American and world public 
as a deliberate bioterror event.
    [Slide.]
    You see on this slide a number of what we call Category A 
pathogens from anthrax to botulism, plague, smallpox, and 
tularemia, but look at the last bullet, the viral hemorrhagic 
fevers including Ebola, Marburg, Lassa and others. The viral 
hemorrhagic fevers are particularly difficult because they have 
a high degree of lethality and a high infectivity upon contact 
with body fluids. Therapy is mainly supportive without specific 
interventions, and we do not have a vaccine.
    And so what is the role of the National Institutes of 
Health--if we could advance the slide--in the research 
endeavor?
    [Slide.]
    As you can see on this slide, we do basic and clinical 
research, and importantly, we supply resources for researchers 
in industry and academia to advance product development. The 
end game of what we do are diagnostics, therapeutics, and 
vaccines. I am sorry. Could we get the slide back on, the last 
slide?
    This is a multi-institutional endeavor. As you can see on 
this slide, the NIH is responsible for fundamental basic 
research and early concept development, something that we did 
relatively alone because of the lack of interest on the part of 
industrial partners in making interventions. We partnered with 
BARDA, who you will hear from shortly with Dr. Robin Robinson, 
and then we partnered with industry, as I will tell you in a 
moment, ultimately in collaboration with the FDA to get the 
approval of products. Next slide.
    [Slide.]
    You have heard a lot about therapeutic interventions. I 
would just like to spend a moment talking to you about a few of 
them. First, it is important to realize that they are all 
experimental. None of them has proven to be effective. So when 
you hear about giving a drug that has a positive effect, we do 
not know at this point, A, is it a positive effect, or B, is it 
causing harm? And that is the reason why we need to study these 
carefully at the same time we rapidly make them available to 
the people who need them.
    The first one on the list is ZMapp. You have heard of it. 
That was given to Dr. Brantley and Nancy Writebol. It looks 
very good in animal models. It still needs to be proven in 
humans. There are others such as the BioCryst product, which is 
a nucleoside analog. You have heard about the Tekmira drug, 
which was developed with support from the Department of 
Defense, which is also being used, and others that you will 
hear about such as Brincidofovir and Favapiravir. These are 
just a few of those that will be going into clinical trials and 
that are actually being used in an experimental way with 
compassionate use with approval from the FDA in certain 
individuals.
    [Slide.]
    Let me turn to this slide here, which is an important one, 
regarding a vaccine. We have been working on an Ebola vaccine 
for a number of years. We did the original studies shown in an 
animal model to be quite favorable. We are now right at the 
point where we are in Phase I trials that some of you may have 
heard of, started at the NIH on September 2nd. Testing of a 
second vaccine was started just a couple of days ago by the 
U.S. military in collaboration with the NIH. When we finish 
those Phase I trials, namely asking is it safe and does it 
induce a response that you would predict would be protective, 
it is important to make sure it is safe. If those parameters 
are met, we will advance to a much larger trial in larger 
numbers of individuals to determine if it is actually effective 
as well as not having a paradoxical negative deleterious 
effect. The reason we think this is important is that if we do 
not control the epidemic with pure public health measures, it 
is entirely conceivable that we may need a vaccine, and it is 
important to prove that it is safe and effective.
    I would like to close by making an announcement to this 
committee because I am sure you will hear about it soon in the 
press. This evening, tonight, we will be admitting to the 
special clinical studies unit, at the National Institutes of 
Health, Nina Pham, otherwise known as Nurse Number One. She 
will be coming to the National Institutes of Health, where we 
will be supplying her with state-of-the-art care in our high-
level containment facilities.
    Thank you very much, Mr. Chairman.
    [The prepared statement of Mr. Fauci follows:]
    
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    
    
    Mr. Murphy. Thank you, Doctor. I now recognize Dr. Robinson 
for 5 minutes for a summary of your statement.

                 STATEMENT OF ROBIN A. ROBINSON

    Mr. Robinson. Good afternoon, Chairman Murphy, Chairman 
Upton, Ranking Members DeGette and Waxman, and other 
distinguished members of the subcommittee. Thank you for the 
opportunity to speak with you today about our efforts by the 
Government on Ebola.
    I am Dr. Robin Robinson, a former vaccine developer in 
industry, and for the last 10 years a public servant working on 
pandemic preparedness and many other biothreats.
    BARDA was created by the Pandemic and All-Hazards 
Preparedness Act in 2006. It is the Government agency 
responsible for supporting advanced development and procurement 
of novel and innovative medical countermeasures such as 
vaccines, therapeutic drugs, diagnostics and medical devices 
for the entire Nation. BARDA exists to address the medical 
consequences of biothreats and emerging infectious diseases. 
BARDA has supported medical countermeasure development for 
manmade threats on a routine basis under Project BioShield in 
responding to emerging threats like the H1N1 pandemic in 2009 
and the avian influenza H7N9 outbreak in China last year.
    Today, we are immersed in responding to Ebola, which is 
simultaneously a biothreat with a material threat determination 
issued by the Department of Homeland Security and an emerging 
infectious disease.
    As you have said and my colleagues have said, when it comes 
to Ebola as a biothreat and emerging infectious disease, the 
best way to protect our country is to address the current 
epidemic in Africa, the worst on record.
    BARDA works with its Federal partners to transition the 
medical countermeasures from early development, as Dr. Fauci 
said, into advanced development, toward ultimate FDA approval.
    Since 2006, we have built an advanced development pipeline 
of more than 150 medical countermeasures for chemical, 
biological, radiological and nuclear threats, and pandemic 
influenza. Seven of these products have been FDA approved in 
the last 2 years, and today we are transitioning several 
promising and maturing Ebola vaccines and therapeutic 
candidates from early development, under NIH and DoD support, 
into advanced development and ensuring that commercial-scale 
manufacturing capacity for these product candidates is 
available as soon as possible.
    BARDA, in concert with our Federal partners, utilizes 
public-private partnerships with industry to ensure that we 
have countermeasures to protect our citizens. Over the past 5 
years, BARDA with NIH, CDC, FDA and our industry partners have 
built a flexible and rapid response infrastructure to develop 
and manufacture medical countermeasures. As a result of the 
Pandemic and All Hazards Preparedness Reauthorization Act, 
improved framework for medical countermeasures development has 
been afforded to Federal and industry partners, and last year 
we made five new vaccine candidates in record time for the H7N9 
outbreaks in China. Currently, we are working with a wider 
array of partners including both small and large pharmaceutical 
companies, Canada, the U.K., western African countries, the 
World Health Organization, and others to make and evaluate the 
safety and efficacy of these Ebola product candidates.
    BARDA has established a medical countermeasure 
infrastructure to assist product developers on a daily basis to 
respond immediately in a public health emergency. We are using 
a number of our core service assistance programs. There is the 
Nonclinical Studies Network, our Centers for Innovation and 
Advanced Development and Manufacturing, and our Fill Finish 
Manufacturing Network to make these products available as soon 
as possible. Additionally, our staff are onsite at the 
manufacturer, people in plant, to provide technical assistance 
and oversight to expedite product availability.
    Additionally, we are working with CDC and others across the 
Federal Government and internationally with our modeling 
efforts to look at the Ebola outbreak as it becomes epidemic 
and also what possible impacts and interventions may occur.
    BARDA supports large-scale production of medical 
countermeasures and response measure for public health 
emergencies like the H1N1 pandemic and H7N9 outbreaks. Today we 
are assisting Ebola vaccine and therapeutic manufacturers with 
scaled-up production. Specifically, we are supporting the 
development and manufacturing of ZMapp monoclonal antibody 
therapy for clinical studies at one manufacturer, expanding 
overall manufacturing capacity of ZMapp by enlisting the help 
of other tobacco plant-based manufacturers, and working on 
alternative Ebola monoclonal antibody candidates to expand 
production capacity. Pending the outcome of ongoing animal 
challenge studies, BARDA is prepared to support advanced 
development of additional promising therapeutic candidates that 
Dr. Fauci talked about to treat Ebola patients.
    On the vaccine front, BARDA is working with industry 
partners to scale up manufacturing of three promising Ebola 
vaccine candidates, one of which we will make an announcement 
today, from pilot scale to commercial scale for clinical 
studies in Africa next year. In addition to BARDA's efforts in 
the Ebola response, ASPR is supporting a number of other 
response activities including supporting health care system 
preparedness, developing policies and guidance on patient 
movement, repatriation, standards of care and clinical 
guidance, supporting the logistical aspect of deploying U.S. 
public health service officers to West Africa, and ongoing 
coordination and communication with national and international 
communities responding to the threat.
    Finally, we face significant challenges, as has been 
discussed, in the coming weeks and months with the Ebola 
epidemic continuing and as these medical countermeasures are 
manufactured and evaluated, but bottom line is that my 
colleagues here and our industry partners will use all of our 
collective capabilities here and abroad to address today's 
Ebola epidemic and to be better prepared for future Ebola 
outbreaks and bioterrorism events going forward.
    I want to thank the committee and subcommittee for your 
generous and continued support over the past decade and the 
opportunity to testify. Thank you.
    [The prepared statement of Mr. Robinson follows:]
    
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    Mr. Murphy. Thank you, Dr. Robinson. Dr. Borio, you are 
recognized for 5 minutes.

                   STATEMENT OF LUCIANA BORIO

    Ms. Borio. Thank you. Good afternoon, Chairman Murphy, 
Ranking Member----
    Mr. Murphy. If you could just please pull the microphone as 
close to you as possible. Thank you.
    Ms. Borio. Good afternoon, Chairman Murphy, Ranking Member 
DeGette and members of the subcommittee. Thank you for the 
opportunity to appear before you today to discuss FDA's actions 
to respond to the Ebola epidemic, a tragic global event. My 
colleagues and I at the FDA are determined to do all we can to 
help end it as quickly as possible.
    The desire and need for safe and effective vaccines and 
treatments is overwhelming. FDA is taking extraordinary steps 
to be proactive and flexible. We are leveraging our authorities 
and working diligently to expedite the development and 
manufacturing availability of safe and effective medical 
products for Ebola. We are providing FDA's unique scientific 
and regulatory advice to companies to guide their submissions. 
We are reviewing data as it is received. These actions help 
advance the development of investigation of products as quickly 
as possible, and for example, in the case of the two vaccines 
that Dr. Fauci mentioned, FDA took only a few days to review 
the applications and to allow the studies to proceed. As a 
result, the vaccine candidate being co-developed by the NIAID 
and GlaxoSmithKline began Phase I clinical testing on September 
2nd and the vaccine candidate being developed by NewLink 
Genetics began similar clinical testing on October 13th. We are 
also partnering with the U.S. Government agencies that support 
medical product development including NIAID, BARDA, and the 
Department of Defense.
    Because of FDA's longstanding collaboration with the DoD, 
FDA was able to authorize the use of the Ebola diagnostic test 
under our emergency use authorization within 24 hours of 
request. We authorized the use of two additional diagnostics 
tests developed by the CDC and these tests of course are 
essential for an effective public health response.
    In addition, we are supporting the World Health 
Organization. Our scientists are providing technical advice to 
the WHO as it works to assess the role of convalescent plasma 
in treating patients with Ebola.
    I recently participated in a consultation focused on Ebola 
vaccines in Geneva, which included dozens of experts from 
around the world as well as from affected and neighboring 
countries in West Africa. Participants agreed that promising 
investigational vaccines must be evaluated in scientifically 
valid clinical trials and in a most urgent manner. The FDA is 
working closely with our Government colleagues and the vaccine 
developers to support this goal.
    It is important to note, though, that while we all want 
access to immediate therapies to cure or prevent Ebola, the 
scientific fact is that these investigational products are in 
the earliest stages of development. There is tremendous hope 
that some of these products will help patients but it is also 
possible some may hurt patients and others may have little or 
no effect. Therefore, access to investigational products should 
be through clinical trials when possible. They allow us to 
learn about product safety and efficacy, and they can provide 
an equitable means for access.
    FDA is working with our NIH colleagues to develop a 
flexible and innovative clinical trial protocol to allow 
companies and clinicians to evaluate multiple investigational 
Ebola products under a common protocol. The goal is to ensure 
accrual of interpretable data and generate actionable results 
in the most expeditious manner. It is important for the global 
community to know the risks and benefits of these products as 
soon as possible.
    Until such trials are established, we will continue to 
enable access to these products when available and requested by 
clinicians. We have mechanisms such as compassionate use, which 
allow access to investigational products outside of clinical 
trials when we assess that the expected benefits outweigh the 
potential risks for the patient.
    I can tell you that every Ebola patient in the United 
States has been treated with at least one investigational 
product. Because Ebola is such a serious and often rapidly 
fatal disease, FDA has approved such requests within a matter 
of a few hours and oftentimes in less than one hour.
    There are more than 250 FDA staff involved in this 
response, and without exception, everyone has been proactive, 
thoughtful, and adaptive to the complex range of issues that 
have emerged. We are fully committed to sustaining our deep 
engagement and aggressive activities to support the robust 
response to the Ebola epidemic.
    Thank you, and I will take your questions later.
    [The prepared statement of Ms. Borio follows:]
   
   
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    Mr. Murphy. Thank you, Dr. Borio. Mr. Wagner, you are 
recognized for 5 minutes.

                  STATEMENT OF JOHN P. WAGNER

    Mr. Wagner. Thank you, Chairman Murphy, Ranking Member 
DeGette and distinguished members of the subcommittee 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, about 1 million travelers arrive in the United 
States. About 280,000 of them arrive at our international 
airports. 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, 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 in coordination with the 
CDC, we have had modern protocols in place for well over a 
decade that have guided response to a variety of significant 
health threats.
    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 CDC is 
working to ensure that frontline 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 
teaches 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 training for its frontline 
personnel by covering key elements of CBP's Bloodborne 
Pathogens Exposure Control Plan, protections from exposure, use 
of personal protective equipment, 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 this virus since the 
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.
    Information sharing is critical, and CBP continues to 
engage with health and medical authorities. Since January of 
2011, CDC's Division of Global Migration and Quarantine has 
stationed a liaison officer at our national targeting center to 
provide subject-matter expertise and facilitate requests for 
information between the two organizations.
    Starting October 1st this year, CBP began providing Ebola 
information notices to travelers entering the United States 
from Guinea, Liberia and Sierra Leone. This tearsheet 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 11th CBP and CDC began 
enhanced screening of travelers from the three affected 
countries entering at JFK Airport, and today we expanded these 
enhanced efforts at Dulles, Chicago O'Hare, Atlanta, and 
Newark. Approximately 94 percent of travelers from the affected 
countries enter the United States through these five airports. 
In coordination with CDC, these targeted travelers are 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.
    Since the additional measures went into effect at JFK, CBP 
has conducted enhanced screening on 155 travelers who were 
identified in advance as being known to have traveled through 
one of these three affected countries. An additional 13 
travelers were identified by CBP officers as needing additional 
screening during the course of our standard interview process 
that is applied at all ports of entry. A total of eight of 
these travelers have been sent to tertiary screening by CDC, 
and it is important to note that so far all passengers were 
examined and released.
    While CBP officers receive training in illness recognition 
and response, if they identify an individual believed to be 
ill, CBP will isolate the traveler from the public in a 
designated area and contact the local CDC quarantine officer 
along with local public health authorities to help with further 
medical assessment. CBP officers are trained to employ 
universal precautions, an infection control approach developed 
by CDC when they encounter individuals with overt symptoms of 
illness or contaminated items in examinations of baggage and 
cargo. When necessary, CBP personnel will take the appropriate 
safety measures based on the level of potential exposure. These 
procedures designed to minimize risk to our officers and the 
public have been used collaboratively by both agencies on a 
number of occasions with positive results. CBP will continue to 
monitor the Ebola outbreak, provide timely information and 
guidance to our field personnel, work closely with 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 the 
attention you are giving to this very important issue. I will 
be happy to answer any of your questions.
    [The prepared statement of Mr. Wagner follows:]
    
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    Mr. Murphy. Thank you. Now we are going to recognize Dr. 
Daniel Varga, Chief Clinical Officer joining us from Texas on 
videoconference. Dr. Varga.

                   STATEMENT OF DANIEL VARGA

    Mr. Varga. Good afternoon, Chairman Murphy, Vice Chair 
Burgess, Ranking Member DeGette and members of the committee. 
My name is Dr. Daniel Varga. I am the Chief Clinical Officer 
and Senior Executive Vice President for Texas Health Resources. 
I am board certified in internal medicine and have more than 24 
years of combined experience in patient practice, medical 
education, and health care administration.
    I am truly sorry that I could not be with you in person 
today, and I deeply appreciate the committee's understanding of 
our situation and how important it is for me to be here in 
Dallas during this very challenging and sensitive time.
    Texas Health Presbyterian Hospital Dallas is one of 13 
wholly owned acute-care hospitals in the Texas Health Resources 
System. We are an 898-bed hospital treating some of the most 
complicated cases in north Texas. Texas Health Dallas is 
recognized as a magnet designated facility for excellence in 
nursing services by the American Nurses Credentialing Center, 
the Nation's leading nursing credentialing program.
    Texas Health Resources is one of the largest faith-based 
centers not-for-profit health systems in the United States and 
the largest in north Texas in terms of patients served. Our 
mission is to improve the health of the people in the 
communities we serve, and we care for all patients regardless 
of their ability to pay. We serve diverse communities, and as 
such, as provide one standard of care for all regardless of 
race or country of origin.
    As the first hospital in the country to both diagnose and 
treat a patient with Ebola, we are committed to using our 
experience to help other hospitals and health care providers 
protect the public health against this insidious virus. It is 
hard for me to put into words how we felt when our patient 
Thomas Eric Duncan lost his struggle with Ebola on October 8th. 
It was devastating to the nurses, doctors, and team who tried 
so hard to save his life, and we keep his family in our 
thoughts and prayers.
    Unfortunately, in our initial treatment of Mr. Duncan, 
despite our best intentions and a highly skilled medical team, 
we made mistakes. We did not correctly diagnose his symptoms as 
those of Ebola, and we are deeply sorry. Also, in our effort to 
communicate to the public quickly and transparently, we 
inadvertently provided some information that was inaccurate and 
had to be corrected. No doubt, that was unsettling to a 
community that was already concerned and confused, and we have 
learned from that experience as well.
    Last weekend, Nurse Nina Pham, a member of our hospital 
family who courageously cared for Mr. Duncan, was also 
diagnosed with Ebola. Our team is doing everything possible to 
help her win that fight, and on Tuesday her condition was 
upgraded to good, and as Dr. Fauci mentioned earlier, Nina's 
care continues to evolve. I can tell you that the prayers of 
the entire Texas Health system are with her. Yesterday, as has 
been noted, we identified a second caregiver with Ebola, and I 
can also tell you that our thoughts and prayers remain with 
Amber as well.
    A lot is being said about what may or may not have occurred 
to cause Nina and Amber to contract Ebola. We know that they 
are both extremely skilled nurses and were using full 
protective measures under the CDC protocols, so we don't yet 
know precisely how or when they were infected. But it is clear 
there was an exposure somewhere, sometime, and we are poring 
over records and observations and doing all we can to find the 
answers.
    You have asked about the sequence of events with regard to 
our preparedness for Ebola and our treatment of Mr. Duncan. Key 
events from our preparation timeline are attached to our 
submitted statement, but here is a brief overview. As the Ebola 
epidemic in Africa worsened over the summer, Texas Health 
hospitals and facilities began educating our physicians, 
nurses, and other staff on the symptoms and risk factors 
associated with the virus. On July 28, an Infection Prevention 
Nurse Specialist at Texas Health received the first Centers for 
Disease Control and Prevention Health Advisory about Evola 
virus disease and began sharing it with other Texas Health 
personnel. The Healthcare Advisory encouraged all healthcare 
providers in the U.S. to consider EVD in the diagnosis of 
febrile illness--in other words, a fever--in persons who had 
recently traveled to affected countries. The CDC advisory was 
also sent to all directors of our emergency departments and 
signage was also posted in the EDs.
    On August 1, Texas Health leaders, including all regional 
and hospital leaders and the ED leaders across our system, 
received an email directing that all hospitals have a hospital 
epidemiologic emergency policy in place to address how to care 
for patients with Ebola-like symptoms. The email also drew 
attention to the fact that our electronic health record 
documentation in emergency departments included a question 
about travel history to be completed on every patient. 
Attachments to the e-mail included a draft THR epidemiologic 
emergencies policy that specifically addressed EVD, CDC-based 
poster to be posted in the ED, and the CDC advisory from 7/28.
    The August 1 CDC Guidelines and Evaluation of U.S. Patients 
Suspected of Having Evola Virus Disease was distributed to 
staff, including physicians, nurses, and other frontline 
caregivers on August 1st and August 4th.
    Over the last 2 months, the Dallas County Health and Human 
Services Department communicated with us frequently as plans 
and preparatory work were put in place for a possible case of 
Ebola. We have also provided the August 27, 2014 Dallas County 
Health Department algorithm and screening questionnaire.
    At 10:30 p.m. on September 25th, Mr. Duncan presented to 
the Texas Health Presbyterian Dallas Emergency Department with 
a fever of 100.1, abdominal pain, dizziness, nausea, and 
headache, symptoms that could be associated with many other 
illnesses. He was examined and underwent numerous tests over a 
period of 4 hours. During his time in the ED, his temperature 
spiked to 103 degrees Fahrenheit but later dropped to 101.2. He 
was discharged early on the morning of September 26th, and we 
have provided a timeline on the notable events of Mr. Duncan's 
initial emergency department visit.
    On September 28th, Mr. Duncan was transported to the 
hospital by ambulance. Once he arrived at the hospital, he met 
several of the criteria of the Ebola algorithm. At that time, 
the CDC was notified. The hospital followed all CDC and Texas 
Department of State Health Services recommendations in an 
effort to ensure the safety of all patients, hospital staff, 
volunteers, nurses, physicians, and visitors. Protective 
equipment included water-impermeable gowns, surgical masks, eye 
protection and gloves. Since the patient was having diarrhea, 
shoe covers were added shortly thereafter.
    We notified the Dallas County Health and Human Services 
Department, and their infectious disease specialists arrived on 
the site shortly thereafter. On September 30th, lab testing 
confirmed----
    Mr. Murphy. Doctor, could you----
    Mr. Varga [continuing]. The first case of the Evola Virus 
Disease diagnosed in the United States at Texas Health Dallas. 
Later that same day, CDC officials were notified, and they 
arrived on our campus October 1st. Physicians----
    Mr. Murphy. Doctor, one moment, please.
    Mr. Varga [continuing]. Nurses----
    Mr. Murphy. Could you hold one moment, please? I know we 
are going way over time, and we do want to hear these details, 
but could you wrap it up? Because a lot of members want to ask 
you questions as well on some of these details, sir.
    Mr. Varga. OK.
    Mr. Murphy. Thank you.
    Mr. Varga. In conclusion, I would like to underscore that 
we have taken all the steps possible to maximize the safety of 
our workers, patients and community, and we will continue to 
make changes as new learnings emerge. Moreover, we are 
determined to be an agent for change across the U.S. healthcare 
system by helping our peers benefit from our experience.
    Texas Health Resources is an organization with a long 
history of excellence. Our mission and our ministry will 
continue, and we will emerge from these trying times stronger 
than ever.
    Thank you for the opportunity to testify, and I'll 
obviously be glad to answer any questions from the committee.
    [The prepared statement of Mr. Varga follows:]
    
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    Mr. Murphy. Thank you. We will be recognizing each person 
on this committee for 5 minutes of questions. We will keep a 
strict time on this as well.
    Let me start off here with Dr. Frieden. A second nurse 
infected with Ebola took a flight to Cleveland after she 
registered a fever. We have a report that says she contacted 
the CDC and was told she could fly. Did she in fact call the 
CDC and ask for guidance on boarding a commercial flight as far 
as you know?
    Mr. Frieden. My understanding is that she did contact CDC 
and we discussed with her her report of symptoms as well as 
other evaluation.
    Mr. Murphy. Were you part of that conversation?
    Mr. Frieden. No, I was not.
    Mr. Murphy. Was there a pre-plan suggesting limiting her 
contacts with other persons?
    Mr. Frieden. The protocol for movement and monitoring of 
people potentially exposed to Ebola identifies as high risk 
someone who did not wear appropriate personal protective 
equipment during the time they cared for a patient with Ebola. 
On----
    Mr. Murphy. Well, let me you ask this. What specifically 
did she tell you? We know Mr. Duncan's medical team was was not 
under the same observation and travel restrictions as people he 
came into contact with, so what specifically did she tell you 
her symptoms were or what was happening?
    Mr. Frieden. I have not seen the transcript of the 
conversation. My understanding is that she reported no symptoms 
to us.
    Mr. Murphy. All right. Let me ask another question here 
quickly. With regard to the new patient being transferred to 
NIH, will people who come into contact with her be under any 
travel restrictions? Dr. Fauci, perhaps you know that? I know--
--
    Mr. Fauci. Well, according to the guidelines, the people 
who will be coming into contact with her will be physicians, 
nurses, and others who will be in personal protective 
equipment, and therefore they are not restricted.
    Mr. Murphy. Why is she being transferred to NIH and away 
from Texas?
    Mr. Fauci. To give the state-of-the-art care in a 
containment facility of highly trained individuals who are 
capable of taking care of her.
    Mr. Murphy. Has her condition deteriorated or improved?
    Mr. Fauci. No, it has not. I have not seen the patient yet. 
I will when she gets here. But at this point, from the report 
that we are getting from our colleagues in Dallas, it is that 
her condition is stable and she seems to be doing reasonably 
well. But I have to verify that myself when my team goes over.
    Mr. Murphy. And if other people come to Dallas or somewhere 
else, will they also be transferred to NIH?
    Mr. Fauci. We have a limited capacity of beds, of being 
able to do this type of high-level care and containment. Our 
total right now is two beds. She will occupy one of them.
    Mr. Murphy. Thank you.
    Dr. Frieden, when we spoke on the phone the other day, you 
remained opposed to travel restrictions because, in your words, 
you said ``cutting commercial ties would hurt these fledgling 
democracies.'' Now, is this the opinion of CDC? Is this your 
opinion or does someone also advise you, someone within the 
administration, any other agencies? Where did this opinion come 
from that that is of high importance?
    Mr. Frieden. My sole concern is to protect Americans. We 
can do that by continuing to take the steps we are taking here 
as well as----
    Mr. Murphy. Did someone advise you on that? Did someone 
outside of yourself, somebody else advise you that that is the 
position, we need to protect fledgling democracies?
    Mr. Frieden. My recollection of that conversation is that 
that discussion was in the context of our ability to stop the 
epidemic at the source.
    Mr. Murphy. But we can get supplies and medical personnel 
into the Ebola hot zones and so stopping planes--and I have 
heard you say this on multiple occasions, that we have 1,000-
plus persons per week coming into the United States from hot 
zones. Am I correct on that? Coming from those areas?
    Mr. Frieden. There are approximately 100 to 150 per day.
    Mr. Murphy. OK. Now, the Duncan case has seriously impacted 
Dallas and northern Ohio but what I don't understand, if the 
administration insists on bringing Ebola cases into the United 
States, clearly you have determined how many Ebola infection 
cases the U.S. public can handle. I mean, NIH can handle two of 
these beds. Do you know that number overall in this country, 
how many we can handle?
    Mr. Frieden. Our goal is for no patients with Ebola----
    Mr. Murphy. I understand, but as long as we don't restrict 
travel and we are not quarantining people and we are not 
limiting their travel, we still have a risk, and so these 
issues of surveillance and containment I don't understand, and 
this is the question the American public is asking: why are we 
still allowing folks to come over here and why once they are 
over here is there no quarantine.
    Mr. Frieden. Our fundamental mission is to protect 
Americans. Right now, we are able to track everyone who comes 
in.
    Mr. Murphy. But you are not stopping them from being around 
other people, Doctor. I understand that, and I have respect for 
you, but my concern is the American public, and even so, they 
are not limited from travel, they are not quarantined for 21 
days because they could still show up with symptoms, they could 
still bypass all the questions that Mr. Wagner referred to and 
the thermometers, and this is what happened with the nurse who 
went to Cleveland. So I am concerned here. Is this going to be 
a maintained position of the administration that there will be 
no travel restrictions?
    Mr. Frieden. We will consider any options to better protect 
Americans.
    Mr. Murphy. Thank you. I now give 5 minutes to Ms. DeGette.
    Ms. DeGette. Thank you, Mr. Chairman.
    Dr. Frieden, I have got some questions for you and Dr. 
Varga for you, and I would appreciate yes or no answers because 
I have a lot to move through and only a short amount of time.
    Dr. Frieden, in the spring of 2014, Ebola began spreading 
through West Africa, causing increasing concern within the 
international public health community, correct?
    Mr. Frieden. Correct.
    Ms. DeGette. Ebola has an incubation period of about 21 
days and is not contagious until the person with the virus 
begins to be symptomatic beginning often with a fever, correct?
    Mr. Frieden. Between 2 and 21 days, yes.
    Ms. DeGette. Ebola is transmitted through contact with a 
patient's bodily fluids including vomit, blood, feces, and 
saliva, and the virus concentrates more heavily as the patient 
becomes sicker, presenting increasingly greater risk to those 
who may be in contact with them, correct?
    Mr. Frieden. Correct.
    Ms. DeGette. Now, the CDC has developed guidance for 
hospitals to follow if patients present with symptoms 
consistent with Ebola, and it distributed them to hospitals 
around the country in the summer of 2014, correct?
    Mr. Frieden. Correct.
    Ms. DeGette. Now, Dr. Varga, can you hear me?
    Mr. Varga. Yes, ma'am.
    Ms. DeGette. Your hospital received the first CDC Health 
Advisory about Ebola on July 28th, and this advisory was given 
to the directors of your emergency departments and signage was 
posted in your emergency room. Is that right?
    Mr. Varga. Yes, ma'am.
    Ms. DeGette. Now, was this information given to your 
emergency room personnel and was there any actual person-to-
person training at Texas Presbyterian for the staff at that 
time? Yes or no.
    Mr. Varga. Was given to the emergency department.
    Ms. DeGette. Was there actual training?
    Mr. Varga. No.
    Ms. DeGette. On August 1st, your hospital received an email 
from the CDC specifying how to care for Ebola patients and 
advising intake personnel to ask a question about travel 
history from West Africa. Is that right?
    Mr. Varga. That is correct.
    Ms. DeGette. Now, on September 25th, almost 2 months after 
the first advisory received by the hospital, Thomas Eric Duncan 
showed up at Texas Presbyterian with a fever that spiked up to 
103 and he told the personnel that he had come from Liberia. 
Despite this, the hospital sent him home. Is that right?
    Mr. Varga. That is not completely correct.
    Ms. DeGette. Well, they did send him home, right?
    Mr. Varga. That is correct.
    Ms. DeGette. Now, 3 days later, on September 28th, he took 
a severe turn for the worse and was brought back by ambulance. 
The hospital staff, nurses, and everybody else wore protective 
equipment. Is that right?
    Mr. Varga. That is correct.
    Ms. DeGette. And then eventually shoe covers were put on, 
too. Do you know how long that took them to put the shoe covers 
on?
    Mr. Varga. I don't.
    Ms. DeGette. Now, because Ebola is highly contagious when 
the patient is symptomatic, the protective gear has to shield 
them from any contact with bodily fluids. Is that right, Dr. 
Frieden?
    Mr. Frieden. Correct.
    Ms. DeGette. Now, I have a slide I would like to put up, 
and I got it from the New York Times today. It is the photo of 
the people in the various protective gear. So the first one on 
the left shows what they are supposed to wear when they are not 
having contact with the bodily fluids. The second one shows 
what they are supposed to have with the bodily fluids. So I 
want to ask you, Dr. Varga, is what they were wearing at first 
before the Ebola was diagnosed, that first set of protective 
gear?

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    Mr. Varga. I am sorry. I can't see the picture right now.
    Ms. DeGette. OK. I was told you would be able to.
    Dr. Frieden, what should they have been wearing of that 
protective gear before the Ebola was diagnosed?
    Mr. Frieden. I can't make out the details, but the 
recommendations vary as to the risk including whether the 
patient is having diarrhea or vomiting and may expose health 
care workers to----
    Ms. DeGette. Well, this guy, he had diarrhea and vomiting. 
So, in your testimony, people should have been completed 
covered. Is that right?
    Mr. Frieden. I would have to look at the exact details to 
know what the answer to that question would be.
    Ms. DeGette. So you don't know whether they should have 
been completely covered if the patient had diarrhea and 
vomiting and he had come from West Africa?
    Mr. Frieden. If the patient had diarrhea or vomiting, then 
additional covering is recommended under the CDC 
recommendations, yes.
    Ms. DeGette. Now, my other question that I want to ask--and 
I am going to have to get--Dr. Varga, I am going to have to get 
your testimony since you can't see my chart.
    Now, subsequently, a number of people, health care workers, 
were put into this group, this protective work. Is that right, 
Dr. Frieden? People who were being monitored.
    Mr. Frieden. So health care----
    Ms. DeGette. And on October 10th, Nina Pham presented with 
a fever, and she was admitted to the hospital. Is that right?
    Mr. Frieden. Yes.
    Ms. DeGette. And then on October 13th, Amber Vinson, who 
was self-monitoring, she presented with a fever and she was 
told by your agency she could board the plane. Is that right? I 
just have one more question.
    Mr. Frieden. That is my understanding.
    Ms. DeGette. Now, your----
    Mr. Frieden. I need to correct that.
    Ms. DeGette. OK.
    Mr. Frieden. I have not reviewed exactly what was said but 
she did contact our agency and she did board the plane.
    Ms. DeGette. And she says she was told to board the plane. 
Now----
    Mr. Frieden. That may well be correct.
    Ms. DeGette. Now, your August 22nd protocols say people who 
are being monitored should not travel by commercial 
conveyances, don't they?
    Mr. Murphy. Time is expired. You can answer the question.
    Ms. DeGette. That is what they say.
    Mr. Frieden. People who are in what is called controlled 
movement should not board commercial airlines.
    Ms. DeGette. Right, and that is people who have close 
contact with these patients, right? That is what your 
guidelines say.
    Mr. Frieden. The guidelines say that health care workers 
with appropriate personal protective equipment don't need to 
be, but people without appropriate personal protective 
equipment do need to travel by controlled transportation.
    Mr. Murphy. The gentlelady's time is expired. We do need 
to----
    Ms. DeGette. Mr. Chairman, I just ask for the record the 
interim guidance dated October 22nd, the interim guidance dated 
August 1st, and the CDC Health Advisory dated July 28th be 
included in the record.
    Mr. Murphy. Without objection, we will include it in the 
record.
    [The information follows:]
   
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    Mr. Murphy. And Dr. Frieden, I need you and also the doctor 
in Texas to get back to this committee as a follow-up to her 
question because your comment you just made to us was that if 
she was wearing appropriate protective gear, she is OK to 
travel; if she was not, she should not have traveled. And you 
just told us we don't know. We need to find that out. It is an 
important question.
    I now recognize the chairman of the committee, Mr. Upton, 
for 5 minutes.
    Mr. Upton. Thank you again, Mr. Chairman.
    I think most Americans realize that, if you are exposed, 
you have 21 days. If you go beyond 21 days, you are at 
virtually no risk of Ebola if you go that far. But it is 
conceivable then that after 14 or 15 days, you in fact can 
still get Ebola. Is that correct?
    Mr. Frieden. Yes.
    Mr. Upton. So I want to go back to the restricting of 
travel, particularly by non-U.S. citizens, these 150 folks a 
day into the United States from West Africa. So the conditions 
as you talked about exit screening, all folks from there are 
exit screened, so it is perfectly conceivable that someone even 
after 14 days can exit screen, they are OK, no fever, and in 
fact, get to their destination, perhaps in the United States, 
and have the worst. Is that right?
    Mr. Frieden. Yes.
    Mr. Upton. So if our fundamental job is to protect the 
American public, the administration, as I understand it, 
because I have looked at the legal language, the President does 
have the legal authority to impose a travel ban because of 
health reasons, including Ebola. Is that not correct?
    Mr. Frieden. I don't have the legal expertise to answer 
that question.
    Mr. Upton. I saw language earlier today--we can share that 
with you--but he does, from what we understand, not only an 
Executive Order that former President Bush issued when he was 
President but also legal standing as well. So if you have the 
authority, and it is my understanding again that a number of 
African countries around West Africa, around particularly these 
three nations, in fact have imposed a travel ban from those 
three countries into their country. Is that not true?
    Mr. Frieden. I don't know the details of the restrictions. 
There are some restrictions.
    Mr. Upton. It is my understanding that they said no and 
including even Jamaica, as I read in the press earlier this 
week, has issued a travel ban from folks coming from West 
Africa. Are you aware of that?
    Mr. Frieden. I don't know the details of what other 
countries have done. I know some of the details, and some of 
them have been in flux.
    Mr. Upton. Well, I guess the question that I have is, if 
other countries are doing the same, and as you said, the 
fundamental job of the United States now is to protect American 
citizens, why cannot we move to a similar ban for folks who may 
or may not have a fever, knowing in fact that the exposure 
rate, 14 days or 15 days, is well within the 21 days and in 
fact knowing 150 folks coming a day, not 100 percent, it is 94 
percent in terms for screening from U.S. airports, it seems to 
me that this is not a failsafe system that has been put into 
place at this point.
    Mr. Frieden. Mr. Chairman, may I give a full answer?
    Mr. Upton. I look forward to it.
    Mr. Frieden. Right now we know who is coming in. If we try 
to eliminate travel, the possibility that some will travel 
overland, will come from other places and we don't know that 
they are coming in will mean that we won't be able to do 
multiple things. We won't be able to check them for fever when 
they leave----
    Mr. Upton. If I can interrupt you just for a second, do we 
not have a record of where they have been before, i.e., a 
passport or travel status as they travel from one country to 
another?
    Mr. Frieden. Borders can be porous--may I finish?
    Mr. Upton. Go ahead.
    Mr. Frieden. Especially in this part of the world. We won't 
be able to check them for fever when they leave. We won't be 
able to check them for fever when they arrive. We won't be 
able, as we do currently, to take a detailed history to see if 
they were exposed when they arrive. When they arrive, we 
wouldn't be able to impose quarantine as we now can if they 
have high-risk contact. We wouldn't be able to obtain detailed 
locating information, which we do now, including not only name 
and date of birth but email addresses, cell phone numbers, 
address, addresses of friends so that we can identify and 
locate them. We wouldn't be able to provide all of that 
information as we do now to State and local health departments 
so that they can monitor them under supervision. We wouldn't be 
able to impose controlled release, conditional release on them 
or active monitoring if they are exposed or to in other ways--
--
    Mr. Upton. My time is expired. I know I have a swift gavel 
over here to my left. But I just don't understand. If we have a 
system in place that requires any airline passenger coming in 
overseas with a date of birth to make sure they are not on the 
anti-terrorist list that we can't look at one's travel history 
and say, ``No, you are not coming here, not until this 
situation''--you are right, it needs to be solved in Africa, 
but until it is, we should not be allowing these folks in, 
period.
    Mr. Murphy. The gentleman's time is expired. I recognize 
Mr. Waxman for 5 minutes.
    Mr. Waxman. Thank you, Mr. Chairman.
    Dr. Frieden, you have a difficult job. In fact, all of your 
colleagues who are involved from the different agencies have a 
difficult job because this is a fast-moving issue, and you are 
trying to explain things to people and educate them with 
limited information and partial authority. In fact, the CDC 
can't even do anything in a State. They have to be invited in 
by the State. You can't tell the States to follow your 
guidelines. You can give them guidelines. So you are dealing 
with a fast-moving situation and you have to strike a balance 
about informing the public on the one hand and keeping it from 
panicking on the other. So let us go to basics.
    If people are frightened about getting Ebola, what 
assurances can we give them that this is not going to be a 
widespread epidemic in the United States, as you have said on 
numerous occasions?
    Mr. Frieden. The concern for Ebola is first and foremost 
among those caring for people with Ebola. That is why we are so 
concerned about infection control anywhere patients with Ebola 
are being cared for. Second, in the health care system as a 
whole, to think about travel because someone who has a fever or 
other signs of infection needs to be asked where have you been 
in the past 21 days, and if they have been in West Africa, 
immediately isolated, assessed and cared for.
    Mr. Waxman. So we have to make sure that we monitor health 
care workers because they are exposed to people who have Ebola. 
The questions have been raised, well, what about all these 
people coming in from Africa from the countries where the Ebola 
epidemic is taking place, and you have been asked why don't we 
just restrict the travel either directly or indirectly from 
anybody coming in from those countries.
    I would like to put up on the screen a map to show the 
passenger flows from those countries. That map shows that if 
you--I will hold it up here. If you are looking at those 
particular countries in Africa, they can go to any country in 
Europe. They can go to Turkey, Egypt, Saudi Arabia. They can go 
to China and India. They can go to other countries in Africa 
and then from those other countries come to the United States. 
So I suppose we can set up a whole bureaucratic apparatus to be 
sure that somebody didn't really travel from Nigeria or 
Cameroon or Senegal or Guinea or Sierra Leone to be sure they 
didn't really get here from any of those countries. That could 
be our emphasis, but it seems to me what you are saying is that 
we want to monitor people before they leave those countries to 
see whether they have this infection, and we want to monitor 
them when they come into these countries to see whether they 
have this infection. Is that what you are proposing to do?
    Mr. Frieden. That is what we are actually doing. We are 
able to screen on entry. We are able to get detailed locating 
information. We are able to determine the risk level. If people 
were to come in by, for example, going overland to another 
country and then entering without our knowing that they were 
from these three countries, we would actually lose that 
information. Currently we have detailed locating information. 
We are taking detailed histories and we are sharing information 
with State and local health departments so that they can do the 
follow-up they decide to do.
    Mr. Waxman. Dr. Fauci, do you agree with Dr. Frieden on 
this point?
    Mr. Fauci. I do.
    Mr. Waxman. You wouldn't put a travel ban in. It sounds 
like, you know, we always seal off our borders, don't let those 
people come in. Now, that is usually a reference to the 
immigration matter, not public health particularly, or it might 
be a tangential issue, but we know certain countries where the 
epidemic is originating. Why not stop them from coming in?
    Mr. Fauci. Well, I believe that Dr. Frieden and yourself 
just articulated it very clearly. It is certainly 
understandable how someone might come to a conclusion that the 
best approach would be to just seal off the border from those 
countries, but now we know what we are dealing with. If you 
have the possibility of doing all of those lines that you 
showed, that is a big web of things that we don't know what we 
are dealing with.
    Mr. Waxman. So what we know is this epidemic can spread if 
there is contact with body fluids from somebody who is showing 
the symptoms of Ebola or someone who has been exposed to that 
individual. If we had a travel ban, wouldn't we just force 
these people to hide their origin and wouldn't we also not know 
where they are coming from if they are going out of their way 
to hide it? A ban or quarantine would hinder efforts to fight 
the epidemic in West Africa, and the worse the epidemic becomes 
in West Africa, the greater it is going to be a problem all 
over the world including the United States.
    Mr. Murphy. The gentleman's time is expired.
    Mr. Waxman. Is that your position? Dr. Fauci, is that your 
position?
    Mr. Fauci. Yes.
    Mr. Murphy. The gentleman's time is expired. Now we 
recognize the vice chair of the full committee for 5 minutes.
    Mrs. Blackburn. Thank you, Mr. Chairman.
    Dr. Frieden, I want to be sure I heard you right. You just 
said to Chairman Upton that we cannot have flight restrictions 
because of a porous border, so do we need to worry about having 
an unsecure southern and northern border? Is that a big part of 
this problem?
    Mr. Frieden. I was referring to the border of the three 
countries in Africa, Liberia----
    Mrs. Blackburn. You are referring to that border, not our 
porous border?
    Mr. Frieden [continuing]. Guinea and Sierra Leone.
    Mrs. Blackburn. Mr. Wagner, would it help you all, the 
Border Patrol, if we secured the southern border and eliminated 
illegal entry?
    Mr. Wagner. Well, travelers coming across the southern 
border, like the northern border, we are going to, you know, 
query their information in our database. We are going to ask 
them their travel history, where they are coming from, how they 
arrived in the country they are coming from----
    Mrs. Blackburn. Yes or no is sufficient. I need to move on.
    Dr. Frieden, I want to come back to you. I would remind you 
that a week before last when I was at the CDC, and I thank you 
for letting me come down to follow up with you all on some of 
our committee work, that I recommended a quarantine in the 
affected region and hold people there, and I still think that 
that is something that we should consider. Quarantining people 
for 21 days before they leave that region, it helps every 
country.
    I want to go back to an issue that you and I talked about 
at the CDC and a subsequent phone call, and that is the medical 
waste, and you assured me that standard protocols were being 
followed for disposal of this waste, and we know that 20, 25 
years ago, hospitals could incinerate their waste. EPA 
regulations now prohibit that, and the waste has to be trucked, 
and they outsource the care of this medical waste and it 
results in that going to central processing centers. So let me 
ask you this. Is Ebola waste as contagious as a patient with 
Ebola?
    Mr. Frieden. Ebola waste or waste from Ebola patients can 
be readily decontaminated. The virus itself is not particularly 
hardy. It is killed by bleach, by autoclaving, by a variety of 
chemicals.
    Mrs. Blackburn. OK. Is Ebola medical waste more dangerous 
than other medical waste?
    Mr. Frieden. The severity of Ebola infection is higher, so 
you want to be certain when you are getting rid of it that you 
handle it effectively.
    Mrs. Blackburn. OK. Is the CDC assessing the capabilities 
of hospitals to manage the medical waste of Ebola patients and 
does the CDC allow offsite disposal of Ebola medical waste?
    Mr. Frieden. My understanding is to the latter question, 
yes, we worked very closely with both the Department of 
Transportation as well as the commercial waste management 
companies to ensure that capability.
    Mrs. Blackburn. So we have an added danger in having to 
truck this waste and move it to facilities. Are the employees 
of the processing centers being trained in how to dispose of 
Ebola waste?
    Mr. Frieden. We have detailed guidelines for the disposal 
of medical waste from care of Ebola patients.
    Mrs. Blackburn. All right. You and I talked a little bit 
about my troops from Fort Campbell that are going to be over 
there, and I have some questions from some of my constituents. 
Are the American troops going to come in contact with any Ebola 
patients or with those exposed to Ebola or included in any of 
these controlled movement groups?
    Mr. Frieden. As I understand it from the Department of 
Defense, their plans do not include any care for patients with 
Ebola or any direct contact with patients with Ebola. That 
said, we would always be careful in country because there is 
the possibility of coming in contact with someone with symptoms 
and being exposed to their body fluids, and that is why the 
Department of Defense is being extremely careful to avoid that 
possibility.
    Mrs. Blackburn. We are still going to rely on self-
reporting?
    Mr. Frieden. No. We are taking temperatures at many 
locations within the country. We are having hand-washing 
stations----
    Ms. Blackburn. So you are moving away from self-reporting? 
Because originally it was--you said our structure was built on 
self-reporting when I visited with you earlier, and I found a 
quote from you from December 2011 at the George Comstock 
lecture in TB research, and I am quoting you: ``Hippocrates was 
right: patients lie. About a third of patients don't take 
medication as prescribed and a third don't take them at all. 
You can either delude yourself and think that patients are 
taking their medications or not. In TB control, it is a simple 
model. If we see people take their meds, we believe they took 
their meds.''
    Now, Dr. Frieden, relying on self-reporting and making 
certain that people tell us the truth before they leave and 
then we catch the fever at the right time if they have a 
temperature. We have got to do better than this. We can do 
better than this. We are here to work with you and we expect a 
better outcome. I yield back.
    Mr. Murphy. The gentlelady's time is expired. I now 
recognize Mr. Braley for 5 minutes.
    Mr. Braley. I would like to thank the panel for joining us 
today.
    Dr. Frieden, I was happy to hear you say we will consider 
any options to protect Americans. I think that is the purpose 
of everyone here in this room today. But I do want to ask you 
about Texas. Are you familiar with the concept of sentinel-
event reporting?
    Mr. Frieden. Yes.
    Mr. Braley. Has CDC done a root-cause analysis of what 
happened at Texas Presbyterian and come up with an action plan 
on what we learned from that incident? We have the detailed 
hospital checklist for Ebola preparedness, which we have heard 
about here today. Have there been any recommendations on 
changing, modifying, or updating this in light of what happened 
at Texas Presbyterian?
    Mr. Frieden. We have a team of more than 20 of some of the 
world's top disease detectives in Texas now. We were there. We 
left the first day the patient was diagnosed. We identified 
three areas of particular focus. The first is the prompt 
diagnosis of anyone who has fever or other symptoms of 
infection and a travel history to West Africa, and Dr. Varga 
spoke about that issue. The second is contact tracing, and the 
graphic that I provided earlier outlines what we are doing 
there very intensively. The State of Texas and the country are 
doing a terrific job along with our staff making sure that 
every single contact of the first patient, Mr. Duncan, is 
monitored, their temperature taken by an outreach worker every 
day for 21 days. They are most of the way through that risk 
period. So of the 48, none have developed symptoms, none have 
developed fever. We are now looking at the contacts, health 
care workers who may have had contact as the two individuals 
who became infected did, and our thoughts are with them, and we 
are delighted that NIH is supporting the hospital in Texas and 
also that Emory University is doing that as well, and the third 
area is after identification and contact tracing is effective 
isolation, and we are looking very closely at what might 
possibly have happened to result in these two exposures.
    Mr. Braley. And I assume if there are any new 
recommendations based upon that analysis, this protocol that 
was sent out will be updated and redistributed?
    Mr. Frieden. We always look at the data to see what we can 
do to better protect Americans.
    Mr. Braley. Thank you.
    Dr. Fauci, you were kind enough to share with us this 
graphic, and in it you mentioned a company in Ames, Iowa, 
called NewLink, which is working on one of the vaccines that 
just went into Phase I clinical trials this week, correct?
    Mr. Fauci. That is correct.
    Mr. Braley. And I had an opportunity to talk to two of 
their employees yesterday, and I know that they are working 
around the clock trying to help come up with a vaccine that 
will meet the protocol and the standards for scalability that I 
think everyone is looking for. The WHO, the Department of 
Defense, HHS, and the public health agency in Canada have 
called this vaccine one of the most advanced in the world, and 
they have requested contracts with HHS to expand the 
manufacturing, to add a third site for manufacturing, to 
complete the scientific studies required to scale up 
manufacturing, and complete the additional safety study to 
provide newly manufactured vaccines that are equivalent to the 
original vaccines, and they have also identified companies to 
work as subcontractors.
    Dr. Robinson, can you tell us what HHS is doing to make 
sure that those contracts are moving forward as quickly as 
possible?
    Mr. Robinson. Thank you, sir. We have reviewed their 
proposal. It looks very favorable, and we will be in the next 
several weeks finalizing the negotiations with them. Prior to 
that, we actually have been helping them with their submissions 
to the FDA and providing assistance onsite and also at the 
manufacturing sites and working with them to expand their 
production with other companies including a very large company 
here in the United States.
    Mr. Fauci. And also, Mr. Braley, the HHS is also involved 
in the other end of it because the trials that were started 
were not only in collaboration with the Department of Defense 
but we admitted our first VSV patient at our clinical center in 
Bethesda for a Phase I trial. So it is not only in the testing 
but also in the ultimate production.
    Mr. Braley. And it is my understanding, Dr. Fauci and Dr. 
Robinson, that the ultimate goal is to also expand this 
clinical testing into some of the affected regions in Africa as 
well once we have an understanding of some of the concerns that 
were identified earlier in your testimonies.
    Mr. Fauci. That is quite correct. In fact, when I was 
saying that after we get through Phase I on the trial, I was 
talking about both vaccines, the GlaxoSmithKline and the 
NewLink both. If they are safe and induce the response we feel 
is appropriate, we will expand both of them into larger trials 
in West Africa.
    Mr. Braley. And then Mr. Wagner, a question for you. We 
have heard a lot today about the issue of travel restrictions. 
Can you sort of walk us through the strengths and weaknesses of 
that approach from your standpoint in border security?
    Mr. Wagner. Well----
    Mr. Murphy. The gentleman's time is expired so if you could 
give a quick answer?
    Mr. Wagner. So we have the ability to use the data that the 
airlines give us to be able to see where travel is originating 
from. There are instances where travelers may go to different 
locations. We might not see that, but through our questioning 
and our review of their passport, we can identify that they 
have been to these affected regions or if they come through one 
of the borders. If they fly to Canada or Mexico it is more 
difficult for us to do it but the possibility is there, but the 
possibility is also greater that we would miss one, so I do 
agree with what the experts, you know, say. It is easier to 
manage it and control it when we know where people are coming 
from voluntarily and not intentionally trying to deceive us.
    Mr. Murphy. The gentleman's time is expired. The word is 
``voluntary.''
    I now recognize Dr. Burgess for 5 minutes.
    Mr. Burgess. Thank you, Mr. Chairman, and I would like to 
stay with what Chairman Upton was talking about on the travel 
restriction.
    The Secretary of Health and Human Services under the Public 
Health Service Act has the authority to issue a travel 
restriction. Under the pandemic plan that was adopted in 2005, 
the President has the ability to issue a travel restriction. 
Two thousand five was geared toward the pandemic avian 
influenza but it was amended in July of this year to include 
the hemorrhagic fevers. So I believe that authority very 
clearly exists. Now, the question is why the Executive Branch 
and why the agency will not exercise that authority. Mr. 
Chairman, I think perhaps this committee should consider 
forwarding to the full House a request that we have a vote on 
travel restriction because people are asking us to do that, and 
I think they are exactly correct to make that request.
    Dr. Frieden, the first nurse who was infected over the 
weekend is now being transferred away from Presbyterian, and 
yet her condition has been serially reported in the news media 
as she is stable and she has been improving, so is the reason 
that she is having to be removed because the personnel are no 
longer willing to stay at Presbyterian to take care of her?
    Mr. Frieden. Texas Presbyterian is really dealing with a 
difficult situation. They are working very hard. Because of the 
events of the past week, they are now dealing with at least 50 
health care workers who may potentially have been exposed. The 
management of those individuals, making sure that if any of 
them develop any symptoms whatsoever, even the slightest, they 
come in immediately to be assessed so that if they develop 
Ebola, we hope no more will, but we know that is a possibility 
since two individuals did become infected, others may. That 
makes it quite challenging to operate a hospital, and we felt 
it would be more prudent to focus on caring for any patients 
who come in, health care workers or others who might come in 
with symptoms.
    Mr. Burgess. I don't disagree, and you and I have talked 
about this, and I am fully in favor of individuals who have 
been diagnosed that they do be taken care of in centers. Dr. 
Fauci, you know that if somebody wants to do research on the 
Ebola, they can't just go to a regular university setting and 
do that. They must go to one of the laboratories where they 
have the capability of protecting the personnel who are not 
only doing the experiments but other personnel surrounding in 
the lab. Is it possible to get--I had a picture from the Dallas 
Morning News which had the CDC-recommended personal protective 
equipment. I think we have it there, and this not only shows 
the personal protective equipment, but it also details the 
order in which it should be put on and removed. I would know 
that shoe covers are not included in this graphic but you do 
see a fair amount of exposed skin around the eyes and the 
forehead and of course the neck. Now, Dr. Frieden, this is 
going to be hard to see, but this is your picture in western 
Africa, and as you can see, there is head-to-toe covering and 
goggles, and I believe if I understand the circumstances 
correctly, you were just about to be dosed with a near-toxic 
dose of chlorine. Is that not correct?
    Mr. Frieden. Yes.
    Mr. Burgess. Well, and that is why you can't have skin 
exposed, because it is impossible to do the disinfection, if 
you will, after taking care of an Ebola patient or being in an 
Ebola ward. It is impossible to do the disinfection if there is 
skin exposed because exposed skin would be killed by the 
chlorine and that would not be good for the person delivering 
the care.
    I mentioned this in my opening statement. I am so 
concerned. We know the numbers in western Africa are going up 
on Ebola. We know the case rate is going to increase. We know 
that 10 percent of those cases are health care workers, and we 
know that 56 percent of those health care workers in western 
Africa will succumb to the illness so that is a pretty dire 
warning for anyone who is involved in delivering health care. 
Dr. Robinson, let me ask you. What kind of stockpile of this 
personal protective equipment do you have available to the 
health care workers who are on the front line? And bear in 
mind, no travel restrictions so a new patient could come in 
tonight and go to any hospital in this country and present 
themselves. Are you going to be able to quickly deliver a 
stockpile of personal protective equipment like this?
    Mr. Robinson. So we know from talking to the manufacturers, 
there are no shortages right now and that they are willing to 
deliver within 24 hours or less.
    Mr. Burgess. Let me just task this question, Dr. Frieden. 
You know, what did you think the first patient was going to 
look like when you knew you were going to have a patient zero 
at some point or that it was a possibility. We had the 
gentleman who died in Nigeria at the end of July who could have 
gotten on a plane to Minneapolis. What did you think that was 
going to look like? What was patient zero going to look like? 
And now you have seen what it really looks like----
    Mr. Murphy. The gentleman's time is expired.
    Mr. Burgess [continuing]. What is the matchup there?
    Mr. Murphy. You can go ahead and answer quickly. Thank you, 
Doctor.
    Mr. Frieden. Our goal has been to get hospitals ready. The 
specific type of personal protective equipment to be used is 
not simple, and there is no single right answer, but there is a 
balance between protective equipment that is more familiar or 
less familiar, that is more flexible and less flexible, that 
can be decontaminated more easily or less easily, so the use of 
different types of protective equipment is something that 
obviously we are looking at very intensively now in Dallas in 
conjunction with the health care workers there.
    Mr. Murphy. Thank you. I now recognize Ms. Schakowsky for 5 
minutes.
    Ms. Schakowsky. Thank you, Mr. Chairman.
    I have so many questions. I just want to begin, though, by 
thanking the health care professionals that are on the front 
line, and I would like to ask unanimous consent to put into the 
record, Mr. Chairman, a letter from Randi Weingarten from the 
American Federation of Teachers, which represents many nurses 
into the record. I would also like unanimous consent to put in 
the record the diary of Paul Farmer from Partners in Health, 
who has among other things said the fact is that weak health 
systems are to blame for Ebola's rapid spread in West Africa, 
and we know that West Africa has 24 percent of global disease 
burden, 3 percent of world health workforce, one doctor in 
Liberia for 90,000 people.
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    Ms. Schakowsky. So I would like to focus on what we are 
going to do to help that infrastructure, but in my limited time 
I want to focus on our infrastructure here.
    We have a vast infrastructure--hospitals, community health 
centers, I want to point out too where people may present 
themselves, nurses, nurses' aides, no one better than the 
United States, but do we have the ability to train and equip, 
as we talk about in military terms in Syria, and do we have the 
ability really to train and equip?
    Let me just put a couple things on the table. In terms of 
the nurses, I still don't feel like we have a good answer of 
why nurse one and nurse two contracted Ebola. Is it because 
there was a problem with not following the protocols or is 
there something wrong with the protocols? And how are we going 
to ensure that even if we have the best protocols in the world 
that everybody knows how to use them?
    Congresswoman DeGette showed the various protective gear 
that our nurses are supposed to have, and yet 2 days apparently 
went by when they were not wearing shoe covers, that their 
necks were not covered, that skin in fact, as Dr. Burgess was 
talking about, was in fact exposed, even as we knew that he had 
Ebola.
    So how are we going to make sure despite how we are going 
to check at the airports--I am from Chicago. I talked to our 
health director today. I know what we are doing. But there is 
still the chance that someone could present anywhere. So how 
come the nurses in Dallas weren't protected and how are we 
going to make sure that everybody can be?
    Mr. Frieden. So first just to clarify one thing, those 
first couple of days, the 28th, 29th, 30th, were before his 
diagnosis was known so he had suspected Ebola. The test was 
being drawn and assessed but he had not yet been diagnosed with 
Ebola, and in our team's review----
    Ms. Schakowsky. Is that--excuse me one second. 
Congresswoman, were you saying otherwise? Can I yield?
    Ms. DeGette. If the gentlelady will yield, but he presented 
with Ebola symptoms. He had been to the emergency room just a 
couple of days earlier saying he had been from Africa, and I 
believe the CDC protocols that were given to the Dallas 
hospital said that people should be wearing that protective 
covering even before the official diagnosis. I would certainly 
hope--thank you for yielding, Ms. Schakowsky.
    Dr. Frieden, I would certainly hope that here going forward 
if a patient shows up saying he is from Africa and he is 
vomiting and he has diarrhea, that you wouldn't say, ``Well, we 
don't have the lab results in yet,'' you would start treating 
that person like they had Ebola.
    Mr. Frieden. Absolutely. I just wanted to clarify that 
those first couple of days, the 28th and 29th, he was being 
isolated for Ebola. The diagnosis was confirmed on the 30th. On 
the 30th we sent a team there----
    Ms. Schakowsky. OK.
    Mr. Frieden. And when we looked at the--to answer your 
question--of those first couple of days, there was some 
variability in the use of personal protective equipment. The 
hospital was certainly trying to implement CDC protocol----
    Ms. Schakowsky. I know, but going forward, how are we going 
to assure that just trying, you know, how are we going to 
educate people, nurses? The nurses are saying across the 
country that they have not been involved and that they are not 
trained properly or have the equipment.
    Mr. Frieden. Three phases. First, think Ebola in anyone 
with travel history and symptoms. Second, any time a patient is 
suspected, isolate them, contact us, and we will talk you 
through how to provide care while we get the test done, and if 
it is confirmed, we will be there within hours with a CDC Ebola 
Response Team.
    Ms. Schakowsky. OK. My time is expired.
    Mr. Murphy. Just in response to that, when did you come up 
with that plan that you just stated to Ms. Schakowsky, the plan 
in terms of training for nurses? When was that decided?
    Mr. Frieden. We look at our preparedness continuously so 
awareness has been something that we have been promoting in 
extensive ways since the outbreak----
    Mr. Murphy. I mean, she was asking specifically for those 
nurses. When was the plan put in place for the Texas hospitals 
and says you need to follow this protocol from this point on?
    Mr. Frieden. The day the diagnosis was confirmed, we sent a 
team to Texas.
    Mr. Murphy. Thank you. Dr. Gingrey is recognized for 5 
minutes.
    Mr. Gingrey. Well, first of all, I want to thank, of 
course, Chairman Murphy for calling the subcommittee back to 
Washington to hold today's hearing on our collective response 
to the ongoing Ebola outbreak and commend my colleagues on both 
sides of the aisle, your near-unanimous attendance to this 
hearing.
    Since my time is very limited, of course, I would like to 
get directly to my questions, and this is kind of a follow-on 
maybe to what Ms. Schakowsky was asking, and I don't think we 
ever got around to an answer on that, and I am going to direct 
the question to Dr. Frieden and to Dr. Varga, maybe first to 
Dr. Varga.
    As we know from new reports yesterday, there has been a 
second health care worker who has contracted Ebola, Ms. Amber 
Vinson. Now that she is receiving isolated treatment at Emory 
University containment unit in Atlanta, we must examine the 
protocol breakdowns that resulted in the contraction of Ebola 
by these two nurses who were directly in contact treating 
Thomas Duncan.
    Dr. Varga, in your written testimony you say that the first 
nurse, Ms. Pham, to contract Ebola was using full protective 
measures under the CDC protocol while treating Mr. Duncan. Has 
your organization in Texas identified where the specific 
breaches in protocol were that resulted in her infection or, 
alternatively, the inadequacies of the protocol? Dr. Varga, 
that question is for you.
    Mr. Varga. Thank you, sir. We are investigating currently 
the source of this obvious exposure and contraction of the 
illness. We have confirmed that Nina through her care with Mr. 
Duncan was wearing protective patient equipment through the 
whole period of time. As Dr. Frieden already mentioned, with 
the diagnosis of the Ebola confirmed, the level of personal 
protective equipment was elevated to the full hazmat style. We 
don't know at this particular juncture what the source or the 
cause of the exposure that caused Nina to contract the disease 
was.
    Mr. Gingrey. Dr. Varga, I am going to interrupt you just 
for a second because of limitation of time. I want to now go to 
Dr. Frieden.
    Dr. Frieden, as Dr. Varga just stated, health care 
personnel were following CDC protocols while treating Mr. 
Duncan, which include the use of so-called PPE, personal 
protective equipment. Do the CDC guidelines, your guidelines, 
on the use of PPE mirror current international standards that 
by the way are being adhered to, those international standards, 
in West Africa in those three countries, Sierra Leone, Guinea, 
and Liberia?
    Mr. Frieden. The international standards are something that 
evolve and change. We use different PPE in different settings. 
There is no single right answer, and this is something we are 
looking at very closely. Our current guidelines are consistent 
with recommendations from the World Health Organization. That 
is my understanding.
    Mr. Gingrey. I would think that there would need to be, Dr. 
Frieden, and I commend you for the job that you are doing and I 
know these are tough times for all of us, but I think some 
consistency is what we need, and that brings me to my next 
question and my last question, and again, it is to you, Dr. 
Frieden.
    This issue of elevated temperature, is it 100.4, is it 
101.5, is it 99.6? I think there is some great confusion 
because initially when people were screening, Mr. Wagner, at 
the airports in West Africa, the temperature threshold was 
101.5, and then I think now the screenings that we are doing at 
these five major airports including Hartsfield International in 
Atlanta, it is now 100.4. When Mr. Duncan came for the first 
time to the Texas Presbyterian Hospital, his temperature was, 
what, 100.1, and within 24 hours, of course, it was 103. So 
when mom and dad are out there when their child has a 
temperature and this fall is flu season and they are going to 
the doctor, they are going to demand being checked for Ebola. 
Give us some guidelines on what is elevated temperature and 
when should parents be concerned?
    Mr. Frieden. Well, first, parents should not be concerned 
about Ebola unless you are living in West Africa or the child 
has had exposure to Ebola, and right now the only people who 
have had exposure to Ebola in the United States are people who 
either are providing care for Ebola patients or the contacts of 
the three Ebola patients, and I outlined those in this sheet. 
For our screening criteria, we are always going to try to have 
an additional margin of safety and so we look at that, and we 
would rather check more people and assess, so we are going to 
always have that extra margin of safety for our screening.
    Mr. Gingrey. Thank you, and I yield back.
    Mr. Murphy. I now recognize Ms. Castor for 5 minutes.
    Ms. Castor. Thank you all for tackling this important 
public health issue of the Ebola virus, and I want to thank the 
experts at the Centers for Disease Control and the NIH and 
medical professionals across the country, especially those at 
Emory University Health Care who have been proactive in 
containing and treating the virus.
    I agree with President Obama and all of you. We have to be 
as aggressive as possible in preventing any transmission of the 
disease within the United States and boosting containment in 
West Africa.
    But I also think we need to pause here. This is a wakeup 
call for America that we cannot allow NIH funding to stagnate 
any longer. Earlier this year in the Budget Committee, I 
offered an amendment to the Republican budget to restore the 
cuts to NIH, the budget cuts that have been inflicted over the 
past 2 years and repair the damage of the Government shutdown 
of last year. Unfortunately, it did not pass on a party-line 
vote. We will only save lives if we can robustly fund medical 
research in America and keep America as the world leader.
    So I would like to turn to some of that research that is 
going on now because it is going to be research that will be 
our longer-term response to Ebola. It will be the vaccines to 
prevent the disease and the drugs to treat it. So I want to 
walk through a basic point here, that the development of 
vaccines and treatments for Ebola is different from the 
development of many other drugs. There is not a large private 
market for Ebola drugs, so the development requires leadership 
of our country, and NIH, as Dr. Fauci has testified, has been 
working on a vaccine for many years, and he reported today they 
have now moved into some Phase I clinical trials.
    Dr. Fauci, can you explain to us why Government support is 
so important for developing Ebola vaccines and treatments?
    Mr. Fauci. Well, when you have a product that you want to 
develop, there is not a great incentive on the part of the 
pharmaceutical companies because it is a disease whose 
characteristics are not a large market. We had the experience 
when you are dealing with emerging and reemerging diseases, be 
it influenza or be it a rare disease that could either be used 
deliberately in bioterror or a rare disease like Ebola, that if 
you look prior to the current epidemic, there were 24 outbreaks 
since 1976. The total number of people in those outbreaks was 
less than 3,000. It was about 2,500. So we were struggling for 
years to get pharmaceutical partners ourselves who were doing 
the fundamental basic and clinical research, and then we did 
get some pharmaceutical partners like we have now with 
GlaxoSmithKline and the NewLink Corporation, which is the 
reason why we are now moving along. So that is one of the 
reasons why we have BARDA, so I showed that slide, Ms. Castor, 
with the NIH and the researchers at this end, and then you have 
to push the envelope further to the product to de-risk it on 
the part of the companies. Companies don't like to take risks 
when they don't have a----
    Ms. Castor. So can you quantify a timeline for an Ebola 
vaccine to be on the market? Is it feasible for any vaccines to 
be approved in time to assist in the current outbreak?
    Mr. Fauci. Well, your question has a couple of assumptions. 
The first is that the vaccine is safe and it works. The second 
is going to be, how long is this outbreak going to last at this 
level. If you look at the kinetics and the dynamics of the 
epidemic, it looks very serious. Our response to it--when I say 
``our,'' I mean the global response--has not kept up with the 
rate of expansion. If that keeps up as the CDC has projected, 
we may need a vaccine to actually be an important part of the 
control of the epidemic itself as opposed to what the original 
purpose of it was, to protect health care workers alone, but 
now if you have a raging epidemic--and to be quite honest with 
you, Ms. Castor, I cannot predict when that will be.
    If you have a lot of rate of infection, a vaccine trial 
takes a much shorter time to give you the answer. If it slows 
down, it is a much longer time. If you have a lot more people 
in your vaccine trial, it takes less time. If we have trouble 
logistically, which we might, of getting people into the trial, 
it might take longer. So I would like to give you a firm answer 
but we can't right now.
    Ms. Castor. In addition to the vaccines, part of 
controlling the virus is early diagnosis and treatment. I know 
there are some diagnostic tests that are being developed. Can 
you speak to the prospects of improved diagnostics that can 
assist in this outbreak?
    Mr. Fauci. Right. Well, there are a couple of us, and when 
I say ``us'' I mean agencies that are working on diagnostics. 
Dr. Frieden's group at the CDC has actually played a major role 
in leadership. We have several grants and contracts out to try 
and get earlier and more sensitive diagnostics.
    Ms. Castor. Thank you.
    Mr. Murphy. Thank you. I now recognize Mr. Gardner for 5 
minutes.
    Mr. Gardner. Thank you, Mr. Chairman, and I thank the 
witnesses for joining us today and the work that you are 
undertaking.
    Dr. Frieden, I want to clarify something that you had said 
earlier. I believe you mentioned that there are approximately 
100 to 150 people a day coming into the United States from the 
affected areas?
    Mr. Frieden. That is my understanding, yes.
    Mr. Gardner. And to Mr. Wagner, you had mentioned that we 
are screening 94 percent of those people?
    Mr. Wagner. As of today with the expansion to the four 
additional locations. That covers about 94 percent.
    Mr. Gardner. OK. So of the 100 to 150, 94 percent are being 
covered. That means that somewhere between 2,000 and 3,000 
people a year are coming into this country without being 
screened from the affected areas?
    Mr. Wagner. Well, they would undergo a different form of 
screening. We are still going to identify that they have been 
to one of those three affected regions, and we are still going 
to ask them questions about their itinerary. We are going to be 
alert to any overt signs of illness and coordinate with CDC and 
public health if they are sick, and we are also going to give 
them a fact sheet about Ebola, about the symptoms, what to 
watch for, and most importantly, who to contact----
    Mr. Gardner. Would we be checking their temperature?
    Mr. Wagner. We will not be checking their temperatures or 
having them fill out a contact sheet about----
    Mr. Gardner. So there are 2,000 to 3,000 people entering 
this country a year without checking their temperature, without 
having the contact sheet that 94 percent of those affected 
people----
    Mr. Wagner. They are going to arrive at hundreds of 
different airports throughout the United States.
    Mr. Gardner. OK. I want to talk a little bit more about the 
travel restrictions.
    Dr. Frieden, how many non-U.S. military flights, commercial 
flights, are currently going into the affected countries?
    Mr. Frieden. I don't have the exact numbers.
    Mr. Gardner. Does anyone on the panel know how many 
commercial flights are going into these areas? Mr. Wagner, you 
don't know?
    Mr. Wagner. From the United States or from anywhere?
    Mr. Gardner. From the United States into those areas.
    Mr. Wagner. There are no direct flights, commercial 
flights, from those three affected areas to the United States.
    Mr. Gardner. And into the area, into West Africa.
    Mr. Wagner. There are flights into West Africa.
    Mr. Gardner. How many?
    Mr. Wagner. That I don't have offhand.
    Mr. Gardner. Anybody on the panel know how many? How many 
coming back into the United States?
    Mr. Wagner. There are no commercial flights coming directly 
into the United States from those three areas.
    Mr. Gardner. And what about Europe?
    Mr. Wagner. There are hundreds of flights a day coming from 
there.
    Mr. Gardner. OK. So people traveling from West Africa to 
Europe to here?
    Mr. Wagner. That is generally how they would get here.
    Mr. Gardner. And 94 percent screening. How many flights are 
required daily, every other day, or weekly to get the supplies 
and personnel to the affected areas?
    Mr. Frieden. The quantity of supplies is quite large. I 
would have to get back to you in terms of the numbers. But 
there are huge quantities needed, but it is not just supplies. 
It is also personnel who need to move back and forth.
    Mr. Gardner. Well, if you could get back to me with that 
number, I would appreciate it.
    Now, Dr. Frieden, are you aware if Nigeria has a travel ban 
from the countries affected with the outbreak right now?
    Mr. Frieden. I believe that is not the case.
    Mr. Gardner. They do not? OK.
    Dr. Frieden, one of the issues that has been brought up 
regularly to me back in the district when I go home, what 
should I tell my local hospital and local doctors that they 
need to do to address Ebola?
    Mr. Frieden. The single most important thing they need to 
do is to make sure that if anyone comes in with fever or other 
symptoms of infection, they need to ask where they have been 
for the past 21 days and whether they have been in West Africa.
    Mr. Gardner. And the training that a small local district 
hospital would receive, is that the same kind that a major 
metropolitan hospital would receive?
    Mr. Frieden. There are a variety of forms of training. We 
support hospitals. Hospitals are regulated by States, not by 
CDC.
    Mr. Gardner. Dr. Frieden, what do we need to do? We are 
entering the flu season now, as somebody else on the panel had 
mentioned. What do we need to do to make sure that people 
understand that there could be similar conditions, similar 
circumstances so that we don't have a situation where people 
are indeed panicked?
    Mr. Frieden. The key issue, it is, as you point out, 
getting into flu season. By all means, get a flu shot. And for 
health care workers, any time someone comes in with a fever or 
other signs of infection, take a travel history. That is really 
important.
    Mr. Gardner. Dr. Frieden, I just want to go back to what I 
said at the beginning. You mentioned that we can't have a 
travel ban because you are afraid of the impact that it would 
have but you don't know how much personnel, equipment, and 
flights are currently in use.
    Mr. Frieden. My point earlier on was that, if passengers 
are not allowed to come directly, there is a high likelihood 
that they will find another way to get here and we won't be 
able to track them as we currently can.
    Mr. Gardner. But we are talking about supplies, equipment, 
and personnel, how many? How many flights? How many personnel? 
How much equipment?
    Mr. Frieden. The point I made earlier was if we are not 
able to track people coming directly, we will lose that ability 
to monitor them for fever, to collect their locating 
information, to share that with local public health authorities 
and to isolate them if they are ill.
    Mr. Gardner. Mr. Chairman, I yield back.
    Mr. Murphy. The gentleman's time is expired. Thank you. I 
now recognize Mr. Welch for 5 minutes.
    Mr. Welch. Thank you.
    I want to follow up on some of Mr. Gardner's questions. 
First of all, I want to understand this. There has been one 
person that came to the United States and then he infected two 
health care workers in Dallas, correct?
    Mr. Frieden. At this point, none of the 48 contacts he had 
before getting isolated have developed symptoms and they are 
mostly well past the maximum incubation period, although not 
completely out of the woods.
    Mr. Welch. All right. And for everybody on the panel, it is 
Code Red. We have had two instances of infection here in the 
United States, but this is such a highly contagious disease 
that we are on full alert, correct?
    Mr. Frieden. It is a very severe disease. It is not nearly 
as contagious as some other diseases, but any infection in a 
health care worker is unacceptable.
    Mr. Welch. That is right, and there is an enormous, 
enormous amount of public concern and apprehension about this 
so we appreciate the full-on efforts that you are making. There 
has been some lessons learned from what happened in Dallas. The 
hospital has been forthcoming about mistakes that were made, 
and now what you are telling us is that there has been 
information provided to all our hospitals in the country about 
what protocols to follow, correct?
    Mr. Frieden. Correct.
    Mr. Welch. Now, just on a practical level, is it feasible 
that all our hospitals are going to be in a position to provide 
state-of-the-art treatment or does it really as a practical 
matter make sense for hospitals to contact you when they have a 
potential infection for you to come and then for us to have 
centers to which that individual who is infected can be 
treated?
    Mr. Frieden. Every hospital needs to be able to think it 
may be Ebola, diagnose it, to call us as they do--we have had 
hundreds of calls--and then we will send a team to determine 
what is best for that hospital and that patient.
    Mr. Welch. And then what we have also heard--Ms. Schakowsky 
asked this question--this is absolutely a public health 
infrastructure issue where it gets out of hand, correct?
    Mr. Frieden. Public health measures can control Ebola.
    Mr. Welch. Right. And they have had effective measures in 
Nigeria where they have been able to contain it but they have 
no public health infrastructure in these three countries where 
the epidemic is now getting some headway, correct?
    Mr. Frieden. Exactly.
    Mr. Welch. And then in the United States, of course, we are 
fortunate to have a pretty good infrastructure but we do have 
to have an answer, I think, to this question that is being 
asked about travel. That is a concern that people have because 
it is seen as a quote, easy answer, and I just want to 
understand what the debate is within the medical community. For 
a lot of us sitting up here, we are hearing from our 
constituents. It sounds like something that we can do and that 
will eliminate any possibility of an infection coming here, but 
that may be a psychological answer but not necessarily an 
effective medical answer.
    All of us have been asking you to give your explanation, 
and anyone else can come in, as to why from a medical 
standpoint you have concluded that a total travel ban is 
inappropriate and not effective.
    Mr. Frieden. First off, many of the people coming to the 
United States from West Africa are American citizens, American 
passport holders, so that is one issue just to be aware of, 
but----
    Mr. Welch. All right. And then by the way, I don't have 
much time, but our health care workers, even if there some risk 
of infection, if we are going to encourage people to go and do 
the important work including our military personnel, we have 
got to take them back and make sure we can treat them if in 
fact they do get the illness, correct?
    Mr. Frieden. People travel, and people will be coming in.
    Mr. Welch. And as I understand it, you say there is 
basically a tradeoff. If you have a full-on ban, there is going 
to be ways around it and then you are going to lose the benefit 
of being able to track folks who may be infected and then that 
could lead to a greater incidence of outbreak, so it is a 
tradeoff. Is that essentially what is going on?
    Mr. Frieden. We are open to any possibility that will 
increase the safety of Americans.
    Mr. Welch. Right. So are there some midpoints that in terms 
of travel restrictions as opposed to a travel ban that may make 
sense to you in coordination with your colleagues, particularly 
Mr. Wagner?
    Mr. Frieden. We would look at any proposal that would 
improve the safety of Americans.
    Mr. Welch. All right. This isn't about funding so I am not 
going to ask you because I think we would know what your 
answers would be, but I just want to share my concern that was 
expressed by Ms. Castor.
    Mr. Chairman, we may want to have a hearing at some point 
about what is the funding requirements to make certain that the 
infrastructure this country needs to be in place before 
something happens is robust, it is strong, we have got people 
who are trained, they are ready to do the job and they have 
everything that they need. So that is not today's hearing but I 
think it is a question that we should address because with 20 
percent across-the-board funding at NIH, I find that to be a 
reckless decision with 12 percent at CDC. I think that is 
definitely the wrong direction. I think this Congress has to 
revisit our priorities on making certain that we have the 
public health infrastructure to be prepared to protect the 
American people.
    Mr. Murphy. If I could just say, we are planning a second 
hearing, and in preparation for that we will also ask if NIH 
does have the flexibility now to transfer funds as well as HHS.
    I now recognize Mr. Griffith for 5 minutes.
    Mr. Griffith. Thank you, Mr. Chairman.
    I believe we should have reasonable travel restrictions. 
Dr. Frieden, in answering a question of my colleague from 
Colorado, Mr. Gardner, you indicated that Nigeria didn't have 
any restrictions, and that is accurate, but I have in my 
possession, and I would ask that it be submitted to the 
committee for the record, a letter from delegate Robert G. 
Marshall of Manassas, Virginia, to Governor Terry McAuliffe, 
Governor of the Commonwealth, and in that he cites the 
International SOS, a prominent medical and travel security 
services company with more than 700 locations in 76 countries, 
reports that African countries have imposed total air, land, 
and water travel bans by persons from countries where Ebola is 
present. The countries include Kenya, Cape Verde, Cameroon, 
Mauritius, South Sudan, Namibia, Gambia, Gabon, Cote d'Ivoire, 
Rwanda, Senegal, Chad and Kenya. South African development 
community members, 14 countries, only allow highly restricted 
entry from Ebola-affected regions with monitoring for 21 days 
and travel to public gatherings discouraged.
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    Mr. Griffith. I find that interesting, Dr. Frieden, because 
some of those countries have had previous outbreaks of Ebola 
themselves. Wouldn't you agree that some of those countries 
have had to face Ebola before?
    Mr. Frieden. I would have to check the list carefully to 
know, but I will take your word for it.
    Mr. Griffith. All right. I will tell you that this is a 
concern to a lot of our constituents and to mine as well, and I 
was checking my Facebook page recently when I saw that a 
Facebook friend of mine, a father from Virginia, asked for 
prayers for his daughter because she lives in the apartment 
complex with the first nurse, Nurse number one, as I think 
somebody referred to earlier, and was very concerned, and while 
I think I know the answer, I would like to get your answer so 
that I can reassure this father and that is, his question is, 
if I count to 21 days and my daughter is not infected, at that 
point can I exhale and breathe a sigh of relief?
    Mr. Frieden. Not only can he do that but he can do that now 
because the first nurse only exposed one person, one contact, 
and that was only in the very early stages of her illness, so 
at most, one person from the community was exposed.
    Mr. Griffith. And I appreciate that. He also asked a second 
question. He said there is some suggestion coming out of Dallas 
that the patient's dog may be infected and may have infected 
other dogs through actual contact or by feces. Can the virus be 
transmitted by dogs? And I will tell you that I did some 
homework on this because I thought it was an interesting 
question and found a CDC publication from March of 2005 that 
did a study on dogs in Africa in the affected areas and a study 
in France as a control group, and they found that while dogs 
show antibodies for Ebola, they are asymptomatic, but the study 
went further to say that there is really a lot of questions 
about how Ebola is transmitted, and in some instances, Gabon in 
1996 and 2004, Republican of Congo likewise in 2004 and the 
Sudan, that there is a question mark as to whether or not, or 
how that Ebola outbreak occurred. It wasn't in the normal or 
standard ways. It wasn't human to human. And this report 
indicates that dogs might be--might be--I don't want to scare 
folks--might be suspect.
    I guess my question to you is, isn't it true that we really 
don't know a whole lot about the various outbreaks of Ebola and 
so when we are trying to assure the American people just like 
previously we didn't think it would come to this country and 
then we thought if it did get to this country, we wouldn't have 
any problems controlling it. Now we have got all kinds of 
people being monitored. Isn't it true there are still a lot of 
questions about how Ebola is spread?
    Mr. Frieden. Although we are still learning a lot about 
Ebola and every other organism that we study and that we 
control, we have a lot of information about Ebola. We have a 
good sense of how it is controlled, and we have looked at the 
issue of exposure to animals. We know that in parts of Africa, 
consumption of forest-living animals can be a cause. We don't 
know of any documented transmission from dogs to humans, but 
that is why the authorities with our agreement have quarantined 
a dog, and we are helping them to assess that situation.
    Mr. Griffith. And it is also true that while we have no 
evidence of transmission from human to dogs, we really don't 
know if there can be. We have what we call in the law--I used 
to be a lawyer--you have a lack of evidence as opposed to 
negative evidence. We don't have clear evidence that you can't 
transmit it either. And what is interesting is, that raised the 
question for me about, OK, we have got no restrictions on 
travel of human beings, how about the dogs? I called Customs. 
They said, well, our experts are there, and then after pushing 
them a little bit, they said that is USDA. We call USDA, and 
Dr. Frieden, they said that would be CDC.
    So I understand all your reasons, and while I don't agree 
with completely, I understand the concerns about 
humanitarianism, et cetera, but don't you think we ought to at 
least restrict travel of dogs?
    Mr. Frieden. We will follow up in terms of what is possible 
and indicated.
    Mr. Murphy. I now recognize Mr. Yarmuth for 5 minutes.
    Mr. Yarmuth. Thank you, Mr. Chairman, and before I begin my 
questioning, I would like to submit for the record an article 
titled ``Will America's fragmented public health system meet 
the Ebola challenge?'' by Mark Rothstein, who is the Director 
of the Institute of Bioethics at the University of Louisville 
Medical School. I would like to submit that for the record. 
Thank you.
    [The information follows:]
   
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    Mr. Yarmuth. I would like to thank the panel for their 
testimony and answering the questions, and this has been a very 
enlightening hearing. I also want to acknowledge at the 
beginning that the Kentucky Air National Guard, which is based 
in my district, is in Senegal right now providing the 
infrastructure for the 101st in their efforts, so I want to 
acknowledge their participation in this effort.
    At the risk of displaying my ignorance, we apparently know 
that you cannot detect the Ebola until the same time it becomes 
symptomatic when it becomes contagious. Is there any other kind 
of test that would indicate whether anything is going on in the 
body? I know that sometimes my doctor will say, well, you have 
got an elevated white blood cell count, something is going on 
there, and may not know exactly what it is. Is that true of the 
Ebola or would that not indicate that something is going on?
    Mr. Frieden. At this point we don't have a test that would 
identify it before someone has symptoms. In fact, the test only 
turns positive when they are sick, and the test is for the 
virus itself and that is why--that is another reason besides 
the patterns of disease that we are confident that it doesn't 
spread. We can't even find tiny amounts of it in people's 
bodies until they get sick.
    Mr. Yarmuth. Is there any research being done as to a 
possible test, earlier test for this?
    Mr. Frieden. There is a lot of research being done to try 
to understand and diagnose and treat and prevent better.
    Mr. Yarmuth. Good. I am a media person by background. That 
is where I spent most of my career, so I am very sensitive to 
how the media treat situations like this, and certainly the 
media can be a very important part of providing public 
information about a potential threat to public safety as this 
is. But they can also go overboard, as we know, and I am 
curious because I see every day comments in the media about the 
spread of Ebola and outbreaks of Ebola, and while yes, 
technically it has spread from one person to two health care 
workers, I know that the public may hear that very differently 
and perceive there to be a much broader and widespread incident 
of Ebola in the country, and I see things like, for instance, 
in the Washington Post today the picture of the woman at Dulles 
Airport who looks like she is mummified because of her concern 
of contracting Ebola, and I know that now one survey showed 98 
percent of the American people are aware of the Ebola situation 
and not even 50 percent know there is an election coming up in 
3 weeks. So the media has certainly let the public know that 
there is something going on.
    My question to you is, has the media coverage so far been 
helpful or harmful in your efforts to have the public have an 
appropriate concern and awareness of what the situation is?
    Mr. Frieden. Well, anytime health care workers become 
infected and ill in this country, it is unacceptable, and our 
thoughts are with the two infected health care workers in 
hoping for their recovery. So it is certainly understandable 
that there is intense media interest. It is new to the United 
States. It is a scary disease, had a movie made about it, and 
it is important to have that attention so that we as a society 
pay attention, and doctors in hospitals and community health 
clinics, and primary care practices think of the possibility of 
Ebola that we generate the societal will and resources to both 
protect Americans and stop it at the source because it has got 
to be stopped at the source to make us completely safe.
    Some of the coverage, I think many would agree, may 
exaggerate the potential risks or may confuse people about the 
risks. There really is a lot we know about Ebola. CDC has an 
entire branch, entire group of professionals who spend their 
careers working on Ebola and other similar infections. They go 
out and stop outbreaks all the time. We have stopped every 
outbreak of Ebola until the current one in West Africa. There 
is zero doubt in my mind that barring a mutation which changes 
it, which we don't think is likely, there will not be a large 
outbreak in the United States. So I think we welcome the 
attention. It would be important at times to put it in 
perspective.
    Mr. Yarmuth. I appreciate that. I agree totally.
    One final question in the last 30 seconds. Is there any 
additional authority that CDC would find more helpful in 
conducting or meeting the responsibilities? I know most of 
yours is guidance and information, but is there any specific 
authority that Congress could grant you that would make it 
easier for you to do your job?
    Mr. Frieden. We are looking at a variety of things, 
emergency procurement, for example, to see in conjunction with 
the administration whether there are some changes that might 
allow us to respond more quickly and effectively.
    Mr. Yarmuth. Thank you. I yield back
    Mr. Murphy. I recognize Mr. Johnson for 5 minutes.
    Mr. Johnson. Thank you, Mr. Chairman, and Dr. Frieden, 
thank you for being here. I thank all of you on the panel for 
being here today.
    You know, this is not about politics, it is not about 
international diplomacy. It is about public health and 
protecting the public safety of the American people 
particularly our health care workers, who if I understood 
correctly, you have acknowledged are some of the high-risk 
folks to be exposed.
    You know, one of my main concerns, Dr. Frieden, is that we 
don't know what we don't know. Throughout testimony and 
questioning today, I have heard you say multiple times ``I 
don't know the details of this, I don't know the details of 
that,'' and I think what the American people are wanting is 
some assurance that somebody does know the details.
    So let me ask you a question. Do we know yet how the two 
health care workers in Dallas contracted the virus? Was it a 
breakdown in the protocol? Was it a breakdown in the training 
of the protocol? Do we know whether or not the protocol works?
    Mr. Frieden. The investigation is ongoing. We have 
identified some possible causes. We are not waiting for the 
investigation to be completed----
    Mr. Johnson. So we don't know?
    Mr. Frieden. We are immediately----
    Mr. Johnson. OK.
    Mr. Frieden [continuing]. Going to take safety measures.
    Mr. Johnson. I get that. We don't know. You know, the 
people in Ohio are concerned, especially now that we know that 
one of those health care workers traveled through Ohio, even 
spent some time in Akron with family members. I applaud 
Governor Kasich's immediate actions to try to address the 
situation.
    You know, in my experience as a military war planner, 26 
\1/2\ years in the military, and I know we have got military 
engaged in this process overseas, we don't wait until the 
bullets start flying to figure out whether our war plan is 
going to work.
    Dr. Frieden, when did the CDC find out that there was an 
outbreak of Ebola in West Africa?
    Mr. Frieden. Late March.
    Mr. Johnson. Late March. One of the things that we do in 
the military is that we conduct what is called operational 
readiness inspections. We give real-world scenarios in 
controlled environments, no notice so that those who are going 
to be responsible for executing a war plan know what to do when 
the first shot is fired, no panic, no second guessing; they 
know what to do. Has the plan to address an Ebola outbreak ever 
been tested by the CDC in a real-world environment?
    Mr. Frieden. Not only has the plan been tested but outbreak 
control has been done multiple times in parts of Africa. What 
had not been done is in this part of Africa which had never 
seen----
    Mr. Johnson. No, I am talking about here in America.
    Mr. Frieden. In America also we do a series of preparedness 
plans, for example----
    Mr. Johnson. Do you know of any hospitals in eastern and 
southeastern Ohio that have participated in any kind of real-
world scenario of an Ebola outbreak?
    Mr. Frieden. I can't speak to that specific example, no.
    Mr. Johnson. OK. Let me go a little bit further. You 
mentioned earlier that 150 per day roughly are coming in from 
West Africa. I think Mr. Wagner indicated 94 percent screening. 
Let me give you a scenario. Let us say a person comes in to the 
country from West Africa, and let us assume that everything in 
the screening process works right. They are maybe in day 14 of 
having been exposed to Ebola in West Africa. They show up here 
in America with no symptoms. They go through the screening 
process, and so they go on about wherever they go--Akron, 
Cleveland, Cincinnati, Los Angeles, wherever. Day 17 or 18 they 
start getting ill and they start seeing a spike in their 
temperature. If they walk into any emergency room in Appalachia 
Ohio and start throwing up, having symptoms, does your plan 
identify that and does your plan tell that hospital emergency 
room what to do in that scenario? They don't know that person 
came from Liberia or any other place.
    Mr. Frieden. We have detailed checklists and algorithms 
that we have distributed widely, provided repeated training and 
information so that health care providers throughout the 
country have a detailed checklist of what to do step by step by 
step to determine whether the person has Ebola, if they do, to 
call for help and we will be there.
    Mr. Johnson. Mr. Chairman, I yield back.
    Mr. Murphy. Thank you. Mr. Green is next in line, but we 
are looking for him, so Mr. Matheson is next for 5 minutes.
    Mr. Matheson. Well, thank you, Mr. Chairman. I have a 
number of questions. I will try to move through them quickly.
    Dr. Frieden, as was mentioned by a couple people in their 
opening statements, it strikes me that controlling the outbreak 
in West Africa is really one of the real key issues to keeping 
Americans safe. There are reports that indicate we may still be 
losing some ground in Liberia, so I guess I would ask the 
question, what would enhance the international community's 
ability to gain control of the situation in West Africa in 
terms of actions and resources?
    Mr. Frieden. The fight against Ebola in West Africa is 
challenging. The health systems are weak. What we are finding 
is that it is moving quickly and there is a real risk it will 
spread to other parts of Africa. Therefore, the key ingredient 
to progress there is speed. Because the outbreak is increasing 
so quickly, the quicker we surge in a response, the quicker we 
blunt the number of cases and the risk to other parts of the 
world including the United States decreases.
    Mr. Matheson. And are you resource-constrained in that 
context?
    Mr. Frieden. Congress has provided money or approval or 
agreement to use money for the Department of Defense. USAID has 
resources going in. At CDC, we received through an anomaly $30 
million for the first 11 weeks of this fiscal year, which we 
appreciate.
    Mr. Matheson. Let me ask you, you have a number--CDC has an 
unprecedented number of people in the field right now in West 
Africa and in Texas. How many people do you have deployed doing 
airport screenings?
    Mr. Frieden. I would have to get back to you with the exact 
number. We are working both to oversee the screenings in West 
Africa and make sure they are done correctly and to screen 
individuals here, collect information on them and transfer that 
information----
    Mr. Matheson. I need you to get that number and also find 
out if those resources are best used there or elsewhere with 
your limited number of people. That would be interesting to 
hear.
    Following up on Mr. Yarmuth's questioning, is there a 
development of a more rapid test to determine if someone has 
Ebola than what we use today?
    Mr. Frieden. A more rapid test would be very helpful. The 
U.S. Navy has a pilot test in development. We are currently 
testing that in parts of West Africa. It is simpler, quicker 
and would be very helpful, even if it isn't quite as sensitive 
in West Africa, but we are working with a number of commercial 
manufacturers also on a more rapid test than there is 
currently.
    Mr. Matheson. It seems to me that when it comes to 
infection control and prevention and hospital epidemiology 
standards, I think they vary widely from hospital to hospital 
in this country. What legislative or regulatory actions could 
strengthen these systems? I mean, how can we reduce this 
variability among hospitals in our country?
    Mr. Frieden. Infection control in our hospitals generally 
is a challenge and something that CDC works hard with hospitals 
and State health departments and State governments to improve. 
Hospitals are regulated by the States within which they 
operate, and the issue of what could be done to improve 
infection control is complex. CDC has a large hospital 
infection prevention program, and there we support regional 
efforts to share lessons and figure out new ways to do things 
better to prevent infection, and that kind of center-of-
excellence model is a very important one.
    Mr. Matheson. But you are suggesting that while you can 
provide the information and the expertise and the guidance, the 
actual implementation and responsibility is still a State 
function more than a Federal function. Do you think we should 
be looking at that issue?
    Mr. Frieden. In the United States, we have a federalist 
system. The CDC provides information and input. There are 
roughly 5,000 hospitals in the country. We are not a regulatory 
agency.
    Mr. Matheson. Right. One other line of question. There is 
no good news about Ebola, but at least it is not transmitted as 
an airborne entity. It is clear that we don't want to 
underestimate its ability to be transmitted, and while the 
focus is on Ebola and rightly so for this hearing, there are 
other airborne transmissible pathogens that ought to be of 
great concern to everyone including this Congress that exist 
around the globe today, MERS being one of them. Is this 
experience we have had with Ebola, how do we learn from it to 
make sure we are prepared for other human-to-human-
transmissible pandemics that may be a higher rate of 
transmission than Ebola?
    Mr. Frieden. I think there are two major lessons, first, to 
prevent it at the source. If we had had the basic public health 
system in place in these three countries a year ago to find it, 
stop it, and prevent it, it would be over already, and second, 
within our country, to continue to support hospital 
preparedness, community preparedness and fundamentally the 
public health measures to find, stop and prevent health 
threats.
    Mr. Matheson. OK. Thanks, Mr. Chairman.
    Mr. Upton [presiding]. Mr. Long is recognized for 5 
minutes.
    Mr. Long. Thank you, Mr. Chairman, and today we have 
referred to--people on the panel, people up here have referred 
to Nurse One and Nurse Two, and these are two young women that 
have dedicated their lives to helping other people, sick 
people, and to refer them as Nurse One and Nurse Two just 
doesn't set well with me. It is kind of reminiscent of Dr. 
Seuss Thing One and Thing Two. These are not things. So for the 
record, I would like to state that the first nurse to contract 
Ebola was Nina Pham, and the second nurse was Amber Joy Vinson. 
These are young women with families. I know one in particular 
has a fiance. And so I think that it would serve as well to 
remember that these are human beings that have dedicated--young 
women that have dedicated their lives to helping other people, 
and for them and nurses everywhere and their families, I would 
just like to open with that.
    Dr. Frieden, you said in your testimony earlier that only 
by direct contact can you contract Ebola. Do you stand by that 
statement?
    Mr. Frieden. Direct contact with someone who is ill or died 
from Ebola or their body fluids.
    Mr. Long. And it is not airborne, Congressman Matheson just 
said, and you agreed it is not an airborne--cannot be 
contracted airborne.
    Mr. Frieden. Ebola spreads person to person, not by the 
airborne route, so it is not like----
    Mr. Long. Do you need personal contact?
    Mr. Frieden. Yes.
    Mr. Long. If you need personal contact with bodily fluids, 
why is there an airliner in the Denver Airport right now that 
Frontier Airlines has scrubbed four times? Aren't they wasting 
money? Why can't they get that back into service? If you have 
to have bodily contact, close contact, why scrub that airliner?
    Mr. Frieden. I understand that people are very concerned 
about Ebola. It is a scary disease. I can't comment----
    Mr. Long. So it is just for public perception? I mean, they 
really don't need to be doing that, right?
    Mr. Frieden. We have detailed guidelines along with the EPA 
for how to clean airliners.
    Mr. Long. Do you need a fever to be contagious?
    Mr. Frieden. You need to be sick. Generally the first 
symptom of illness is fever.
    Mr. Long. So do you need a fever to be contagious?
    Mr. Frieden. Late in the disease when people are deathly 
ill, they may not have fever but they would be likely be unable 
to walk at that point.
    Mr. Long. This 21-day period that you need to show symptoms 
within 21 days from exposure, during that period could you be 
contagious the third day of that point?
    Mr. Frieden. Only if you were sick, only if you had 
symptoms.
    Mr. Long. OK. And the incubation period is anywhere from 
zero to 21 days?
    Mr. Frieden. Two to 21 days, generally within the first 10 
days or so.
    Mr. Long. You said here today that there are 100 to 150 
people a day coming from West Africa into the United States. 
You are opposed to travel restrictions, which the constituents 
in the 7th District in Missouri are very much in favor of 
travel restrictions. I predict you are going to put on or the 
President is going to put on travel restrictions. I don't know 
if it is going to be today or tomorrow or 2 weeks or a month 
from now but I think that they are coming and I think sooner 
rather than later. If there are 150 a day, and you rationalize, 
well, we don't really need to worry about that because they 
could get across borders, they could go by land and then get 
here. With that 100 to 150 a day, don't you think that number 
might be reduced to five or ten a day if we did put on travel 
restrictions?
    Mr. Frieden. I can't comment on what numbers would----
    Mr. Long. If someone had to make an effort other than going 
out to their local airport and jumping on a plane, if they 
really had to try to get here, don't you think that number 
would dramatically drop?
    Mr. Frieden. I know that people do come back, and right now 
we are able to screen them, collect their information----
    Mr. Long. What if they don't come back? A lot of people 
come in this country and we lose track of them. They don't come 
back. What happens then? My point is, if you have got 150 a day 
coming in or you have five coming in a day, I and my 
constituents would rather have five a day coming in, and this 
thing of checking for temperatures like it is going to help is 
kind of like scrubbing a plane that doesn't need to be 
scrubbed.
    But I would like to recommend the folks reading this copy 
of Bloomberg Business Week ``Ebola is coming, coming to 
America. The United States had a chance to stop the virus in 
its tracks but it missed.'' That issue came out before Mr. 
Duncan came to this country and before he was diagnosed with 
Ebola. There is some good reading in there that I would 
recommend.
    I would also recommend to you if you want to Google a 
hospital from hell, it is swamped by Ebola in the New York 
Times just a few days ago, hospital from hell, if you get a 
chance to read that. I think that everyone would be in favor of 
the travel restrictions we have talked about here today, and 
today OSHA, Occupational Safety and Health Administration, just 
today said that Customs and Border Patrol immigration 
enforcement agents are at risk of coming into contact with 
Ebola.
    Mr. Wagner, are we prepared for that? Are your agents, are 
they protected to the fullest extent what they need?
    Mr. Wagner. We----
    Mr. Long. This just came out today.
    Mr. Wagner. We issue them personal protective gear and we 
train them on how to wear it and what circumstances to wear it, 
but they encounter all different kinds of travelers with a 
whole host of different potential communicable diseases. So you 
know, we are aware and we do train to recognize signs of overt 
illness and we have the protocols with health professionals to 
get those travelers into that care and to protect our 
employees.
    Mr. Long. To me, they fall in the same category of the 
nurses. They are there to save us and help people and protect 
people in this country, so God bless, and I will yield back.
    Mr. Upton. The gentleman's time has expired. The gentlelady 
from North Carolina, Mrs. Ellmers.
    Mrs. Ellmers. Thank you so much, Mr. Chairman, and I have a 
number of questions.
    I would like to start with Dr. Varga in regard to the two 
nurses that were exposed. My understanding is, one of the 
nurses, the first nurse, Ms. Pham, was exposed in the emergency 
room. Is that correct?
    Mr. Varga. I am sorry. Could you repeat the question, 
please?
    Mrs. Ellmers. The first nurse was exposed in the emergency 
room. Is that correct?
    Mr. Varga. No, that would not be correct. Nina was one of 
our ICU nurses and came in contact with Mr. Duncan when Mr. 
Duncan was transferred from the emergency department up to the 
ED.
    Mrs. Ellmers. So that was sometime from September 28th to 
the 30th. Is that correct?
    Mr. Varga. That is correct.
    Mrs. Ellmers. OK. And then the second nurse, Ms. Vinson, 
was she also an ICU nurse?
    Mr. Varga. That is correct.
    Mrs. Ellmers. OK. So they were exposed after the point that 
we would have already started recognizing that Ebola was being 
questioned. Is that correct?
    Mr. Varga. No, that is not correct. The nurses in the MICU 
from the time they had first contact with Mr. Duncan were in 
personal protective equipment according to the CDC guidelines. 
Nina cared for Mr. Duncan----
    Mrs. Ellmers. OK. Dr. Varga, I am going to stop you right 
there. So they were already using universal precautions but 
also were using some of the more isolation? And just answer yes 
or no.
    Mr. Varga. Yes.
    Mrs. Ellmers. OK. To that, I would like to move on to Dr. 
Frieden. On October 6th, I sent a letter to the CDC, to CBP, 
and HHS calling for travel restrictions. So there is no 
question I believe travel restrictions need to be put in place, 
and now after having this subcommittee hearing, I believe even 
more strongly that we need them, and I just want to back up to 
a couple questions for Dr. Frieden and Dr. Fauci. Are there 
multiple strains of Ebola?
    Mr. Frieden. There are five different subspecies. This 
outbreak is one particular subspecies, Ebola Zaire, and all of 
the strains that we have seen have been closely related.
    Mrs. Ellmers. OK. So we know that it is isolated to one 
particular strain?
    Mr. Frieden. Yes.
    Mrs. Ellmers. Now, you had mentioned, and I believe the 
quote was, ``unless it mutates, there will not be an outbreak 
here in the United States.'' Is that correct?
    Mr. Frieden. There will not be a large outbreak here 
barring a mutation.
    Mrs. Ellmers. Well, the question I have is, when the nurses 
were using the protective gear then, how is this that this has 
happened? It tells me that something is changing here, and are 
we currently looking into this situation right now?
    Mr. Frieden. We are absolutely looking for other mutations 
or changes. What we have seen is a very little change in the 
virus. We don't think it is spreading by any different way.
    Mrs. Ellmers. And you have already said a couple of times 
that you don't believe that this is airborne, and yet I know 
how nurses are. I was one for 21 years before coming to 
Congress. You are protecting yourself. You are protecting your 
patient. You are protecting your family. They followed 
precautions, I am sure, and now we are having this 
conversation, and I am very concerned about that.
    Mr. Frieden. We are confident that this is not airborne 
transmission. These nurses were working very hard. They were 
working with a patient who was very ill, who was having lots of 
vomiting, lots of diarrhea. There was a lot of infectious 
material, and the investigation is ongoing but we immediately 
implemented a series of measures to increase the level of 
safety.
    Mrs. Ellmers. OK. I am going to move on.
    Dr. Borio, in the discussion of fast tracking a test for 
Ebola, where is the FDA on that? Is there a fast-track process 
right now that you know of?
    Ms. Borio. For diagnostic tests?
    Mrs. Ellmers. Yes.
    Ms. Borio. So there are three diagnostic tests that are 
authorized for use under our EUA authorities, and we have also 
taken some practice steps by contacting manufacturers, 
commercial manufacturers, who we know have potential interest 
in technologies to be brought to bear here, and we reached out 
to a handful who might be interested in working with us.
    Mrs. Ellmers. OK. So you are in the process of looking 
towards a fast-track process?
    Ms. Borio. Yes. We would expedite every such test.
    Mrs. Ellmers. Great. Thank you.
    And then Dr. Frieden, lastly, I am speaking on behalf of my 
constituents and every American in this country. I just don't 
believe that it is acceptable that the quote that you had given 
us, ``we won't be able to track them,'' is the reasoning for 
why we should not implement travel restrictions. I do believe 
we can, and Mr. Wagner, as far as our Customs and Border 
Patrol, do you believe that there is a way that we can 
implement tracking?
    Mr. Wagner. Tracking?
    Mrs. Ellmers. Tracking of individuals if we do not allow 
them to come----
    Mr. Wagner. Yes, we have ways to determine a person's 
itinerary and travel history through the questioning or review 
of the passport. It is easier when they are coming on a direct 
ticket from those places----
    Ms. Ellmers. True, but as you pointed out, they are coming 
from----
    Mr. Murphy. The gentlelady's time is expired.
    Mrs. Ellmers. Thank you, Mr. Chairman. I thank you for 
indulging my overtime here.
    Mr. Murphy. I now recognize Mr. Scalise for 5 minutes.
    Mr. Scalise. Thank you, Mr. Chairman. I appreciate you 
holding this hearing, and I want to thank all of the panelists 
for coming and participating, and I have talked to a number of 
health care professionals as well as many constituents and 
listened to the panel as well. I want to join with Chairman 
Upton in urging the President to immediately institute a travel 
ban until such time that they can firmly and scientifically 
prove that Americans are safe from having more Ebola patients 
coming into the United States, and Dr. Frieden, you expressed 
disagreement with that. Have you all had any conversations 
within the White House about a travel ban and whether or not 
the President has the authority, because many of us have said 
the President does have the authority to do it today.
    Mr. Frieden. From the point of view of CDC, we are willing 
to consider anything that will reduce risk of----
    Mr. Scalise. But have you considered that and have you 
ruled it out or have you not considered it at all? Have you had 
conversations with the White House about a travel ban? That is 
a yes or no question. Have you had conversations with the White 
House about a travel ban?
    Mr. Frieden. We discussed many aspects----
    Mr. Scalise. How about a travel ban? Have you had that 
conversation----
    Mr. Frieden. We have had discussions on the issue of travel 
to and from West Africa.
    Mr. Scalise. And have you all ruled it out?
    Mr. Frieden. I can't speak for the White House. I can tell 
you that----
    Mr. Scalise. You can speak for the CDC. If you were in 
those conversations, maybe they had their own conversations 
without you but if you were involved in conversations with the 
White House about a travel ban, did they rule it out? Are they 
still considering it?
    Mr. Frieden. From the CDC's perspective, we will consider 
anything that will better protect----
    Mr. Scalise. So are you going to answer the question about 
your conversations with the White House? Is the White House 
considering a travel ban?
    Mr. Frieden. I can't speak for the White House.
    Mr. Scalise. Do you know if they have ruled out a travel 
ban?
    Mr. Frieden. I can't speak for the White House.
    Mr. Scalise. Have you had conversations with them about it?
    Mr. Frieden. We have discussed the issue of travel.
    Mr. Scalise. All right. I would urge you at a minimum, if 
you have ruled out a travel ban, if you don't think it is the 
right way to go, there are a lot of people that would disagree 
with you. At a minimum, you ought to look at least immediately 
suspending visas to non-U.S. nationals seeking to travel into 
the United States from Sierra Leone, Liberia, and Guinea. Have 
you all considered that or discussed it or ruled it out?
    Mr. Frieden. At CDC, our authority is to quarantine 
individuals who require isolation.
    Mr. Scalise. But earlier you said you don't think there 
should be a travel ban. What about at least looking at 
suspending visas to non-U.S. citizens? Have you looked at that?
    Mr. Frieden. CDC doesn't issue visas.
    Mr. Scalise. But you can make a recommendation to the White 
House that it would be in the best interest of the American 
people to have that kind of suspension issue, can't you? Are 
you not aware of that?
    Mr. Frieden. We would certainly consider anything that will 
reduce risk to Americans.
    Mr. Scalise. Let me ask you this. Do you have a high level 
of confidence that our U.S. troops that are over there right 
now--I have got estimates that are around 350 U.S. troops are 
already in those three affected countries. Up to 3,000 troops 
are going to be sent over by President Obama. Do you have a 
high level of confidence that those U.S. troops are protected 
with all the protocols in place so that they will not contract 
Ebola?
    Mr. Frieden. We have worked very closely with DoD on their 
protocols and----
    Mr. Scalise. So do you have a high level of confidence that 
they are protected?
    Mr. Frieden. I would not say that there is zero risk. They 
are in those countries but they are not participating in high-
risk activities that----
    Mr. Scalise. Are you consulting with DoD? Who establishes 
the protocols in that case? Is the CDC involved in that?
    Mr. Frieden. They are following the CDC's protocols but 
they follow their own----
    Mr. Scalise. Let me ask you about the protocols because I 
have read reports that some people with some of the other 
organizations that have been over there for a while--you have 
got the group Samaritan's Purse, a gentleman by the name of 
Sean Kaufman, who is involved with some of the doctors that 
have been over there that have gotten infected. They have been 
working for decades in some cases. He said that he warned your 
agency that the guidelines that you had on Ebola were lax and 
his response was, ``They kind of blew me off,'' meaning your 
agency blew him off when he was warning you that your protocols 
were lax. Are you aware of that?
    Mr. Frieden. I saw that quotation. We take all 
suggestions----
    Mr. Scalise. Have you identified who blew him off in your 
agency?
    Mr. Frieden. I don't know that that occurred.
    Mr. Scalise. Well, I would hope that you would go and find 
out because there is a real concern. You know, one of the 
biggest concerns I get from the hospitals in my district that I 
have talked to, and I have talked to a number of hospital 
officials, medical officials, professionals in my district. 
They are concerned that they haven't had consistent protocols. 
There has been at least four just in the last few weeks where 
the protocols keep changing. Now, with the nurse, the first 
nurse that was infected, I believe you personally said that the 
protocols were breached originally. Have you backed away from 
that?
    Mr. Frieden. We are looking at what might----
    Mr. Scalise. You said the protocols were breached. Were the 
protocols breached with the first nurse that was infected? Yes 
or no.
    Mr. Frieden. Our review of the records suggests that in the 
first few days of----
    Mr. Scalise. If you didn't know for a fact, you shouldn't 
have said it.
    Mr. Murphy. The gentleman's time is expired.
    Mr. Scalise. Do you withdraw that statement, or do you 
still stand by the statement that protocols were breached by 
the first nurse?
    Mr. Frieden. There was a definite exposure that resulted--
--
    Mr. Scalise. Were protocols breached, yes or no?
    Mr. Murphy. The gentleman's time is expired.
    Mr. Scalise. Yield back.
    Mr. Murphy. Thank you.
    It is the tradition of this committee that the ranking 
member and the chairman have a final 2-minute wrap-up. Ms. 
DeGette, 2 minutes.
    Ms. DeGette. Dr. Frieden, would it be fair to say that it 
looks like the first nurse, Ms. Pham, was exposed in the first 
couple of days before the diagnosis came in?
    Mr. Frieden. That is our leading hypothesis at this point.
    Ms. DeGette. Thank you.
    Now, Dr. Varga, we have still got you, I hope.
    Mr. Varga. Yes, I am here.
    Ms. DeGette. Have you now seen my chart from the New York 
Times about the protective gear?
    Mr. Varga. Yes, ma'am.
    Ms. DeGette. Do you know which of these types of protective 
gear Ms. Pham and the other health care workers were wearing 
during those first 2 days?
    Mr. Varga. Ms. Pham would have been wearing or Nina would 
have been wearing the second garb. The folks in the ED most 
likely would have been wearing the first picture.
    Ms. DeGette. OK. Thank you. So it is your testimony you 
don't really know how Ms. Pham was--well, either one of these 
wonderful nurses were exposed. Is that correct?
    Mr. Varga. That is correct.
    Ms. DeGette. OK. I just want to say one last thing. I think 
that we have had a lot of discussion today about a lot of 
issues, and my takeaway is this--and Dr. Frieden, I am going to 
make a statement and I would ask you to comment on it. It seems 
to me that, aside from trying to stop this Ebola in Africa, the 
thing we can do here is, number one, we can give better 
training to the people in our emergency rooms and our first 
responders, not just send them out emails or bulletins. Number 
two, we can have more robust protective gear at an early stage 
if somebody looks like they might have a risk for Ebola, and 
number three, I think it might be really useful to put CDC on 
the ground much earlier. Here, they didn't come into this 
Dallas hospital until after the diagnosis. So there were 2 days 
when people were moving in and out of Mr. Duncan's room, and we 
don't know exactly what happened. Dr. Frieden, could you 
comment very briefly on that?
    Mr. Frieden. I will agree completely on the training. We 
are looking very carefully at the personal protective equipment 
issue. We consult immediately every time, and there have been 
more than 300 consultations for hospitals that have thought 
they might have a patient with Ebola. Only Mr. Duncan was 
confirmed to have Ebola.
    We can't be everywhere. Everyone has to do their part but 
we will do everything we can to support the front lines.
    Ms. DeGette. And Mr. Chairman, I would ask for both this 
protective gear chart and also our map of the flights to be 
included in the record, and I would also ask----
    Mr. Murphy. Without objection.
    [The map follows:]
  
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    Ms. DeGette. I would also ask all of our witnesses if they 
would continue to keep this committee updated as to changes in 
procedures or developments that are made as we go along, and I 
would ask unanimous consent to put in the other members' 
opening statements in the record.
    Mr. Griffith. Mr. Chairman, I had previously asked for 
unanimous consent for the letter that I quoted from.
    Mr. Murphy. Yes, that was granted.
    Mr. Griffith. I don't think we ever agreed on it but----
    Mr. Murphy. It is so ordered.
    Mr. Griffith. Thank you.
    Mr. Murphy. I now recognize myself for a final 2 minutes.
    So having listened to all your testimony, a couple of 
things that stand out for me. One, I appreciate Dr. Daniel 
Varga's statement of honesty that we made mistakes. I didn't 
hear that from any of you, and that troubles me. Because what 
has happened here, is your protocol depends on everyone being 
honest 100 percent of the time. I am not a medical expert. I 
study behavior as a psychologist. People are not honest 100 
percent of the time.
    Secondly, it relies on tools for taking temperatures, which 
have their own reliability and validity issues, a 1 in 21 
chance during those 21 days it may register something, and a 
person can mask it with some analgesics, so that is not 
helpful.
    We also have to recognize human behavior, that protocols 
may not be followed. That is why you have a failsafe system of 
basically a buddy watching you put on your garb, watch you take 
it off, making sure you use other things, and I think the 
example of how this failed was, there is an assumption in the 
travel--Dr. Frieden, you said CDC granted her travel with the 
assumption that she used all the right protective gear but we 
have looked at this, and you are not aware of what she wore and 
it does not appear she wore the proper ones. So to this extent, 
these are my recommendations based on what we have heard in 
this hearing.
    I believe we need an immediate ban on commercial non-
essential travel from Guinea, Liberia, and Sierra Leone until 
we have an accurate and thorough screening process and we treat 
this disease. Number two, a mandatory quarantine order for any 
American who was treated an Ebola patient or has traveled to 
and returned from the Ebola hot zone countries. This includes a 
prohibition of domestic travel because of an assumption, and 
without this assumption of what they wore was donned and 
removed properly. Number three, immediate training and thorough 
training for U.S. health care hospital workers to include a 
review of personal protective equipment used in the treatment 
of possible Ebola-infected patients, their wear and removal. 
Number four, identify and designate specific medical centers 
equipped and trained to treat potential Ebola patients and 
expansion of those as soon as possible. Number five, identify 
gaps in statutory language that may prevent CDC and any other 
Federal agency including BARDA, FDA, and NIH from taking more 
aggressive and immediate action to protect public health from 
Ebola including letting us know of any abilities now to 
transfer funds immediately or any other action Congress needs 
to do to facilitate your needs. Number six, accelerate 
directives on development and deployment of clinical trials for 
all promising Ebola vaccines, investigational drugs, and 
diagnostic tests. Number seven, acquisition of additional 
airplanes and vehicles capable of transporting American medical 
and military personnel who may have contracted Ebola in Africa 
to return to the United States beyond the current capacity of 
two. Number eight, additional contact tracing and testing 
resources for public health agencies, and number nine, to 
provide information to Congress regarding any resources needed 
to assist health interventions, aggressive health interventions 
in Africa so we can stop Ebola there.
    I appreciate all the members coming back today for this 
hearing, and I particularly appreciate the testimony of the 
panel. I ask unanimous consent that the members' written 
opening statements be introduced into the record. Without 
objection, the documents will be entered into the record.
    Mr. Burgess. Yes, I have a document to enter into the 
record, the Office of Inspector General, Department of Homeland 
Security, and then the photograph that I demonstrated earlier 
today.
    Mr. Murphy. So ordered. That will be included in the 
record. \1\
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    \1\ The information has been retained in committee files and also 
is available at  http://docs.house.gov/meetings/IF/IF02/20141016/
102718/HHRG-113-IF02-20141016-SD010.pdf.
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    [The photograph follows:]
    
    
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    Again, I thank all the witnesses and members----
    Ms. Schakowsky. Mr. Chairman.
    Mr. Murphy [continuing]. Who have participated in the 
hearing.
    Ms. Schakowsky. Mr. Chairman, I just want an 
acknowledgement that the things I wanted included in the 
record----
    Mr. Murphy. Yes, those are included, as well.
    Ms. Schakowsky. Thank you.
    Mr. Murphy. We will also have a hearing in November. We 
will follow up. We will notify members of the participants in 
that and when that will be.
    I ask all members to submit questions for the record and 
ask that the witnesses please agree to respond promptly to the 
questions, and with that, this hearing adjourned.
    [Whereupon, at 2:55 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]
   
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