[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]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
93-903 PDF WASHINGTON : 2015
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Publishing
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800;
DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC,
Washington, DC 20402-0001
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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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?
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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\
---------------------------------------------------------------------------
\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.
---------------------------------------------------------------------------
[The photograph follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
[all]