[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
UPDATE ON 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
__________
NOVEMBER 18, 2014
__________
Serial No. 113-180
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
______________
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COMMITTEE ON ENERGY AND COMMERCE
FRED UPTON, Michigan
Chairman
RALPH M. HALL, Texas HENRY A. WAXMAN, California
JOE BARTON, Texas Ranking Member
Chairman Emeritus JOHN D. DINGELL, Michigan
ED WHITFIELD, Kentucky FRANK PALLONE, Jr., New Jersey
JOHN SHIMKUS, Illinois BOBBY L. RUSH, Illinois
JOSEPH R. PITTS, Pennsylvania ANNA G. ESHOO, California
GREG WALDEN, Oregon ELIOT L. ENGEL, New York
LEE TERRY, Nebraska GENE GREEN, Texas
MIKE ROGERS, Michigan DIANA DeGETTE, Colorado
TIM MURPHY, Pennsylvania LOIS CAPPS, California
MICHAEL C. BURGESS, Texas MICHAEL F. DOYLE, Pennsylvania
MARSHA BLACKBURN, Tennessee JANICE D. SCHAKOWSKY, Illinois
Vice Chairman JIM MATHESON, Utah
PHIL GINGREY, Georgia G.K. BUTTERFIELD, North Carolina
STEVE SCALISE, Louisiana JOHN BARROW, Georgia
ROBERT E. LATTA, Ohio DORIS O. MATSUI, California
CATHY McMORRIS RODGERS, Washington DONNA M. CHRISTENSEN, Virgin
GREGG HARPER, Mississippi Islands
LEONARD LANCE, New Jersey KATHY CASTOR, Florida
BILL CASSIDY, Louisiana JOHN P. SARBANES, Maryland
BRETT GUTHRIE, Kentucky JERRY McNERNEY, California
PETE OLSON, Texas BRUCE L. BRALEY, Iowa
DAVID B. McKINLEY, West Virginia PETER WELCH, Vermont
CORY GARDNER, Colorado BEN RAY LUJAN, New Mexico
MIKE POMPEO, Kansas PAUL TONKO, New York
ADAM KINZINGER, Illinois JOHN A. YARMUTH, Kentucky
H. MORGAN GRIFFITH, Virginia
GUS M. BILIRAKIS, Florida
BILL JOHNSON, Ohio
BILLY LONG, Missouri
RENEE L. ELLMERS, North Carolina
_____
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................ 1
Prepared statement........................................... 4
Hon. Kathy Castor, a Representative in Congress from the State of
Florida, opening statement..................................... 5
Hon. Marsha Blackburn, a Representative in Congress from the
State of Tennessee, opening statement.......................... 7
Hon. Michael C. Burgess, a Representative in Congress from the
State of Texas, opening statement.............................. 7
Prepared statement........................................... 8
Hon. Henry A. Waxman, a Representative in Congress from the State
of California, opening statement............................... 9
Hon. Fred Upton, a Representative in Congress from the State of
Michigan, prepared statement................................... 176
Witnesses
Thomas R. Frieden, Director, Centers for Disease Control and
Prevention..................................................... 10
Prepared statement........................................... 13
Answers to submitted questions............................... 180
Nicole Lurie, Assistant Secretary for Preparedness and Response,
Department of Health and Human Services........................ 24
Prepared statement........................................... 26
Answers to submitted questions............................... 185
Boris D. Lushniak, Acting Surgeon General of the United States,
Department of Health and Human Services........................ 40
Prepared statement........................................... 43
Answers to submitted questions............................... 189
Ken Isaacs, Vice President, Programs and Government Relations,
Samaritan's Purse.............................................. 90
Prepared statement........................................... 93
Answers to submitted questions............................... 191
Jeff Gold, Chancellor, University of Nebraska Medical Center..... 137
Prepared statement........................................... 139
Answers to submitted questions............................... 195
David Lakey, Commissioner, Texas Department of State Health
Services, on Behalf of the Association of State and Territorial
Health Officials............................................... 145
Prepared statement........................................... 147
Answers to submitted questions............................... 204
Submitted Material
Statement of American Hospital Association dated November 18,
2014, submitted by Mr. Burgess................................. 57
Statement of the American Federation of State, County, and
Municipal Employees dated November 18, 2014, submitted by Mr.
Green.......................................................... 169
Subcommittee memorandum.......................................... 177
UPDATE ON THE U.S. PUBLIC HEALTH RESPONSE TO THE EBOLA OUTBREAK
----------
TUESDAY, NOVEMBER 18, 2014
House of Representatives,
Subcommittee on Oversight and Investigations,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 1:38 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, Scalise, Harper, Olson, Gardner, Griffith, Johnson,
Long, Ellmers, Terry, Barton, DeGette, Braley, Lujan, Castor,
Tonko, Yarmuth, Green, and Waxman (ex officio).
Staff present: Sean Bonyun, Communications Director;
Leighton Brown, Press Assistant; Noelle Clemente, Press
Secretary; Brenda Destro, Professional Staff Member, Health;
Brad Grantz, Policy Coordinator, Oversight and Investigations;
Brittany Havens, Legislative Clerk; Sean Hayes, Deputy Chief
Counsel, Oversight and Investigations; Charles Ingebretson,
Chief Counsel, Oversight and Investigations; Carly McWilliams,
Professional Staff Member, Health; Emily Newman, Counsel,
Oversight and Investigations; Alan Slobodin, Deputy Chief
Counsel, Oversight and Investigations; Tom Wilbur, Digital
Media Advisor; Peter Bodner, Democratic Counsel; Brian Cohen,
Democratic Staff Director, Oversight and Investigations, and
Senior Policy Advisor; Lisa Goldman, Democratic Counsel; Amy
Hall, Democratic Senior Professional Staff Member; Elizabeth
Letter, Democratic Professional Staff Member; and Nick Richter,
Democratic Staff Assistant.
Mr. Murphy. Good morning. Today we convene our hearing on
the Update on the U.S. Public Health Response to the Ebola
Outbreak, from the Subcommittee on Oversight and
Investigations.
I will begin with a 5-minute opening statement.
OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA
Yesterday, Dr. Frieden, you shared with me a well-known
quotation worth repeating: ``Life can only be understood
backward, but it must be lived forward.'' Today, we will review
the lessons learned so far from the Ebola epidemic in West
Africa and the plan to move forward as the administration asks
taxpayers for $6.2 billion in new spending to fight this deadly
outbreak.
So I want to see a plan that is simple and direct. Number
one, prevent Americans from contracting Ebola; two, treat those
who contract Ebola effectively; and three, stop the spread of
Ebola at its source in West Africa. On the side of Ebola,
however, its goal is to spread, kill, mutate, and repeat. There
is no cure or vaccine so we have to work together to break the
chain.
The steps we must take begin with erecting a strong
perimeter of defense. That is why I outlined 10 recommendations
at our last hearing which included a ban on non-essential
commercial travel; a 21-day quarantine or isolation for those
who have had hands-on treatment of an Ebola patient; upgrades
and training for personal protective equipment; designating
specific Ebola-ready medical centers; accelerate development of
promising vaccines, drugs, and diagnostic tests; additional
aircraft and vehicles capable of transporting American medical
and military personnel who may have contracted Ebola back here
for treatment; additional contact tracing and testing resources
for public health agencies; and information for Congress
regarding any resources needed.
Some of these measures have been implemented, and others
are still needing to occur.
Our role here is to all work together to help define the
mission and ensure the policies put forth are straightforward
and flexible to accommodate the ever-changing nature of this
Ebola outbreak. Like Occam's Razor, the best solution is the
simplest one with the fewest assumptions.
As we have seen, missteps are caused by ignorance and
arrogance. They are corrected by knowledge, humility, and
honesty. Let us consider some of the false assumptions the
Federal Government's response has been based upon. Any hospital
could treat an Ebola patient. A negative Ebola test result
means a patient doesn't have Ebola, but just this week, a
physician from Sierra Leone died after being flown to Nebraska
for emergency treatment after initial tests showed a negative
result for the virus. His colleagues are now in quarantine,
causing even greater anxiety in a medical profession that has
already lost more than 500 to Ebola. Hospitals and health care
workers would have some proper guidance on personal protective
equipment. Self-isolation and quarantine orders aren't
necessary, it was said. CDC guidelines do not require a three
week self-isolation period for healthcare professionals who
have been treating Ebola patients in West Africa. It was said
that these volunteers can return to work immediately. But the
hospitals I talked to did not agree. I asked an ER doctor from
my district about whether any of his colleagues volunteering in
West Africa could come back to work immediately. He had a
simple response, and quoting him, he said, ``They should stay
away.''
The administration continues to oppose travel restrictions
and quarantines, yet respected institutions have such policies
to ensure public health is protected. The Department of Defense
has a quarantine policy as well as many local hospitals and
medical institutions throughout the U.S. It is impossible for
the American people to understand why the Government would have
one standard for the military and yet another standard for
people who may have been in the same, or possibly more perilous
circumstances.
Consider the cost of the administration's position. Senator
Schumer has asked the Federal Government to reimburse New York
$20 million for the costs associated with the 500 healthcare
workers it took to prevent an outbreak in New York City because
of the case of Dr. Craig Spencer. Now, the taxpayers have every
right to ask: Wouldn't it have been more cost effective for the
administration to instead require all returning healthcare
workers to adhere to a 21-day isolation policy?
We all need honesty and humility today. The American public
is fine with a doctor who says, ``This is our plan based on
what we know today, but as the facts change--as they most
assuredly will--then we have to change our approaches.'' A
patient and the public expect that.
Now, Anthony Fauci of the NIH has said we should not look
at the what ifs. I categorically disagree. That is exactly what
we need to do, what Congress needs to do, and everybody
involved with this needs to do. What if the outbreak migrates
to other countries? What if the outbreak extends to other
continents? And if we get new information that says a change in
policy is needed, tell us what you have learned and why a
change is required.
As one example, we have set up screening protocols at five
different airports to accept passengers from West Africa. Is
this complex approach the easiest and safest way to deal with
an Ebola threat? Are we hoping that we will be lucky enough to
catch each potential carrier? Can we track the hundreds or
perhaps thousands who might otherwise have been exposed if we
have 5 U.S. arrival points, countless potential destinations,
and numerous connections through Europe? With a disease that
has no margin of error like Ebola, I would rather be good than
lucky.
We need to consider whether there should be a simpler
approach of one arrival point that would allow us to easily
track those returning aid workers and Government professionals
coming from West Africa. The administration must also review
whether Government charter flights are needed to help get aid
workers to West Africa since many commercial airlines have
ceased traveling there, and they also have concerns about
shipping supplies to Africa.
I would like to ask the administration's Ebola czar, Ron
Klain, about this issue, but when we asked for him to appear
before our subcommittee, we were told that he ``wasn't ready.''
Another congressional committee made a similar request, and I
understand they were told that the White House Ebola response
coordinator had ``no operational responsibility.'' But for very
few press interviews, this individual seems to be missing-in-
action. No wonder the American people have concerns with the
administration's response planning. We want to clear that up
today, and we have good panels to do that.
The public is given plans that keep changing from agencies
that sometimes feel paralyzed, led by a czar who isn't ready
against a disease that is killing more every day. Well, we
stand ready to work with the administration to keep the
American people safe from the Ebola outbreak. I welcome all the
witnesses and look forward to learning more about the latest
public health actions on Ebola, and more details about the
emergency funding request.
[The prepared statement of Mr. Murphy follows:]
Prepared statement of Hon. Tim Murphy
Yesterday, Dr. Frieden you shared with me a well-known
quotation--`Life can only be understoodbackward, but it must be
lived forward.'
Today, we will review the lessons learned so far from the
Ebola epidemic in West Africa and the plan moving forward as
the administration asks taxpayers for $6.2 billion in new
spending to fight the outbreak. I want to see a plan that is
simple and direct:
1. Prevent Americans from contracting Ebola
2. Treat those who contract Ebola effectively
3. Stop the spread of Ebola at its source in West Africa.
On the side of the Ebola virus is to spread, kill, mutate,
and repeat. There is no cure or vaccine so we must break the
chain.
The steps we must take begin with erecting a strong
perimeter of defense. That's why I outlined ten
recommendations, which included:
A ban on non-essential commercial travel;
A 21-day quarantine or isolation for those who
have treated an Ebola patient
Upgrades and training for personal protective
equipment
Designating specific Ebola-ready medical centers
Accelerate development of promising vaccines,
drugs, and diagnostic tests;
Additional airplanes and vehicles capable of
transporting American medical and military personnel who may
have contracted Ebola back here for treatment;
Additional contact tracing and testing resources
for public health agencies;
Information for Congress regarding any resources
needed.
Some of these measures have been implemented. Others still
need to occur.
Our role here is to help define the mission and ensure the
policies put forth are straightforward and flexible to
accommodate the ever-changing nature of this Ebola outbreak.
Like Occam's Razor, the best solution is the simplest one with
the fewest assumptions.
As we've seen, missteps are caused by ignorance and
arrogance. They are corrected by knowledge, humility, and
honesty.
Consider some of the false assumptions the Federal
Government's response has been based upon:
Any hospital could treat an Ebola patient.
A negative Ebola test result means a patient
doesn't have Ebola. Just this week, a physician from Sierra
Leone died after being flown to Nebraska for emergency
treatment after an initial test showed a negative result for
the virus. His colleagues are now in quarantine, causing even
greater anxiety in a medical profession that has already lost
more than 500 to Ebola.
Hospitals and health care workers were had proper
guidance on personal protective equipment.
Self-isolation and quarantine orders aren't
necessary. CDC guidelines do not require a three week self-
isolation period for healthcare professionals who've been
treating Ebola patients in West Africa. These volunteers can
return to work immediately.
But the hospitals I talk to don't all agree. I asked an ER
doctor from my district about whether any of his colleagues
volunteering in West Africa could come back to work
immediately. He had a simple response. They, quote ``should
stay away.''
The administration continues to oppose travel restrictions
and quarantines, yet respected institutions have such policies
to ensure public health is protected.
The Department of Defense has a quarantine policy as well
as many local hospitals and medical institutions throughout the
U.S. It's impossible for the American people to understand why
the Government would have one standard for the military and yet
another standard for people who may have been in the same--or
possibly more perilous--circumstances.
Consider the cost of the administration's position. Senator
Schumer has asked the Federal Government to reimburse New York
$20 million for the costs associated with the 500 healthcare
workers it took to prevent an outbreak in New York City because
of the case of Dr. Craig Spencer.
The taxpayers have every right to ask: Wouldn't it have
been more cost effective for the administration to instead
require all returning healthcare workers adhere to a 21-day
isolation policy?
We need honesty and humility today. The American public is
fine with a doctor who says, ``This is our plan based on what
we know today.'' But as the facts change, and they most
assuredly will, then we must change our approach. A patient and
the public expect that.
Anthony Fauci of the NIH has said we should not look at the
``What ifs.''
I categorically disagree. That is exactly what we need to
do.
What if the outbreak migrates to other countries? What if
the outbreak extends to other continents?
If we get new information that says a change in policy is
needed, tell us what you have learned and why a changed is
required.
As one example, we have set up screening protocols at five
different airports to accept passengers from West Africa. Is
this complex approach the easiest and safest way to deal with
an Ebola threat? Are we hoping that we will be lucky enough to
catch each potential carrier? Can we track the hundreds of
thousands who might otherwise be exposed if we have five US
arrival points, countless potential destinations, and numerous
connections through Europe?
With a disease that has no margin of error like Ebola, I'd
rather be good than lucky.
We need to consider whether there should be a simpler
approach of one arrival point that would allow us to easily
track those returning aid workers and professionals coming from
West Africa.
The administration must also review whether Government
charter flights are needed to help get aid workers to West
Africa since must commercial airlines have ceased traveling
there.
I'd like to ask the administration's Ebola czar, Ron Klain,
about this issue. But when we asked for him to appear before
our subcommittee, we were told that he ``wasn't ready.'' When
another Congressional committee made a similar request, I
understand they were told that the White House Ebola response
coordinator had ``no operational responsibility.'' But for a
very few press interviews, this individual seems to be missing-
in-action. No wonder the American people have concerns with the
administration's response planning.
The public is given plans that keep changing from agencies
that are paralyzed--led by a czar who isn't ready against a
disease that is killing more every day.
We stand ready to work with the administration to keep the
American people safe from the Ebola outbreak. I welcome all the
witnesses and look forward to learning more about the latest
public health actions on Ebola and more details about the
emergency funding request.
Mr. Murphy. I now turn toward Ms. Castor for 5 minutes for
an opening statement.
OPENING STATEMENT OF HON. KATHY CASTOR, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF FLORIDA
Ms. Castor. Chairman Murphy, thank you very much for
holding today's hearing, the second that we have had on the
Ebola outbreak. And at our hearing last month, Americans were
rightfully concerned about the news they were hearing. It was
just weeks after Thomas Duncan arrived at Texas Presbyterian
with Ebola, and just days after two nurses who had treated him
had become infected. In response to these cases, the CDC
updated their protocols for treatment of Ebola patients, and
issued travel guidelines for those who had treated or been
exposed to Ebola.
Our hearing back then was held just 3 weeks before the
election, and it seemed that much of the discussion of
quarantines and travel bans reflected political concerns,
instead of the advice of public health experts. But today, when
we look at where things stand with regard to domestic
preparedness, we are in a much better place. No cases of Ebola
have been transmitted to any member of the general public in
the United States. With new procedures in place, and with the
exception of Dr. Craig Spencer in New York, no individual has
knowingly entered the U.S. while infected with Ebola. Airport
screening and new CDC monitoring guidelines implemented by
State and local public health departments are in place, and we
have successfully treated 8 Ebola patients that have entered
U.S. hospitals.
I want to give credit to these hospitals and healthcare
professionals that have treated these patients. The
professionals at Emory University, the NIH, the University of
Nebraska Medical Center, Bellevue, and Texas Presbyterian.
Their readiness has made a huge difference. And I want to
welcome Dr. Gold from the University of Nebraska and thank him
for sharing his expertise today.
Unfortunately, the news from West Africa is not as good.
While case counts in Liberia have slowed, there continue to be
rapid increases in the number of Ebola cases in Sierra Leone
and Guinea, and officials are now concerned about the
appearance of Ebola in Mali. And that, Mr. Chairman, is why we
need to continue to focus on the U.S. response in West Africa.
It is a credit to our country that we are leading the effort to
end the epidemic in West Africa, and the early results from
Liberia indicate that our efforts and the efforts of our
partner countries can make a real difference, but there is
still much work to do.
I want to acknowledge all of the medical professionals who
are doing that work, and in particular, say a few words about
Dr. Martin Salia. We learned yesterday that Dr. Salia, who had
been flown to Nebraska for treatment after developing Ebola
while working in Sierra Leone, died from the disease. We send
our condolences to his family, and acknowledge his bravery and
selflessness in helping fight this disease.
West Africa is balanced on the edge, and if our efforts and
the efforts of the World Health Organization are not
successful, millions of people in these countries facing a
looming humanitarian crisis will continue to suffer. And I am
glad that Mr. Isaacs from Samaritan's Purse is here to give the
perspective of the international aid community on the West
African outbreak.
Mr. Isaacs, your group and other groups like yours are
doing difficult but critical work, and you deserve support. We
are now in a much better position to addresses cases of Ebola
that appear in the United States than we were a few months ago.
And I appreciate Dr. Frieden, Dr. Lushniak, Dr. Lurie, Dr.
Lakey for joining us today to share lessons learned, and tell
us how we can continue to improve and move forward. And I am
also looking forward to the perspective of our witnesses on the
administration's supplemental Ebola budget request. It is
critical that Congress support this appropriations request. It
would support domestic preparedness, help fortify 50 Ebola
treatment centers nationwide, it would support the development
of treatments and vaccines for Ebola, and it would support
USAID and the U.S. Military in their critical efforts to
eliminate Ebola in West Africa.
Mr. Chairman, I suspect that in the year to come, we will
have our share of discussions over the budget, but I know we
all support the goals of the President's Ebola Outbreak Plan to
combat it, and I hope we can move quickly to provide the
requested appropriations.
Thank you, and I yield back.
Mr. Murphy. The gentlelady yields back.
Now recognize the vice chair of the full committee, Mrs.
Blackburn, for 5 minutes.
OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TENNESSEE
Mrs. Blackburn. Thank you, Mr. Chairman. I appreciate the
hearing, and I want to say welcome to all of our witnesses. We
appreciate your time.
I think we have to realize, with the nearly 15,000 cases
and over 5,000 deaths, that this Ebola epidemic is the worst
since the discovery of the virus in '76. And you need to look
at what the precedent is there: 2,400 known cases of Ebola
prior to this outbreak. So we know that this is something that
is going to be difficult and take some time to deal with, and
we appreciate your efforts on that part.
And there is a little bit of good news coming out of
Liberia. There is also kind of a mixed bag of news that is
coming out of the region, and it all leads us to look at the
magnitude of the situation in front of us, as well as the
human-to-human transmission of the virus which has drawn
attention to the need to be better prepared to keep Americans
safe, and that is our goal. You know, most Americans believe it
is the job of ASPR and the job the CDC to keep Americans safe
from infectious disease, and that all efforts need to be on the
table when it comes to keeping Americans safe. Don't take
anything off the table.
The chairman mentioned some of those suggestions that were
made at the last hearing. Indeed, yesterday I was at Fort
Campbell with some of my troops who are over there now trying
to build the hospitals, and are training their medical
personnel. And I think it is of concern to us that the
administration has been opposed to travel bans and to
quarantines; items that we think might work. Even the Institute
of Medicine recently held a workshop where researchers raised a
number of questions about the characteristics of the Ebola
virus. They concluded, and I am quoting, ``many of the current
risk quarantine policies and public health mitigation measures
could be better informed and more effective if the means and
potential routes for transmission were more thoroughly
characterized. Until we know more about the nature of the
deadly virus, it seems prudent to keep all commonsense measures
on the table.''
And with that, I yield to Dr. Burgess.
OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF TEXAS
Mr. Burgess. I thank the gentlelady for yielding. I thank
our witnesses for being here today. Dr. Lakey, good to see you
again.
This epidemic will surely go down in history as one of the
most serious public health--from a global perspective, one of
the most serious public health crises of the last 100 years.
At our last hearing, we had a great deal to discuss, and
certainly many of the brave pronouncements from the middle of
September were found to be non-operational by the middle of
October, and there were failures in dealing with this crisis.
Certainly, communication was lacking. Systems and protocols
broke down, and provisions that we all thought were readily at
hand were never in place to begin with. I hope we know better
than to let this happen again. This summer's emergency, to me,
emphasized one thing, and that is have a lot of humility when
you are dealing with this virus because it is difficult to
predict.
As a physician, one of my biggest concerns since July has
been the safety and the protection of healthcare workers. I
want to thank the CDC for always being responsive to my
telephone calls over the last several months, and the various
conference calls that we had over the summer were helpful. And
I have to tell you something, until you have this damn thing in
your backyard, it is just hard to estimate how it is going to
affect daily life on so many levels. Sure, we had a hospital
that was hurt by the crisis. We are probably lucky we didn't
have more than one that was hurt. Trash collection, sewer
treatment, school districts, every one down the line was
affected by having this virus in our area.
So we do have to take great care and closely follow the
epidemic in Western Africa. It is important that that be
brought under control. I also have to tell you I am grateful
for the services of the hospitals that have handled the known
Ebola patients, but I am much more worried about that unknown
patient who could walk through an emergency room door at 3
o'clock tomorrow morning, unknown to anyone, unannounced, and
provide the same set of circumstances that we have already been
through. I am not sure we have learned entirely the lessons.
Thank you, Mr. Chairman. I will yield back.
[The prepared statement of Mr. Burgess follows:]
Prepared statement of Hon. Michael C. Burgess
This Ebola epidemic will surely go down in history as one
of the most serious public health crises of the last several
hundred years.
At our last hearing, we had a lot to discuss. Overall, we
failed in our response to the Ebola crisis. Communication was
lacking, systems of protocol broke down, and provisions were
never in place to deal with this crisis to begin with. We know
better than to let this happen again. This summer's emergency
only emphasized that we must have humility when discussing
Ebola.
As a physician, one of my biggest concerns over the last
six months or so was the safety and protection of health
workers. I could not--and still do not--understand why health
workers on the front lines of the epidemic in Africa were so
much better protected than the nurses and doctors who treated
Ebola patients in the United States. It is not only vital to
contain the Ebola virus wherever it may be, but we must also
ensure we are doing all we can to protect those who are serving
these very sick and contagious patients. Until it is in your
back yard as it was in mine in Texas, it is hard to comprehend
the depth of the issue at hand.
I commend Dr. Frieden, the CDC and the other members of the
panel for making yourselves available to the Congress so we may
discuss policies that better protect the American public from
infectious diseases like Ebola. I thank all of our witnesses
for being here today.
It is my hope that we continue to make progress in this
fight. Today's hearing is another good start. We must examine
the response plan, protocol, U.S. guidelines, travel
restriction policies, budget for dealing with this crisis and
protective gear and proper precautions for health workers. But
finally, we must also take great care to closely follow the
epidemic in West Africa, as it is only a matter of time before
another patient walks through the doors of an unsuspecting U.S.
hospital.
When--not if--that happens, we must be prepared.
I yield back.
Mr. Murphy. Gentleman yields back.
I now recognize the ranking member of the full committee,
Mr. Waxman, for 5 minutes.
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 you are
holding this hearing. This is a very important topic, and it is
appropriate for Congress to learn about it because the American
people want to know what is happening and want some answers.
But I picked up a couple of comments from the other side about
having humility, learning from what has happened, and hope we
know better because of what we have learned. When we last had a
hearing in October, there was a pronounced disconnect between
what the public health experts were telling the committee, and
the rhetoric of some of the committee members. Some members
called for quarantines and travel bans that experts had
determined would be harmful. Some claim that the
administration's protocols for screening and tracking travelers
wouldn't work. Some even insinuated that immigrants with Ebola
would soon be crossing the southern border, or that Ebola had
mutated and become transmissible by air. This is hysterical.
Rhetoric certainly induces a great deal of fear.
But, Mr. Chairman, none of these things were true. After
two cases were transmitted in Texas, the Centers for Disease
Control acted quickly and decisively to acknowledge the gaps
and revise protocols. It has learned from its experiences. It
has now been 33 days since our last Ebola hearing, and since
then, not one case of Ebola has been transmitted in the United
States. Only one traveler since then, Dr. Craig Spencer, has
unknowingly brought a case of Ebola into the country, and it
appears that our healthcare system responded effectively. Dr.
Spencer knew how to immediately report his symptoms, was
quickly isolated, and safely transported to a hospital equipped
to treat a patient with Ebola, and his close contacts were
monitored.
The health experts told us that our public health measures
could protect the public from Ebola, and it turns out, Mr.
Chairman, they were right.
So it is good that we have a chance today to show some
humility and acknowledge that the fears that were expressed
openly at our last hearing were not justified. As I said in
that first hearing, we should have a sense of urgency about the
epidemic in Africa. There is a lot of work to be done to stop
the ongoing humanitarian crisis there, and we should view the
appearance of Ebola cases in the United States as a wakeup call
about the need for us to invest in public health preparedness
at the Federal, State, and local levels.
President Obama is trying to address these challenges, and
we should support those efforts, because if we don't stop Ebola
in Africa, it could travel to other places, it could spread, so
we have to control the epidemic where it is happening.
On November 5, the President submitted a $6.2 billion
emergency supplemental funding request to Congress to improve
domestic and global health capacities in 3 critical areas;
containment and treatment in West Africa; enhanced prevention,
detection and response to Ebola entering the U.S.; and
buttressing the U.S. public health system to respond rapidly
and flexibly to all hazards in the future. It is critical, Mr.
Chairman, that Congress support this request.
There is ample precedent for an emergency public health
supplemental appropriation of this magnitude. In November 2005,
the Bush administration requested $7.1 billion in emergency
supplemental funding to speed up the development of a vaccine,
and fund State, local, and Federal preparedness. Ultimately, a
bipartisan Congress provided President Bush with over $6
billion of this funding. In 2009, Congress provided the Obama
administration with nearly $7 billion in emergency spending
authority to combat H1N1 influenza virus. Congress did the
right thing by making those investments. They saved lives, they
enhanced our preparedness, and the Congress should do the right
thing now.
Thank you, Mr. Chairman. Yield back the balance of my time.
Mr. Murphy. The gentleman yields back.
I would now like to introduce the distinguished panel for
today's hearing, for the first panel.
We are joined by Dr. Thomas Frieden, the Director of the
Centers for Disease Control and Prevention; the Honorable
Nicole Lurie, the Assistant Secretary for Preparedness and
Response at the U.S. Department of Health and Human Services;
Rear Admiral Boris Lushniak, the Acting United States Surgeon
General, who also oversees the operations of the United States
Public Health Service Commissioned Corps, comprised of
approximately 6,000 uniformed health officers.
I will now swear in the witnesses.
You are aware that the committee is holding an
investigative hearing, and when doing so, has had the practice
of taking testimony under oath. Do you have any objections to
testifying under oath? All the witnesses say they do not. 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 you desire to be advised by counsel during your
testimony today? All the panelists waives that. In that case,
if you will all please rise and raise your right hand, I will
swear you in.
[Witnesses sworn.]
Mr. Murphy. Thank you. All of the panelists have answered
in the affirmative. So you are under oath and subject to the
penalties set forth in Title XVIII, section 1001 of the United
States Code. You may now each give a 5-minute summary of your
written statement. We will start with you, Dr. Frieden.
STATEMENTS OF THOMAS R. FRIEDEN, DIRECTOR, CENTERS FOR DISEASE
CONTROL AND PREVENTION; NICOLE LURIE, ASSISTANT SECRETARY FOR
PREPAREDNESS AND RESPONSE, DEPARTMENT OF HEALTH AND HUMAN
SERVICES; AND BORIS D. LUSHNIAK, ACTING SURGEON GENERAL OF THE
UNITED STATES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
STATEMENT OF THOMAS R. FRIEDEN
Mr. Frieden. Thank you very much, Chairman Murphy,
Congresswoman Castor, Full Committee Ranking Member Waxman, and
the other members of the committee. We appreciate the
opportunity to come before you today and discuss what has
happened in the past month since the last hearing.
In the basics of Ebola, we continue to see the pattern that
we have seen over the past 4 decades. In fact, in the more than
400 contacts that we have traced in the U.S., we have not seen
spread outside of that one incident in Dallas in the healthcare
setting, among more than 2,000 travelers who have been
monitored since arriving from West Africa. We have seen a
series with fevers but none with Ebola.
So nothing changes the experience that we have to date that
Ebola spreads from someone who is sick, and it spreads through
either unsafe caregiving in the home or healthcare facility, or
in Africa, unsafe burial practices.
Emergency funding is absolutely critical to protect
Americans. It is critical to stop the outbreak at the source in
Africa, and to strengthen our protections here at home.
Globally, in each of the three epicenter countries we have seen
rapid change, and flexibility is absolutely key to the
response. In Liberia, we have seen promising developments in
recent weeks, with some decrease in numbers, but still the
number of new cases each week is in the many hundreds, and our
ability to stop it is very challenging because it is now
present in at least 13 of the 15 counties of Liberia, and our
staff are now responding to as many as one new cluster or
outbreak per day, compared over the past 4 decades with one
cluster or outbreak every year or 2. It is going to require a
very intensive effort to trace each one of those chains of
transmission and stop it so that we can end Ebola.
In Sierra Leone, we are still seeing areas with widespread
transmission, although some of the areas that have implemented
the strategies we recommend have seen significant decreases as
well. Guinea, in some ways, is the most interesting or
concerning or instructive to look at because it shows what
might happen in the future if we have progress in the first 2
countries. There is a challenge to trace each outbreak, each
case, to reach each community and end the chains of
transmission. That is why the emergency funding request
outlines a comprehensive approach that is simple,
straightforward, and focused, and approaches things by
prevention, detection, response, 3 main categories. In West
Africa, that prevention involves quarantine and screening,
involves infection control and hospitals and burials, it
involves detection so that we find outbreaks promptly, and
strengthen surveillance and strengthen the ability of
healthcare facilities and public health workers there to stop
chains of transmission, and response through core public health
functions of contact tracing, training, infection control,
public health education and outreach, and the use of rapid
response teams.
Globally, we are also seeing new threats with the cluster
of cases in Mali. CDC has surged. We have 12 staff on the
ground today in Mali. We were there before their first case,
and they are now tracing more than 400 contacts, and we are
helping them to do that and to test any who may have symptoms
that could be Ebola. We also are aware that with the end of the
rainy season, other parts of West Africa may experience an
increase in travelers from the affected countries, and may be
at increased risk. The metaphor of a forest fire holds here,
with the center burning still strongly, with a series of
brushfires around the region, and with sparks that have the
potential of igniting new sources and new challenges in the
struggle against Ebola.
Globally, the funding request also addresses the global
health security aspect so that we can, with an emergency focus,
stop the kind of vulnerabilities that keep other countries
vulnerable and us vulnerable. Most of that, about 3\3/4\4 of
the CDC component of that request, is to strengthen the warning
systems; detection, laboratory networks, and others. There are
also funds to respond rapidly and to prevent wherever possible.
For the part of the funding request that covers the U.S.,
we have made progress. We are doing that through a series of
levels, but each of those is going to require significant
investments. Stopping it at the source in Africa, screening all
travelers when they leave Africa, screening travelers when they
arrive to the U.S., tracing each traveler for 21 days after
they arrive here in all of the 50 States. The States have
really stepped up and are doing an excellent job of that, with
CDC support and guidance, with excellent participation from
Customs and Border Protection, which is now providing
electronically collected data in just a question of hours to
the States. We are seeing most States reaching 100 percent of
travelers regularly, according to the information that they are
reporting to us. So this is a relatively new program, but it is
going smoothly. It is, however, working on borrowed dollars,
and we will need funding from the emergency funding request to
support this and other key measures of prevention, detection
and response within the U.S., public health systems, hospitals,
laboratory networks, active monitoring, and more.
Finally, I would emphasize that intensive public health
action can stop Ebola. In Nigeria, they were able to surge and
stop a cluster from spreading. Mali is now in the balance of
whether it becomes the next Nigeria, having successfully
contained a cluster, or the next Liberia or Sierra Leone, with
widespread transmission. This is a real warning that we must
not let down our guard. The shifts and the changes in the
epidemiology in Africa are just an emphasis of the need for a
rapid and effective response, and emphasized that the only way
to protect us in the U.S. is to stop it at the source, and to
build the systems both in Africa and in the U.S. that will
find, stop and prevent Ebola and other infectious disease
threats.
Thank you very much.
[The prepared statement of Mr. Frieden follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you.
Dr. Lurie, you are recognized for 5 minutes.
STATEMENT OF NICOLE LURIE
Ms. Lurie. All right, good afternoon, Chairman Murphy,
Member Castor, and other members of the committee.
I am Dr. Nicole Lurie, the Assistant Secretary for
Preparedness and Response, or ASPR, at HHS. I appreciate the
opportunity to talk to you today about actions that ASPR has
taken to enhance our national preparedness and strengthen our
resilience to public health threats.
While it is essential that we continue to focus on
controlling the Ebola outbreak in West Africa, we also have a
critical responsibility to protect our country from this
disease. Today I will highlight three areas in which ASPR's
work is critical to our domestic response.
First, the Biomedical Advance Research and Development
Authority, or BARDA. Building on its previous successes in
medical countermeasure development, BARDA is speeding the
development, testing, and manufacture of Ebola vaccines and
treatments. Second, the Hospital Preparedness Program has,
since the beginning of this outbreak, been preparing hospitals
and first responders to recognize and treat patients with
suspected Ebola. And, third, our Federal resources and
responders, whether the National Disaster Medical System, the
Medical Reserve Corps, other public health service, stand ready
to support a comprehensive response should it be needed in the
coming months.
BARDA, in coordination with other medical countermeasure
partners, has a great track record in expanding the medical
countermeasures pipeline, and building needed infrastructure to
do so. In addition to developing and procuring 12 products
since Project Bioshield's inception over a decade ago, BARDA's
Centers for Innovation in Advanced Development and
Manufacturing, and its Fill Finish Manufacturing Network, are
being used to produce, formulate, and fill vaccines and
treatments for Ebola.
Complementing our success and medical countermeasure
development, ASPR has made great strides in U.S. healthcare
system preparedness. HPP, or Hospital Preparedness Program,
investments have fostered an increased level of preparedness
throughout communities in this country, and decreased reliance
on Federal aid following disasters. In the last several years,
HPP awardees have demonstrated their ability to respond to and
quickly recover from disasters, including tornadoes, floods,
hurricanes, and fungal meningitis from contaminated steroids.
Through HPP, ASPR is actively engaged in Ebola preparedness
by developing and disseminating information, guidance and
checklists, and serving as a clearinghouse for lessons learned.
Together with CDC, we have launched an aggressive outreach and
education campaign that has now reached well over 360,000
people through webinars and and national calls, including with
public health officials, hospital executives, frontline
healthcare workers and others across the U.S. My office, along
with the CDC, continues to recruit hospitals willing and able
to provide definitive care to patients with Ebola in the United
States. Concurrently, we are working with personal protective
equipment manufacturers to coordinate supply and distribution,
and are working with HPP-funded healthcare coalitions to
collaboratively assess needs and share supplies across
communities.
The likelihood of a significant Ebola outbreak in the
United States is quite small, but ASPR, HHS and our interagency
partners are, as you know, part of a coordinated, whole-of-
Government response, a response that extends on the one hand to
West Africa, and on the other, through State and local
Governments and to hospitals and communities throughout the
United States. As is typical for other emergencies and
disasters, ASPR is responsible for public health and medical
services, and coordinates Federal assistance to supplement
State, local, territorial, and tribal resources, and response
to public health and medical care needs during emergencies.
I would like to close with an overview of the recent
emergency funding request from the administration that includes
$2.43 billion for HHS.
ASPR's request supports two major components; BARDA's
product development efforts, and HPP's preparedness
initiatives. Specifically, funding will support development of
an Ebola vaccine and therapeutic candidates, clinical trials,
and commercial-scale manufacturing. Funding will ensure that
communities will be able to purchase additional personal
protective equipment, that healthcare workers will receive
additional training, and patient detection, isolation and
infection control, and that we further build our preparedness
for the future by ensuring that all States have facilities that
can handle an infectious disease as serious as Ebola.
Mr. Chairman and members of the committee, the top priority
of my office is protecting the health of Americans. I can
assure you that my team, the Department, and our partners have
been working and continue to work to ensure our Nation is
prepared to respond to threats like Ebola.
I thank you for this opportunity to address these issues,
and welcome your questions.
[The prepared statement of Ms. Lurie follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you.
Now, Dr. Lushniak, you are recognized for 5 minutes.
STATEMENT OF BORIS D. LUSHNIAK
Mr. Lushniak. Great. Thank you so much for this
opportunity, Chairman Murphy, Member Castor, members of the
Oversight and Investigations Subcommittee, and thanks again for
having us here to testify about the U.S. Public Health Service
Commission Corps and its role in responding to the Ebola
outbreak in West Africa.
I am here to provide information to you about what the
Office of the Surgeon General, and specifically the United
States Public Health Service Commission Corps, has contributed
to this U.S. Government-wide effort to stop the spread of Ebola
virus disease, in essence where it began, in West Africa.
The Commission Corps of the U.S. Public Health Service is
made up of 6,700 uniformed officers. They are assigned to 26
different departments and agencies of the Federal Government,
serving in 800 locations worldwide. I am very proud of this
group of officers. They are highly trained, mobile, medical and
public health professionals, operating under the departmental
leadership of the Secretary of Health and Human Services, and
the day-to-day oversight of the Surgeon General and the
Assistant Secretary for Health.
The Commission Corps is one of the seven uniformed services
of our Nation. The only uniformed service of its kind in the
world. It is an unarmed, uniformed service dedicated to a
public health mission, and to medical care for underserved and
vulnerable populations. The mission of the Corps is to protect,
promote, and advance the health and safety of the Nation.
For 125 years, this is an anniversary year for us, Corps
officers have been the Government's dependable resource for
health expertise and public health emergency services, working
closely with the ASPR in times of war in the past, and other
national or international emergencies. Corps officers, like
officers in our other sister services, can be deployed at a
moment's notice anywhere in the world to meet the needs of the
President, the HHS, to address needs related to the well-being,
security, and defense of the United States.
We have had a long history of doing this; protecting the
health and safety of the Nation by addressing infectious
disease overseas. Smallpox, as an example, polio, now Ebola. To
ensure that we can meet the mandate to respond rapidly to
urgent or emergency public healthcare needs around the globe,
the Corps has established a tiered response system composed of
41 different general, as well as specialty response teams. We
have deployed in the past to events ranging from terrorist
events; 9/11, the Boston bombings, anthrax, natural disasters,
hurricanes, Katrina, Rita, Wilma and Sandy, humanitarian
assistance in Haiti, Indian Ocean tsunami, reconstruction
stabilization in Iraq and Afghanistan, public health crisis,
H1N1, suicide clusters on Indian reservations, to hospital
infrastructure rescue in the Mariana Islands. Over the past 10
years, the Corps has undertaken over 15,000 officer deployments
in support of nearly 500 distinct missions and events. Corps
officers now are currently operating in both the United States
and in West Africa in clinical, epidemiological, education,
management, liaison roles, supporting the Department of Health
and Human Services, as well as working under the auspices of
the Centers for Disease Control and Prevention. We have 900
officers stationed with the CDC.
One critical element of the Department's plan for combating
the Ebola outbreak targets the ongoing need for healthcare
personnel in the Ebola-affected countries. United Nations
estimated that 1,000 international healthcare workers would be
needed on the ground in West Africa to bring the outbreak to an
end. There is a wide consensus that in order to create
conditions that will encourage both West African and
international healthcare workers to contribute, yes, their time
and skill to contain and ultimately end the Ebola outbreak, it
is essential to establish a dedicated facility to provide high-
level care for those healthcare workers should they become
infected with the virus. In support of this objective, the
Corps has deployed trained clinicians, physicians, nurses,
behavioral health specialists, infection control officers,
pharmacists, laboratory workers, administrative management
personnel, to Liberia to staff the Monrovian Medical Unit, the
MMU. This is a U.S. Government-funded 25 bed hospital that has
been configured to function as an Ebola treatment unit. It
provides advanced Ebola treatment to Liberian and international
healthcare workers, and to nongovernmental organizations and
U.N. personnel involved in the Ebola response.
DoD, the State Department, USAID, have provided invaluable
support for this mission. It is being carried out with the full
cooperation of the Liberian Government and its Ministry of
Health.
The first team of the United States Public Health Service
Commission Corps officers completed one week of advanced
training in Alabama in October. They arrived in Liberia on
October 27. The full complement, a staffing of 70 Corps
officers, each of whom voluntarily accepted this assignment to
provide direct care for Ebola patients. Additional training was
completed in Liberia with support of NGOs such as Medecins Sans
Frontiers and the International Medical Corps. We have the
equipment, we have gone through safety, clinical care, and
management protocols. On November 12, the MMU accepted its
first patient, a Liberian healthcare worker. Today, the fourth
patient is soon to be admitted. Four overlapping teams of 70
officers will be scheduled for rotations of approximately 60-
day deployments, for an estimated 6 months of operations at
this MMU.
In conclusion, the safety of our personnel is our highest
priority. We are making every effort to ensure that all Corps
officers on the ground are working in an environment that will
minimize any risk to their personal safety and security,
following guidance from the CDC. To ensure the safety of our
officers, their families, friends, coworkers, and the
communities in which they live, work and play, upon return,
officers will undergo exposure risk assessment and, as
indicated, be monitored by public health authorities. We look
forward to welcoming home our personnel returning from this
mission, providing them support, and thanking them for their
extraordinary efforts on behalf of the Nation and peoples of
West Africa.
Thank you, Mr. Chairman, other members, and members of the
subcommittee, and I will be happy to answer your questions at
this time.
[The prepared statement of Mr. Lushniak follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Doctor.
I will now authorize myself 5 minutes for questions for our
panel.
Dr. Frieden, in the weeks that you have been dealing with
this in the United States, can you highlight perhaps the top 3
things, lessons learned and modified from this that could give
the public assurances that you are adapting as need be?
Mr. Frieden. The most important principle that we are
following in Ebola control is to find out as quickly as
possible, as definitively as possible, what works, and then to
implement that, both on the ground in West Africa and in the
U.S. What we have found is that treating Ebola in the U.S. is
difficult. The two infections in Dallas were an indication of
that, and we immediately moved to add a margin of safety to our
guidelines for infection control and personal protective
equipment. We also have put into place multiple levels of
protection. Our top priority is protecting Americans, and we do
that through control at the source in Africa, screening on
exit, screening on entry, and the active monitoring program, as
well as work with individual hospitals and health departments.
We have something called rapid Ebola preparedness teams
that have now visited more than 30 hospitals in more than 10
States to get those hospitals ready for the next Ebola case, if
one occurs, and actually, a team had been to Bellevue before
Dr. Spencer even became ill.
Mr. Murphy. OK.
Mr. Frieden. So that rapid response is key and rapid
adjustment as we learn more about Ebola and Ebola in the U.S.
Mr. Murphy. OK, I want to get back on the hospitals issue
in a minute here.
Dr. Lurie, in August of 2014, under Section 564(b) of the
Food and Drug Cosmetic Act, Secretary Burwell declared that
circumstances exist justifying the authorization of emergency
use of in vitro diagnostics for detection of the Ebola virus.
Did you help advise Secretary Burwell of that declaration, do
you recall?
Ms. Lurie. Yes.
Mr. Murphy. OK. So even though she declared Ebola to be an
emergency for purposes of the FDA law, she has not declared
Ebola to be a public health emergency under this, and she has
not made this declaration even though the World Health
Organization, in August, declared Ebola to be a public health
emergency.
Do you agree or disagree, is this a public health emergency
in the United States?
Ms. Lurie. So in order for an investigational diagnostic
test or drug to be used in the United States, the Secretary has
the authority to declare that the conditions of a potential
public health emergency exist. As I think Dr. Frieden and
others have highlighted, fortunately, we have been very
successful in the United States in detecting and controlling
this disease. We have had two very unfortunate cases of
transmission of this disease in the United States, but not
others, and we believe that all of our efforts are quite
effective in controlling the disease at this time.
Mr. Murphy. We hope so, but ``fortunately'' is also an
operative word there, and we want to make sure we are doing
everything that we possibly can.
On page 6 of your testimony, you mentioned you are
responsible for coordinating the Emergency Support Function
Number 8 response using domestic or--emergencies. Is that an
operational responsibility that you have?
Ms. Lurie. So my responsibilities are both policy and
advice, and we have operational response under ESF 8, yes.
Mr. Murphy. And that has been activated under the response
to Ebola?
Ms. Lurie. Yes, the Secretary's operations center is
activated, and all components of ASPR are hard at work.
Mr. Murphy. I am just trying to clarify, so you are still
the coordinator for emergency support function, or is that now
Mr. Klain?
Ms. Lurie. Mr. Klain is the Ebola coordinator for the
country, yes.
Mr. Murphy. OK. So let me look at this. What data are you
modeling, or have you done a data modeling, to determine the
number of cases we may anticipate in the United States? Have
you done any of that data modeling?
Ms. Lurie. So one of the things that we have done,
actually, as a lesson learned from H1N1, is brought together
modelers from all across the Federal Government.
Mr. Murphy. And how many cases are you planning for in the
United States?
Ms. Lurie. So I think our models suggest that if we
continue to be very aggressive about our exit screening from
West Africa, our entry screening, tracking travelers for 21
days with active and direct active monitoring, as we are doing,
that we might expect a handful of cases in the United States,
potentially in an unrecognized cluster, but that we don't
anticipate that we are looking at a widespread outbreak.
Mr. Murphy. So you are asking for $6.2 billion here, but
you are saying you are expecting a handful of cases. And
Senator Schumer just said, look, you owe New York City $20
million because we had to track all these people that came in
contact with someone, but you don't believe in a policy of some
kind of self-isolation, even though many of these NGOs do
believe in self-isolation. So there is a disconnect here:
Expect a handful of cases, don't expect more, but asking for 50
hospitals to be prepared throughout the United States, but--
help me understand where this----
Ms. Lurie. Sure.
Mr. Murphy [continuing]. $6.2 billion----
Ms. Lurie. I would be happy to. I don't think that there is
really a disconnect at all. Our strategy for hospital
preparedness looks first at being sure that beyond the bio-
containment facilities at Emory and Nebraska and NIH we have
good strong hospital capacity to recognize, and treat through
the entire course of illness, an Ebola patient, first in the 5
cities where all passengers are being funneled. A next ring of
hospitals is needed for geographic dispersion around the
country to places where travelers are most likely to go, and
that is a pretty good range of States now throughout the
country.
One of the things that we have learned, and you had asked
Dr. Frieden about lessons learned, is that Mother Nature always
has the upper hand. That means that we have to think about what
is next after Ebola. Ebola has taught us that we really need
high-containment facilities. So far our planning has been for
pandemic preparedness on something that is airborne like
pandemic flu. The containment needs, the infection control
needs for something like Ebola are very, very different.
So part of this emergency request is being able to meet our
needs now by having a broad geographically dispersed network of
hospitals able to treat Ebola, but it is also building toward
the future because we don't know where the next cases are going
to show up, or the next kinds of travelers are going to show
up, but we need to be prepared not only for today but for the
next decade and for the next century.
Mr. Murphy. I am way over my time.
I recognize Ms. Castor for 5 minutes.
Ms. Castor. Thank you very much.
On November 5, the President requested $6.2 billion from
Congress to enhance the U.S. Ebola response. The President's
request focuses on stopping the outbreak at its source in West
Africa.
Dr. Frieden, in your testimony you said you were focused in
West Africa on prevention, detection, and response. Can you go
into greater detail. The President's request designates $603
million to CDC for international response efforts. Discuss how
these funds would specifically be used.
Mr. Frieden. Thank you very much. Our approach would be on
the prevention side to implement and strengthen quarantine and
screening procedures so that those can be continued long-term,
and individuals with Ebola or potentially exposed to Ebola
would be isolated, traced, and then promptly isolated if they
become ill.
Second on the prevention side is infection control. This is
an enormous challenge for West Africa because each of the
facilities caring for patients needs to think of the
possibility of Ebola in countries where malaria is endemic, and
where the symptoms of malaria and Ebola are not easily
distinguishable. So that prevention is infection control and
quarantine.
On the detection side, laboratory and related services to
find infections and find illnesses as soon as they occur. That
relates to some of the U.S. funding which would allow us to
work with companies and other parts of the U.S. Government to
optimize some of the testing modalities. And then surveillance,
so we are tracking what is going on with the detection. And
training of healthcare facilities to identify cases so they are
found, isolated, cared for, and don't cause outbreaks. And then
response; the core public health activities of contact tracing,
training of healthcare workers, surveillance, public health
education, outreach, rapid response teams, and support
diminished periods of help so that we don't need to be there
long-term. So we are training people to do the kind of
prevention, detection, response that we are doing now.
Ms. Castor. And what, if any, public health infrastructure
was in place in West Africa beforehand?
Mr. Frieden. There were very weak systems in place prior to
this, public health or healthcare, really a shortage of trained
workers, so part of our effort is to build up those systems so
that they can continue that for many years to come.
Ms. Castor. OK, and the budget request also would direct
$1.98 billion to USAID, $112 million to the Department of
Defense, and $127 million to the Department of State. Can you
go through how funding to those agencies would assist in the
broader effort?
Mr. Frieden. I would have to refer you to them for the
details, but in general, USAID is coordinating under the DART,
or Disaster Assistance Response Team, process, and they are
enlisting many partners within countries, for example, for
burial teams which now exist all over Liberia, and are rapidly
and safely and respectfully collecting human remains of people
who may have died from Ebola.
We are also addressing some of the critically important
areas of supporting development in areas like the Guinea forest
region where there is a lot of resistance and some resentment,
and services in that region are going to be very important in
allowing us to get in and do Ebola control.
Ms. Castor. OK. Dr. Lushniak, how would the supplemental
funding assist the public health service in their work in West
Africa?
Mr. Lushniak. I think to the large extent, certainly
running the Monrovia Medical Unit, it is supported by multiple
agencies. Within the Department of Health and Human Services,
certainly, the supplement will assist us in that endeavor. DoD
plays a key partnership role. They are really supplying us with
equipment, supplies, a lot of the logistical support on the
ground. USAID, as mentioned by Dr. Frieden, is really out there
also pushing ahead. And so, you know, from our perspective is
that to have a continuous presence on the ground, and if we
strongly believe that this mission is important, as I do, which
is providing that medical care to healthcare workers, that the
supplemental will assure a success in that mission.
Ms. Castor. Now, we have heard from Doctors Without Borders
and other international organizations about the need for
flexibility and adaptability in our response and in that budget
request. Dr. Frieden, what measures are built into the
supplemental budget request that would give us that flexibility
and adaptability?
Mr. Frieden. Well, first, there is the contingency fund of
$1.5 billion requested by the President, split essentially
equally between the State Department/USAID and HHS, including
CDC. That would be available, for example, if the disease
breaks out in another part of Africa that we need to
intensively surge to, or if we do have an effective vaccine, to
implement a vaccine campaign will be quite challenging.
Second, within the budget request there is transfer
authority, and that is extremely important so that we can adapt
our response to what is needed. And third, within the CDC
budget in particular, it would be a single budget line, so we
would have flexibility within CDC to spend the resources
specifically for Ebola control, as they will be most efficient
and most effective.
Ms. Castor. Thank you very much. I yield back.
Mr. Murphy. Gentlelady yields back.
I now recognize Mrs. Blackburn for 5 minutes.
Mrs. Blackburn. Thank you, Mr. Chairman.
Dr. Frieden, let me come to you. As I mentioned in my
opening, keeping Americans safe, this is where our focus ought
to be. And you said in your testimony $621 million would be
used to fortify domestic public health strategies, and you
didn't mention the managing of waste products from patients
with Ebola. And according to the Institutes of Medicine report
from earlier this month, a patient with Ebola generates 30 to
40 times more medical waste than another patient. The report
also states there is limited ability to handle Ebola medical
waste in the U.S.
So I have a couple of questions. I can take a yes-or-no
answer on these and be very happy with that. It will help us
move quickly.
Will part of this funding, this $621 million, be directed
to managing the medical waste products from treating Ebola
patients, or will hospitals be expected to building on-site
incinerators or autoclaves to decontaminate the waste?
Mr. Frieden. Yes, funding will go to support hospitals to
strengthen their waste management systems.
Ms. Blackburn. OK, and then do you have any plans to
require sterilization of category A waste, including Ebola
waste, on-site or as close as the source--to the source as
possible?
Mr. Frieden. CDC already provides guidelines for the
management of waste potentially contaminated with the Ebola
virus, and we would continue to recommend those same
guidelines.
Ms. Blackburn. Does this include on-site?
Mr. Frieden. Decontamination can be done either on-site or
can safely be moved off-site----
Ms. Blackburn. Where is it going to go?
Mr. Frieden. Where we are supporting hospitals to deal with
Ebola, we would want that done on-site.
Ms. Blackburn. All right. Kind of got a little skirting the
question there. Do you plan to procure and utilize mobile
medical waste sterilizers?
Mr. Frieden. That would be one option that could be
considered.
Ms. Blackburn. Do you plan to do it?
Mr. Frieden. It would depend on whether it made sense for
the facility itself.
Ms. Blackburn. OK. What about the waste in Africa where we
are supporting efforts?
Mr. Frieden. In Africa, incineration is the method used for
waste disposal in general.
Ms. Blackburn. OK. On-site?
Mr. Frieden. Generally on-site, yes.
Ms. Blackburn. On-site, OK.
Dr. Lurie, I would like to come to you for a moment, if I
may please. The funding request includes $157 million for BARDA
to support the manufacture of vaccines and synthetic
therapeutics for use in clinical trials. Would this funding be
slated to support manufacturing at one of the 3 Centers for
Innovation in Advanced Development and Manufacturing that were
established through previous funding for BARDA, or are you
looking at other potential manufacturing partners?
Ms. Lurie. Right now, funding is being used, and it would
be anticipated to use to support both vaccine development,
vaccine manufacturing, and fill and finish vaccine capacity.
Also the continued capacity, and fill and finish of therapeutic
products such as ZMapp. We are actively engaged both with the
Centers for Innovation in Advance Development and
Manufacturing, and with the Fill/Finish Network components to
look at the role that they can play.
Mrs. Blackburn. So you are engaging other partners.
Ms. Lurie. We are engaging a range of partners----
Mrs. Blackburn. Private sector.
Ms. Lurie. Yes.
Mrs. Blackburn. OK.
Ms. Lurie. We are engaging the range of partners that it is
going to take to get us vaccine and therapeutics.
Mrs. Blackburn. OK. Well, we had read Secretary Burwell's
testimony last week, as I am sure you have, from the Senate
Approps. Committee, and it seems as if the funding for BARDA
would go to manufacturing quantities of those products that
undergo successful early development at NIH, and we know there
are several private companies who have committed significant
resources to development treatments or vaccines for Ebola, and
we want to make certain that those companies are involved in
processes going forward.
So it is my understanding you are saying you plan to
include them and invite them.
Ms. Lurie. So any company with a promising product is
always welcomed into BARDA, and we have a system to sit and
talk with them, determine whether they have promising
candidates, and for them to submit proposals that get
evaluated. What I can tell you in this sense is that it is
generally NIH's role to support the early development of
products. It is BARDA's role to support the advanced
development of products, and BARDA is, and will continue to
support the advanced development of both vaccines and
therapeutics, and to get them scaled up so that if they work,
they can be used in a mass vaccination campaign, or in
therapies.
Mrs. Blackburn. Thank you. I yield back.
Mr. Murphy. Gentlelady yields back.
I now recognize Mr. Waxman for 5 minutes.
Mr. Waxman. Thank you, Mr. Chairman.
Dr. Frieden, you and a number of other experts have said
numerous times, and you said it here today, the key to
protecting Americans from Ebola is stopping the disease at its
source in West Africa.
Can you explain the approach being taken in West Africa to
contain the spread of this disease?
Mr. Frieden. In brief, to identify patients who have Ebola
promptly, get them isolated and cared for safely, and in the
event that individuals die, have them buried respectfully and
safely without spreading disease. To turn off those 2 main
drivers of the infection; unsafe care and unsafe burial. That
is what we have done to date in every outbreak until now, but
the size, scale and speed required now remains daunting.
Instead of dozens or a handful of cases, still hundreds or
thousands of cases to deal with.
Mr. Waxman. So would you say the approach is working but
the epidemic is moving too quickly to keep up with the amount
of cases?
Mr. Frieden. I think the decrease in cases in some areas
within West Africa is proof of principle that the approach
works, but we are still very far from the finish line.
Mr. Waxman. Um-hum. Well, what are the consequences of
failure in Africa?
Mr. Frieden. If we are not able to stop the Ebola epidemic
in West Africa, the risks are very high that it would spread to
other parts of Africa because of travel within Africa. If that
were to occur, then it could be a matter of many years before
we would be able to control it, and the threat to the U.S. and
other countries would be proportionately greater.
Mr. Waxman. Well, some people say if that is the concern,
why don't we just seal off Africa, not let people travel here
from Africa. Would that solve the problem?
Mr. Frieden. From the standpoint of public health, we look
at first and foremost protecting Americans from risk,
protecting Americans from threats, and currently we have
systems in place that trace each person who leaves one of the
three affected countries, each person who arrives to the U.S.,
and follows them for 21 days. We have already had people
develop fever who have called up the Health Department with the
24/7 number that we provided to them, and have been safely
transported and safely cared for, and have ruled out for Ebola,
but those systems rely on knowing where people are coming from
and how they are getting here.
Mr. Waxman. The President has asked for more money in a
supplemental budget. A big portion of that is going to go to
our efforts in Africa to try to stop and contain this disease,
but some of that money is going to be used right here in the
United States to enhance U.S. Government response to the Ebola
outbreak. The request includes $621 million for CDC for
domestic Ebola response. Can you give a brief summary of what
programs and initiatives are covered by this funding?
Mr. Frieden. Thank you. These would allow us to work with
States so that all travelers are traced on a daily basis, and
if they become ill, are promptly and safely taken to a facility
that is ready to care for them. They would result in safer
hospitals, not just from Ebola but also other infectious
disease threats. There is a small research component that would
allow us to implement a vaccine trial, probably in Sierra
Leone, in the coming months to determine whether vaccination
works. Other research would help us with rapid diagnostics so
that we could detect more rapidly if someone became ill. We
also would support all jurisdictions to be better prepared for
Ebola and other infectious disease threats, have safer
hospitals, more rapid response, and work very closely between
the State and the hospital systems within the State on
infection control generally, Ebola and other deadly threats,
specifically, working very closely with the funding for ASPR
and other parts of hospital preparedness.
Mr. Waxman. Well, it seems to me that it shouldn't be
partisan in any way for us to give the grant of money the
President has requested to deal with this terrible epidemic in
Africa, and to protect Americans as well, and the request is
quite balanced in helping us deal with the situation as we now
have it. And past times, we have always had bipartisan support.
But talking about here in the United States, what if we had a
pandemic flu, that would certainly be a lot more dangerous
because of how fast it could spread. Would these funds help us
to deal with that? And secondly, are we prepared for a pandemic
flu? Do we have a stockpile of the medications, and are we
ready--as you said, we don't know what will come next, but if
that happened, are we ready for it?
Mr. Frieden. We always work to be better prepared today
than we were yesterday, and better prepared tomorrow than we
are today. A pandemic of influenza remains one of the most
concerning possibilities in all of infectious disease threats.
The funding in the emergency funding request would assist this
country, health departments, hospitals, the healthcare system,
the public, to be better prepared for Ebola and other
infectious disease threats, such as pandemic influenza, yes.
Mr. Waxman. OK, thank you. Thank you, Mr. Chairman.
Mr. Murphy. I now recognize Dr. Burgess for 5 minutes.
Mr. Burgess. Thank you, Mr. Chairman.
Before I start my questioning, I would like to submit for
the record this document from the American Hospital Association
for the record for today's hearing.
Mr. Murphy. Without objection.
[The information follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. And, Dr. Frieden, the administration's
additional funding request states that money will go toward 50
Ebola treatment centers throughout the United States. Some
States--Texas--have already started to designate sites on their
own. So will State-designated centers be included in that
number 50, or will that be in addition to?
Mr. Frieden. I will comment, and Dr. Lurie may want to
continue.
Our approach is to strengthen the statewide systems. It
would be the States that would be responsible for--in
collaboration and communication with hospitals, determining
which hospitals would be used, but what we have asked each
State to do is four things related to the active monitoring
program. First, establish the program, including information
flow from the State Health Department to local health
departments. Second, establish a 24/7 hotline for any traveler
or anyone who thinks they may have Ebola, to call so that they
can be safely managed. Third, establish safe transport between
wherever that person calls from, and the facility that the
State has decided will be the facility to assess them or treat
them for Ebola. And the fourth is to work with their hospitals
to identify facilities that are able to do that assessment and
treatment.
Mr. Burgess. I would just add, it would be great if you had
a 24/7 hotline for hospitals when they find that that suspected
patient is on their doorstep at 3 o'clock in the morning.
But, Dr. Lurie, let me ask you the same question. The 50
centers that are designated in the President's budget request,
is that in addition to the State-designated centers, or would
those two State-designated centers in Texas fall under the
purview of the 50 centers that President Obama is describing?
Ms. Lurie. So as Dr. Frieden said, our process and our
plans have been to work through the States to identify
facilities. The process works basically----
Mr. Burgess. So make----
Ms. Lurie [continuing]. As such----
Mr. Burgess. Make it real simple. The 2 centers that
Governor Perry has designated in the State of Texas, do those
fall under the parameters of what the President's budget
request as it exists today?
Ms. Lurie. The funding will go to the States, and the
States, in conjunction with the hospitals, will determine which
of the hospitals will serve as infectious disease containment
centers or the Ebola treatment centers.
Mr. Burgess. I guess that is as close as I am going to get
to an answer.
Let me just ask you a question, Dr. Lurie. Do you report to
Ron Klain? Is that someone how who is in the hierarchal
reporting structure that you have? Is he a person to whom you
report?
Ms. Lurie. I report to the Secretary, and I interface with
Mr. Klain on a very regular basis.
Mr. Burgess. Well, in your testimony, you say that, under
the national response framework, my office, your office is
responsible for coordinating the Emergency Support Function
Number 8 Response, which is listed here. So where does Mr.
Klain's responsibility fall in the Emergency Support Function
Number 8?
Ms. Lurie. So during different kinds of events in the
United States, whether they are national disasters or whether
they are other kinds of emergencies, either FEMA is activated,
as it is for hurricanes and floods, and I know we have worked
together in Texas on a number of those things, FEMA is
activated in Emergency Support Function Number 8, public health
and medical services are activated under that framework.
In other kinds of emergencies----
Mr. Burgess. And that is--let me just interrupt for a
minute. And that is under the coordination and control of
Secretary Burwell, is that correct?
Ms. Lurie. Emergency Support Function 8, yes.
Mr. Burgess. Does Mr. Klain have a role with Emergency
Support Function Number 8?
Ms. Lurie. So in this situation, we have not had a declared
national emergency, FEMA has not been activated, however, we do
have, obviously, a very serious situation in the United States,
and Mr. Klain is the national----
Mr. Burgess. Let me interrupt you for a moment because----
Ms. Lurie [continuing]. Coordinator for this country.
Mr. Burgess [continuing]. My time is going to run out. So I
guess it is not fair to say that you have an emergency plan,
but do you have a very serious situation plan that you are
working under?
Ms. Lurie. We are doing very aggressive planning, both for
what we have in the here and now, and for all the what ifs. And
we work across HHS and with all of the rest of the components
of the Federal Government on that what-if planning.
Mr. Burgess. And I am going to assume that you will be able
to make the details of that plan available to the committee
staff?
Ms. Lurie. It continues to be in draft. We continue to work
through the what-if with our partners across Government, yes.
Mr. Burgess. Well, yes was the answer, you will----
Ms. Lurie. Yes, we can--when we have the rest of the plan
together, it is something that is a whole-of-Government plan,
it is not an HHS plan.
Mr. Burgess. OK, well, it is time.
And then, Dr. Frieden, I just have to ask you. We had 2
nurses that worked at Presbyterian Hospital that were infected.
I am just going to tell you, when you get that call at 2
o'clock on a Sunday morning that a nurse has been infected, you
don't have a lot of confidence that things are working the way
they were outlined.
Do you have any insight as to how those two nurses became
infected, and what we can do to protect our healthcare workers
going forward?
Mr. Frieden. While we don't know definitively how those
infections occurred, the evidence points to them having been
infected in the first 48 hours after Mr. Duncan was admitted to
the hospital, before his diagnosis was confirmed. That is
consistent with the period of time between onset of symptoms
and exposure. It is also consistent with the observations of
the team from CDC that arrived on the day of diagnosis of Mr.
Duncan, and found that in the intense efforts of the healthcare
workers to protect themselves, they may have inadvertently
increased their risk by some of the ways that they were working
with personal protective equipment. And that is why CDC
immediately strengthened the margin of safety, and established
new guidelines for personal protective equipment that include,
as 2 critical components, practicing repeatedly so that
healthcare workers have comfort with the equipment they will be
using, and direct observation of every step of putting on and
taking off the protective equipment.
Mr. Burgess. And this just underscores why it is so
important to have those treatment centers available around the
country, because I can just tell you, the average ICU is not
set up for that type of activity of the donning and doffing of
the protective equipment.
I also have a problem with the time frame that you just
enumerated because Mr. Duncan's family never became
symptomatic, and I would suspect it is later in the course when
he was throwing off really massive amounts of viral particles
where the greater risk for exposure to those healthcare workers
occurred, but I am sure you and I will have future discussions
about that.
I will yield back.
Mr. Murphy. And just to clarify, Dr. Frieden, during that
time Mr. Duncan--at what point did he actually disclose that he
had been in Western Africa and been exposed to Ebola?
Mr. Frieden. My understanding is that he disclosed that he
was from West Africa on the earlier emergency department visit,
which started on the 25th of September. He was admitted on the
28th of September.
Mr. Murphy. OK, thank you.
Now Mr. Green is recognized for 5 minutes.
Mr. Green. Thank you, Mr. Chairman.
And to follow up my colleague from Texas, I know our State
has designated two locations, but about 2 months ago I was at
the Texas Medical Center in Houston and there was some interest
in trying to do that, too, and that may not be one of the two
locations that the Governor has designated, but I will have a
question later for Dr. Gold from the University of Nebraska how
it was unique that the University of Nebraska created that
facility there and how it happened.
But let me get to my questions for you, Dr. Frieden. What
is the process and timeline for updating and communicating
changes to protocols to local healthcare providers--because we
know there was an issue about that last month--what is the
process, or have the processes changed at the CDC from what we
did, say, in October?
Mr. Frieden. With respect to CDC guidelines, we use the
latest data, information and experience to develop guidelines.
We consult widely with affected parties to get input, and then
as soon as we have a clear set of guidelines that we
communicate, we then disseminate those through a wide variety
of networks.
Mr. Green. What we have learned from the fear is isolation
and personnel protection from the experience at Texas
Presbyterian, and how are these lessons being shared with other
hospitals so we can avoid the same errors. And, again, the
feeling that somebody shows up at 3 o'clock at one of my not-
for-profit hospitals in urban Houston, how are they going to be
able to deal with something like that?
Mr. Frieden. We are dealing with this from both sides of
the equation. First, the patient side, and what we have done is
for every single person coming from West Africa, they are
greeted, they are asked detailed questions, their temperature
is taken, and they are provided a care kit that includes a
thermometer, a log for taking their temperature, a wallet card
with a 24/7 number to call, and we have already had multiple
times in the past few weeks individuals take their temperature,
find that they had an elevated temperature, call that number,
be safely transported to, and safely cared for in, a facility.
They all ruled out for Ebola, but the system worked in those
cases.
We can't guarantee that it will work in every case, and
that is why we are working very intensively with hospitals
throughout the U.S. to prepare them for the possibility that
they could have someone with Ebola. We have released
guidelines, we have done, in conjunction with the rest of HHS,
training sessions, we have had hospital visits by rapid Ebola
preparedness teams to more than 30 hospitals in more than 10
States, and we will continue to work intensively with the
healthcare system so that they are increasingly well prepared
to address a possible case of Ebola.
Mr. Green. The CDC is not a regulatory agency. How can you
provide clarity over the CDC's authority and responsibilities
in setting and enforcement of these protocols? Do you have any
authority and enforcement over hospital settings?
Mr. Frieden. CDC provides guidelines and information. We
provide tools and feedback to facilities. We do not regulate in
this area. That would be up to other entities within the
Federal and State Governments.
Mr. Green. OK, thank you.
Dr. Lurie, without a commercial market, the development and
manufacture of many medical countermeasures, like those against
Ebola and other infectious diseases, require a public-private
partnership. Congress recognized this when it created the
Project Bioshield, successfully driving innovation by providing
a stable source of funding so that a reliable market for
medical countermeasures was in place.
Dr. Lurie, as you know, the development and medical
countermeasure for a biological threat agent can take a decade
or more, and often $1 billion to develop. The U.S. Government
research on Ebola countermeasures goes back a decade, but the
level of investment and urgency was not enough to prepare us
for the current situation. Can you provide a dollar figure on
how much investments you perceive is needed for Ebola vaccines
and drugs to allow us to get to the chance of successfully
developing a product?
Ms. Lurie. So I am sorry, I didn't hear the last part of
the question.
Mr. Green. OK. Can you give----
Ms. Lurie. Could I provide a dollar figure for what?
Mr. Green. Can you provide us an estimated dollar amount on
how much investment you perceive is needed for Ebola vaccines
and drugs to allow us the best chance of successfully
developing these products? Again, like I said earlier, our
research program in Ebola has been going on for a decade. Are
there any resources you could use that would--and how much
would we need to do to get the drugs----
Ms. Lurie. Absolutely.
Mr. Green [continuing]. And vaccines?
Ms. Lurie. And, in fact, one of the reasons that we now
have two vaccines that are finishing safety trials is because
of prior investments made across the U.S. Government in trying
to develop an Ebola vaccine, and also with Ebola therapeutics.
As you know--may know right now, those vaccines are finishing
those early trials and, thanks to money that was provided in
the CR, we have been able to accelerate some of the work both
on vaccines and on therapeutics.
Whether these vaccines work is going to be something that
we are going to learn over the next coming months with the
trial in West Africa. At the same time, we have now gone ahead
and invested in the advanced development of 3 other vaccine
candidates, and additional ways of scaling up and making the
therapeutics so that we never put all of our eggs in one
basket. We always want to do better, and we will continue to do
that through the investments.
We have really appreciated the support from Congress, from
BARDA, and Project Bioshield in this regard.
Mr. Green. OK, thank you, Mr. Chairman. I know I am out of
time, and I want to thank our colleague--our panel today, and I
am waiting for our second panel.
Mr. Murphy. Gentleman yields back.
Now I recognize the chairman emeritus, Mr. Barton, for 5
minutes.
Mr. Barton. Thank you, Mr. Chairman.
And Congressman Green didn't want to brag, but he has a
family member who is very active in this up at Nebraska, and we
appreciate his family being on the frontlines, and I am sure he
is--I think it is your daughter--isn't it your daughter that
works up there? So we want to welcome out witnesses, and on the
second panel, Dr. Lakey, from Texas, we are glad that you are
here.
My first question, I am going to ask the Rear Admiral, the
Acting Surgeon General. I believe that we should treat this
first and foremost as a health issue and not as any other kind
of an issue, and it puzzles me that we have not really
effectively put in a travel ban from West Africa. I know we
have alerted people and all of that, but when we had the
hearing down in Dallas-Fort Worth, at the airport, the answer
we got was because we need to send personnel over there, we
don't want to prevent people traveling to here.
As a pier public health official, as the Surgeon General,
why would we not put in a true quarantine and just flat prevent
any travel from West Africa?
Mr. Lushniak. Well, certainly, as stated, and have a strong
belief in this, is that currently as we have it, you know, the
idea of having a travel ban prohibits all travel. To some
extent there is that sense of travel of healthcare workers to
Western Africa, and I stated earlier the real resolution to
this issue is solving the problem in West Africa, but at the
same time, instilling a travel ban has a total loss of control
of who enters and how they enter this country. And as Dr.
Frieden stated earlier, we have set up these systems, the
systems that are in place right now allow us to know where
people are coming from, it allows us to track them
appropriately through the public health endeavors at the State
and local level, and to be able ultimately to follow them
appropriately, to be able to intervene if symptoms appear, and
then be able to direct them, detect them appropriately and to
instill the right response for that.
So right now as the system works, as the Acting Surgeon
General, I find that the appropriate course of action.
Mr. Barton. OK. Well, it just puzzles me, if we were to
have a health outbreak, tuberculosis or something, there
wouldn't be any question in my area that the Texas Department
of Health would put a true quarantine in place. And I
understand some of the external reasons, but, you know, if you
are trying to contain an epidemic, it is old-fashioned but an
absolute ban and absolute quarantine does work.
I want to ask Dr. Frieden, there has been some concern that
perhaps we don't really know how this disease is transmitted,
and unless something has come out very recently, some of the
individuals in Texas that were potentially infected and put on
the watch list had no apparent means of transmission, yet they
were symptomatic. Is your agency conducting any research right
now to see if perhaps there might be more methods of
transmission than we think exist today?
Mr. Frieden. We do a broad variety of research specifically
on Ebola and on the public health spread and epidemiology of
it. The two infections that occurred in this country of the two
nurses at Texas Presbyterian are infections that occurred at a
time when Mr. Duncan was highly infectious. He had production
of large quantities of highly infectious material, through
diarrhea and vomiting, and that would be our leading
explanation of how they are most likely to have been infected,
although we do not know for certain.
We describe what we see, and what we see in Africa is that
people become infected by caring for or touching someone who is
either very ill with Ebola or who has died from it. And when we
analyze the amount of virus in a patient's body, it goes from
undetectable when they are exposed but not ill, to very small
quantities when they first become ill, and then as they get
sicker, the quantities increase enormously. And if someone dies
from Ebola, the quantities are quite large----
Mr. Barton. Well----
Mr. Frieden [continuing]. Of infectious material.
Mr. Barton [continuing]. As a medical professional
yourself, what is your confidence level that there is no other
method of transmission than we know about today? In other
words, are you 100 percent certain that there is no other way,
are you 70 percent certain?
Mr. Frieden. In medicine, we say never say never. So I
would not be surprised if there were unusual occurrences of
spread from a variety of ways, but the way it is spreading by
and large in Africa, the way it spread here, and the risk to
people here are brought by those two main mechanisms of
touching body fluids of someone very ill. I will mention that
one of the things that we looked at in our new guidance in the
U.S. is what is done in U.S. healthcare facilities is very
different from what is done in African healthcare facilities.
There is more hands-on nursing care. There may be artificial
respiration or ventilation of someone, and that may generate
infectious particles and that is why we have strengthened the
level of respiratory protection in our personal protective
equipment----
Mr. Barton. Thank you.
Mr. Frieden [continuing]. Guidelines.
Mr. Barton. Thank you, Mr. Chairman. My time has expired.
Mr. Murphy. Thank you.
Now I recognize Mr. Braley for 5 minutes.
Mr. Braley. Thank you, Mr. Chairman.
And, Dr. Lurie, I want to clarify some of the questions
that Congresswoman Blackburn was asking you earlier because, at
our first hearing on October 16, Dr. Fauci was kind enough to
present us with some materials and walked us through them,
including this product development pipeline, which I think you
described in your testimony, talking about early concept and
product development being the province of NIH, the advanced
development being the province of BARDA, then commercial
manufacturing by the industry itself, and then regulatory
review. And then the next page in his presentation dealt with
Ebola therapeutics and development. It is my understanding
these are the treatments that are being developed for the
symptoms of the Ebola virus, as opposed to a vaccine that would
hopefully prevent the virus from spreading, correct? And then
he had a slide that talked about the Ebola vaccines that were
in or approaching phase 1 trial. The first one is the
GlaxoSmithKline, the second one was NewLink Genetics, which is
based in Ames, Iowa, and when I asked him questions about that
at the time, and I also questioned Dr. Robinson, in this
particular slide, it appeared there were only two companies;
GlaxoSmithKline and NewLink, that actually had phase 1 trials
ongoing.
Has there been any change to that since our hearing on
October 16?
Ms. Lurie. Since the hearing on October 16, the phase 1
trials have been underway. They are almost completed. We are
analyzing the data, and I think we are all very optimistic that
we will be able to start the next phase of the trial, which
will be a randomized control trial with both of those vaccines
in West Africa.
Mr. Braley. This slide indicated that there was a third
company, Crucell, but they were not expected to engage in phase
1 trials until the fall of 2015, which is a substantial ways
away from where we are today.
Ms. Lurie. There are other potential vaccine candidates in
the pipeline. We are supporting some of those, but you are
right, they are behind this timeline, and we are right now
focused on trying to figure out if these vaccines are safe and
effective, and if they are, get them into use to control the
epidemic in West Africa.
Mr. Braley. And----
Ms. Lurie. So part of the emergency funding request will be
$157 million for BARDA to continue to accelerate the
development and manufacturing of vaccines and therapeutics for
this outbreak.
Mr. Braley. And my understanding from talking to the folks
at NewLink Genetics is that these clinical trials that have
been ongoing at Walter Reed and the National Institute of
Allergy and Infectious Disease have been progressing well, that
there has been good rapport between the oversight agencies and
the company involved, and that there is continuing to be
ongoing interactions with the Department of Defense sponsors as
well, which would be the Defense Threat Reduction Agency and
the Joint Vaccine Acquisition Program. Is that your
understanding as well?
Ms. Lurie. That is. In fact, every week, either once a week
or twice a week, I run a call with all of the parties, NIH,
CDC, FDA, BARDA, the DoD components, so that we are all joined
at the hip through every step of the process. We know what is
going on, we share information, we know what to anticipate.
FDA has been a really key partner in this as well because,
in fact, it is their regulatory authority that is going to
determine, you know, ultimately what moves forward and what
doesn't, as well as, obviously, the results from the trial. I
never thought I would find myself in this situation, but I am
saying we are all racing to catch up with FDA. It is a great
situation to be in, that everybody is working extremely
effectively together.
Mr. Braley. Great.
Dr. Lushniak, Mr. Barton asked you a question about trying
to contain an epidemic with an absolute quarantine. Is there an
Ebola epidemic in the United States right now?
Mr. Lushniak. There is not an Ebola epidemic in the United
States. The epidemic is, at this point in time, limited to
Western Africa, and once again, that is why we are trying to
contain it there.
Mr. Braley. And one of the things that we have talked about
during these hearings is the importance of focusing on facts
and science and medicine. In 1900, the two leading causes of
death in this country were influenza, pneumonia and
tuberculosis, and neither one of those are a leading cause of
death anymore because of the response of science and medicine
and public health.
So when you look at the fact that, in 2012, there were 35
million people living with HIV around the globe, and that there
are currently 14 to 15,000 diagnosed cases of Ebola, it seems
to me that, with the proper application of science and medicine
and public health, we should be able to manage this crisis if
we devote the necessary resources on a global basis. Would you
agree with that?
Mr. Lushniak. Yes, I agree.
Mr. Braley. Thank you.
Mr. Murphy. Mr. Scalise, you are recognized for 5 minutes.
Mr. Scalise. Thank you, Mr. Chairman, and I appreciate you
having this second hearing on Ebola. And I want to thank the
panelists for coming. I would have liked to have seen Mr. Klain
be a part of this. I know the committee has made a request for
him to appear. I am not sure what, you know, if he is the Ebola
czar, what his real role is if he is not going to be coming
before the committees that hold the administration accountable,
and have some transparency to talk about it. I hope he is not
planning just to be a propaganda czar; that he would actually
be focused on working with us to get solutions to this, but I
do want to thank the panelists that are here.
Dr. Frieden, the last time that you were here we had talked
about a number of things. One of those was the comments that we
heard from Samaritan's Purse. It is a group that is going to be
on the second panel. I am not sure if you saw their testimony.
One of the things I had asked you about were some of their
comments they had previously made, that they were blown off, in
essence, by your agency, and I had asked if you knew about
that. You said you had heard about it, hadn't looked into it.
Have you looked into it to see what is going on? There are some
people in your agency that maybe warrant taking advice from
groups like that seriously enough. Can you follow up on that
last conversation we had about those complaints that
Samaritan's Purse made?
Mr. Frieden. I am not familiar with suggestions or
complaints or concerns that have been raised with us that we
have not addressed. I have received one communication from
Samaritan's Purse, a very helpful communication about safety of
our own staff, and we immediately acted upon that.
Mr. Scalise. At the last hearing, I had read to you some
comments that they had made. One was a quote where they said
they kind of blew me off, and then they made some other
comments that implied that maybe they weren't being taken
seriously by your agency. They never said it was you, but I
asked if you had looked into that or heard about it. Your quote
was, ``I don't know that that occurred,'' and then you had said
you would look into it, and so that is why I was asking if you
had looked into it since our last hearing.
They make some other claims in their testimony that they
are going to give today. This is some of the comments that they
make: ``Many public health experts are telling us that we know
the disease, how to fight it and how to stop it. Everything we
have seen in this current outbreak, however, suggests that we
do not know the science of Ebola as well as we think we do.''
Do you agree with that statement, or have any response?
Mr. Frieden. I think we are certainly still learning about
Ebola and what is the best way to fight it. That is a critical
component of our activities, it is a critical component of the
emergency funding request as well.
Mr. Scalise. All right. They also say the disease has been
underestimated from day 1. Do you know if that maybe was going
on, is it still going on, do you think that it was being
underestimated, maybe now not being underestimated to that
level?
Mr. Frieden. CDC publications estimated the degree of
underreporting could be as high as a factor of 2.5 back over
the summer. Our sense is that that is likely to have decreased
in some areas. Fundamentally, the more out of control it gets,
the more systems don't keep up with it, including systems to
track the disease, and if patients don't have a place to come
in, they are much less likely to be counted and accounted for.
Mr. Scalise. Is there any new conversation that you have
had with the administration, especially the White House, about
what has been talked about by a lot of our Members of having
some sort of travel ban, or at least a holding period for folks
who are over there, having direct contact with people in West
Africa that have Ebola, and then come back into the United
States, to at least have some longer period to look at them to
make sure they don't come back with Ebola? Have you all had
those conversations since we last met?
Mr. Frieden. Yes, we have. My top priority as CDC director
is to protect the American people, and I have said, and others
have said, that we will look at anything that will reduce the
risk to Americans. What we don't want to do is inadvertently
make it worse by, for example, interfering with the system that
we have now which allows us to track people when they leave,
when they arrive, and for 21 days after. We are at 100 percent
follow-up in most States for people who have come into this
country, and that kind of system, if we don't have it, could
result paradoxically in a greater rather than a lower degree of
risk.
Mr. Scalise. Well, let me ask you about Ron Klain because,
again, we did ask that he come and participate in this. He has
been designated by President Obama as the Ebola czar. Have you
had contact with him about strategy about how to deal with
this?
Mr. Frieden. Mr. Klain is the Ebola Response Coordinator. I
have frequent contact with him. He coordinates the response of
different parts of the U.S. Government. He advances----
Mr. Scalise. Have the two of you all had any disagreements
on how to approach this?
Mr. Frieden. No, we have not.
Mr. Scalise. None. If you did, who would ultimately make
the decision, if you felt we ought to go this way and he felt
the administration ought to go that way, is there a hierarchy
right now?
Mr. Frieden. Mr. Klain has been very clear that technical
decisions, scientific decisions that are the purview of CDC are
made by CDC.
Mr. Scalise. All right, I am out of time, and I appreciate
your answers. And thanks for coming again.
Thanks. Yield back.
Mr. Murphy. OK, gentleman yields back.
Now I recognize Mr. Tonko for 5 minutes.
Mr. Tonko. Thank you, Mr. Chair, and thank you to our
panelists for your dedicated work on this issue, and for
appearing before us today.
We have heard time and time again that the key to keeping
the United States safe is to eradicate the virus at its source,
and while we have had early indications of momentum begin to
emerge in Liberia, it seems as if the situations in Sierra
Leone and Guinea are not showing the same promising signs.
So, Dr. Frieden, in your opinion, do we have the resources
deployed in these countries to turn the tide of Ebola, and if
not, what additional resources are needed?
Mr. Frieden. The emergency funding request is essential to
our ability to both protect ourselves here at home and stop
Ebola at the source, and also to prevent the next Ebola. There
are too many blind spots, too many weak links in places in
Africa and elsewhere where we have large amounts of travel,
where we have animal-human interface, and we have large numbers
of people, and that is why all three of the CDC components of
this, and all of the components of the emergency funding
request are so important. The three CDC related components are
domestic preparedness, stopping Ebola in West Africa, and
preventing the next Ebola through our global health security
work.
Mr. Tonko. Thank you. And I know that as of a few weeks
ago, the count on the ground through CDC is four individuals
from CDC in Guinea. While I know that France is taking the lead
on Ebola response in this country, does the United States need
to take a more leadership-active role, or does it have the
capacity to do so?
Mr. Frieden. Excuse me. For the CDC-specific response, we
provide a comprehensive public health approach in each of the
affected countries. As of today, we have approximately 175
staff on the ground in West Africa. We actually have the most
staff in Sierra Leone, where the needs are greatest. We also
have more than 20 staff, or roughly 20 staff, in Guinea, but
there are additional needs for staff in Guinea, and we have
worked very hard with the African Union and with other partners
to get French-speaking staff there. With the cluster in Mali,
we now have 12 staff as of today in Mali dealing with that
cluster and trying to stop it at the source.
Mr. Tonko. And what about engaging a more international
impact? How does the international community get engaged to
devote its additional resources for this world health crisis?
Mr. Frieden. There has been a very robust global response.
My understanding is that currently contributions from other
countries total more than $1 billion. The World Bank has been
very proactive and effective. Also we have seen the UK stepping
up in Sierra Leone, and increasingly French and EU support to
Guinea and other areas.
Mr. Tonko. Um-hum. And, Dr. Frieden, we keep hearing that
there is a great need for medical volunteers to travel to West
Africa. Do you have a sense of how many medical personnel are
needed, and how would one get involved?
Mr. Frieden. For American healthcare workers, the U.S.
Agency for International Development, USAID, maintains a Web
site. On that Web site you can go and volunteer.
We ask that Americans who want to be involved do so through
another organization, so they are not going as individuals but
as part of an organized approach. And there is a broad need for
assistance, including French-speaking assistance, including not
just clinical care, but also epidemiologic interventions and
public health measures.
Mr. Tonko. So that is reaching out for volunteers. Is there
any activism in terms of encourage or recruiting personnel?
Mr. Frieden. There has been quite a bit of effort by
individual organizations within the U.S., as well as USAID. For
our own part at CDC, we are looking at epidemiologists among
not only our own staff, but former staff and people from the
broader public health community who may be able to deploy.
What we are finding is that this is going to be a long
road. It is going to take many months, and so we need people
who are willing to go not just for a week or a month, but for
several months or longer, so that they can get that maximum
effectiveness by being there. Although for the clinical
interventions, where you are working in the isolation unit, we
would like to limit that to 4 to 6 weeks at most so people can
be well-rested, and minimize their chance of taking a risk that
might result in infection.
Mr. Tonko. Um-hum. And, Dr. Frieden, we have heard
anecdotally that hospitals across the country are having
difficulty sourcing PPE. What is the CDC's role in facilitating
the PPE supply chain and the allocation of these PPEs, and
could the U.S. ramp up manufacturing of PPE needed to contain a
domestic Ebola outbreak?
Mr. Frieden. Dr. Lurie and ASPR can address some of the
manufacturing aspects. From the CDC perspective, we operate the
Strategic National Stockpile. We have already stockpiled PPE to
enable us to rapidly, within hours, deploy PPE to any hospital
within the U.S. That is one of the components of the emergency
funding request, but in addition, we have conducted what are
called REP, or rapid emergency preparedness, visits to more
than 30 hospitals in more than 10 States. One component of that
is addressing whether they have sufficient PPE. We have
prioritized hospitals near those five airports where people
come in, or where a large number of the African diaspora live,
and we already have identified dozens of hospitals which are
prepared in terms of their procedures and have ample PPE, but
we understand that not every hospital in America can get every
amount of personal protective equipment they want, and that is
why Dr. Lurie's office has been working closely with
manufacturers to both ramp up manufacture and prioritize those
facilities most likely to need it. And we have been working
with the SNS, or Strategic National Stockpile, to have PPE that
we could deploy very quickly to hospitals around the country.
Mr. Tonko. Thank you.
I yield back, Mr. Chair.
Mr. Murphy. Thank you.
Mr. Harper is recognized for 5 minutes.
Mr. Harper. Thank you, Mr. Chairman, and thanks to each of
you for being here and shedding some light on this evolving
situation.
And both you, Dr. Frieden, and you, Dr. Lurie, have told us
that this emergency funding request supports non-immediate,
non-Ebola-specific funding as part of this. Not all of this
would be directly for Ebola, would it?
Mr. Frieden. No, I would disagree with that.
Mr. Harper. OK.
Mr. Frieden. The request is divided into 2 components;
immediate and contingency.
Mr. Harper. All right.
Mr. Frieden. All of it is addressing Ebola. It addresses it
with respect to the CDC in three ways; domestic preparedness
for Ebola and other infectious disease threats, because we
think it would be most responsible to not only address Ebola,
but also strengthen our system more broadly. Stopping Ebola in
West Africa, and addressing the risk that there will be another
Ebola outbreak, spread of Ebola, or spread of a disease like
Ebola elsewhere in the world through the global health security
component.
Mr. Harper. Could not some of that be handled through the
traditional appropriations process?
Mr. Frieden. The situation is urgent with respect to Ebola.
CDC models indicate that for each month of delay in control,
the size of the outbreak can triple. So as a CDC director, I am
not going to address the mechanism, but I can say that the need
for urgent funds, with flexibility in those use of funds, is
crucial.
Mr. Harper. If I could, Dr. Frieden, ask you, you had
commented earlier that 2,000 travelers had been monitored, or
are being monitored. How many are being monitored this moment?
What is that number?
Mr. Frieden. It is roughly 1,500. The number of travelers
entering is lower than it had been previously.
Mr. Harper. Who maintains that list of who is being
monitored?
Mr. Frieden. So every person who comes through, goes
through the CBP process, Customs and Border Protection. We work
in conjunction with CBP. That information is collected from the
travelers, and within hours, we provide it to each State health
department. We then monitor with the State health departments
and resolve challenges, if someone is hard to find or moves
from State to State.
Mr. Harper. OK, are there any that were being monitored
that you have lost track of?
Mr. Frieden. A tiny fraction. Actually, less than 1 percent
have been monitored and then not found. Some of those were
later found to have left the country to go back on travel or
otherwise. The program is relatively new, it only started about
a month ago, and what we are finding is an excellent
participation from the States and the travelers, but it is
challenging, and one of the things that would be supported in
the emergency funding request are funds for State health
departments to operate those systems.
Mr. Harper. And of those that are being monitored, how many
are being told to seek medical attention?
Mr. Frieden. We do expect that there will be a steady
stream of people with symptoms. It you just take a set of 1,500
adults, you are going to expect some to have flu, some type of
other illnesses, and from West Africa, more, because malaria is
common. So, for example, in the past several weeks, there have
been four individuals who used the care kit to check and report
Ebola, that we provided them at the airport, took their
temperature, found that it was elevated, called the number that
they were provided with, were safely transported to a
healthcare facility, and safely cared for there. They all ruled
out for Ebola, but they were cared for in a safe way.
Mr. Harper. All right, let me ask for just a moment. We
talked a little bit today about waste management, and what to
do about the waste of treated Ebola patients. Is any of that
waste being transported across the country as part of this
process?
Mr. Frieden. My understanding is that some of the
facilities are autoclaving it, and that the decision of the
waste management companies was then to take that autoclaved
material, which is, as far as everything we know, sterile, and
then moving it to another State for incineration.
Mr. Harper. OK, and so that is meaning that the waste is
being transported across the country?
Mr. Frieden. This is really a----
Mr. Harper. I know it is being autoclaved, but anything not
being autoclaved that is being transported?
Mr. Frieden. I am not aware of anything in that category at
present.
Mr. Harper. If it is being transported through various
States, are the States notified of that transport?
Mr. Frieden. I am not familiar with the details. The EPA
has been looking at different measures. They have had a meeting
with the medical waste hauling industry to get input from them.
We have worked with the Department of Transportation, and what
we have done in the individual cases is ensure that there is
the appropriate authority in place from the Federal level, from
DOT, and from the State level for the management of waste.
Mr. Harper. I yield back.
Mr. Murphy. Mr. Long, you are recognized for 5 minutes.
Mr. Long. Thank you, Mr. Chairman.
Dr.--is it Lushniak?
Mr. Lushniak. Yes.
Mr. Long. OK, you said that a travel ban, I think I am
quoting you right, would cause us to lose contact on how many
people are traveling to this country. What do you mean by that?
Mr. Lushniak. Well, right now, we have a system, and the
system is an open system. We know when people are entering, we
know where they are coming from, we know, through our
cooperative efforts with the Customs and Border Protection
people, of when they are arriving. They are arriving through
five funnels, airports, right now, and we have that
connectivity. With a travel ban, you know, the essence of a
travel ban is what--no one moves, however----
Mr. Long. It is from those countries----
Mr. Lushniak. It is from those countries----
Mr. Long [continuing]. That are hot zones.
Mr. Lushniak. But at the same time, there is this potential
that people move from country A to country B, from B to C, from
C to the United States, and they can very well be from Western
Africa. So in our, you know, or my assessment of this, in
essence, is what we have right now is a system, and a system
that works following these individuals who are coming from
Western Africa, from the affected nations----
Mr. Long. But if they weren't coming, if we had a travel
ban on them, how could we lose track of them?
Mr. Lushniak. Well, through multiple routes. It is
rerouting from one country to another, to another. In other
words, the United States----
Mr. Long. They are not going to have a passport or a visa
or something that says where they started?
Mr. Lushniak. Well, again, that system can be sort of
worked around, if you will. You know, right now, we have a
precise system, a system that is allowed to follow people who
come in. We know where they are coming in from, which allows us
to follow them.
Mr. Long. I am from Missouri and you have to show me. I
mean that doesn't follow to me, it doesn't make any sense that
if we had a travel ban from these hot zone countries, if they
weren't coming in from those countries, how we could lose track
of them.
Mr. Lushniak. Well----
Mr. Long. If they are not coming in the first place----
Mr. Lushniak. Um-hum.
Mr. Long [continuing]. And if they want to do a workaround,
we are going to have on their passport where they started,
correct?
Mr. Lushniak. Potentially, if the passports are correct, if
they have not been manipulated.
Mr. Long. Dr. Frieden, let me ask you. You were talking
about the travel ban also, and you said that there are less
people coming in now, and the last time we were here, I believe
it was October the 16th, when you were last in to testify, at
that time, the number we were using was 100 to 150 people per
day. Do we know what that number is now?
Mr. Frieden. From the data that I have seen until recently,
it has been closer to 70 to 80 per day.
Mr. Long. So it has been cut by about 50 percent for one
reason or another.
Mr. Frieden. That is my understanding.
Mr. Long. And some people seem to think that if we just
wrote a big check or gave you an unlimited checkbook, that this
problem would go away. Do you think enough money would fix this
problem?
Mr. Frieden. I think we have the ability to stop Ebola, but
that is going to require doing what the emergency funding
request asks for, strengthening our system here at home,
stopping it at the source in Africa, and preventing another
Ebola or Ebola-like situation where the world is most
vulnerable.
Mr. Long. There was a story out yesterday on the AP, and I
am sure you have seen the story, of a nurse that was diagnosed
with Ebola in Mali, and she was diagnosed with Ebola after she
had deceased. That is the first time they knew she had Ebola.
And I know she worked in a hospital and a care center that
dealt with the elite. Some people would probably call them the
1 percent of Mali, but she dealt with people in the elite, also
U.N. peacekeepers that had been injured, and after she
deceased, they found out she had Ebola and they didn't know
where it had come from. And the first Ebola death in Mali was 8
days after we had our last hearing in here, I think it was the
24th of October was the first death. Then they went back and
they were trying to figure out how she had contracted this, and
then they went back and they found out that there was a 70-
year-old gentleman that had come from, I don't know if it was
Sierra Leone or where it was, but one of the--I think it was
Guinea, he came from Guinea--and apparently the person that
brought him to the hospital later deceased, they are not sure
that was Ebola, but they found out that instead of kidney
disease, he deceased from Ebola. And it is just disconcerting
to me and my constituents how, in a hospital in that area, that
they didn't even know that she obviously had symptoms before
she passed away from Ebola. And one thing, just to wrap up
really quickly, I know I am kind of hitting two or three
different areas, but Dr. Spencer, we heard one of the folks on
the other side of the aisle earlier say that he self-
quarantined, took care of himself. Was he not very misleading--
he didn't answer where he had been. He said he had been home in
his apartment, and they checked the subway passes and they
checked his credit card and things and found out that he had
actually been to the bowling alley, that pizza parlor, and
taking public transportation, did he not, in New York?
Mr. Frieden. So in terms of the Mali situation, we have 12
staff on the ground there now.
Mr. Long. Right.
Mr. Frieden. And as----
Mr. Long. And they have been there how long?
Mr. Frieden. We have had staff in Mali since before their
first case----
Mr. Long. OK.
Mr. Frieden [continuing]. Helping them with Ebola
preparedness. And then the 2-year-old who died, who you
mentioned, was unrelated as far as we know to the current case.
The 70-year-old gentleman who died actually lives in a town
that is on the border.
Mr. Long. I am talking about a nurse that passed away, not
a 2-year-old. I didn't mention a 2-year-old, so this----
Mr. Frieden. No, the source case for that nurse is the 70-
year-old who you mentioned, sir. He lived in the town of
Kurmali, which is on the border between Mali and Guinea, and
his Ebola diagnosis was not recognized. He had other health
problems. People thought he had died from the other health
problems. And there is now a cluster of cases there, and we are
working very intensively to try to stop it because, given the
challenges of Mali, if Ebola gets into Mali, it is going to be
very hard to get out, so we are hoping to be able to stop
that----
Mr. Long. And they went back 3 weeks later and tried to
sanitize the mosque that he had been prepared for burial in,
correct?
Mr. Frieden. That is my understanding.
Mr. Long. So I would like to see, as I said back on the
16th, a travel ban, and I still don't understand how you can
lose track of people that never came in the first place.
I yield back.
Mr. Murphy. Thank you.
Mrs. Ellmers, you are recognized for 5 minutes.
Mrs. Ellmers. Thank you, Mr. Chairman, and thank you to our
panel.
Dr. Frieden, one of the things that I have been doing is
reaching out to the hospitals in North Carolina, and in my
district alone, I have a number of hospitals that are saying
that they are experiencing delays in receiving some of the
protective equipment and protective wear that they need--
specifically, a short supply of Tyvek suits, shrouds, and N95
masks. They are being told that it could be 6 to 8 weeks, or
possibly even longer. What role does the CDC play in this, and
why would there be a delay in this equipment?
Mr. Frieden. We have looked at three levels of hospitals.
First, the hospitals around the airports. We want to make sure
that they have ample supply. Also, the hospitals, I should say,
which are the specialty facilities like Nebraska, Emory and
NIH. Second is the facilities where large numbers of people
from the African diaspora live, where we might have another
case. And third is all of the other facilities in the country.
And given the number of facilities, there is not currently
enough PPE on the market of some of the products to give every
hospital as much as they would like.
At CDC, we have a Strategic National Stockpile, and that
stockpile already has enough PPE to distribute to hospitals
that urgently need it within hours. We also have worked,
through our rapid Ebola preparedness teams, or REP teams, with
several dozen hospitals around the country to get them ready.
When we work with them, we have found that, although they might
have shortages of some protective equipment, they have been
able to meet those shortages by contacting the manufacturers.
And I understand that what Dr. Lurie and her office has done is
to work with the manufacturers to both scale up, so they are
working very hard to produce more, and prioritize facilities
that are most likely to need supplies. For some of the
products, such as N95s----
Mrs. Ellmers. Um-hum.
Mr. Frieden [continuing]. We have ample supplies in the
Strategic National Stockpile, and we could provide as needed.
Mrs. Ellmers. OK. And, Dr. Lurie, do you want to comment on
that as well?
Ms. Lurie. Sure. One of the things that my office has done
through our critical infrastructure programs, since the very
beginning, is we try to work with the manufacturers and
distributors.
Mrs. Ellmers. Um-hum.
Ms. Lurie. I have personally spoken to the leadership at
each of the manufacturing companies, and each of them now have
gone to 24/7----
Mrs. Ellmers. Manufacturing.
Ms. Lurie [continuing]. Three shifts a day manufacturing.
Mrs. Ellmers. Um-hum.
Ms. Lurie. In addition, they have all made a commitment to
work with us, and we are actively doing this so that if a
hospital is on our first list of being----
Mrs. Ellmers. Um-hum.
Ms. Lurie [continuing]. Really ready to take care of Ebola
patients, or needs PPE urgently, they will prioritize the
orders.
What they told me, very interestingly, is that because a
lot of people are frightened, that many hospitals are, they
think, double and triple ordering PPE from different
distributors and different manufacturers because they want to
be sure that they get some.
Mrs. Ellmers. Um-hum.
Ms. Lurie. So part of our job is to be sure working within
that people get what they need. And as Dr. Frieden said,
through the Strategic National Stockpile, we are very confident
that we can get enough PPE to any hospital that has an Ebola
patient.
Mrs. Ellmers. OK.
Ms. Lurie. We also want to be sure that they have enough.
The manufacturers and distributors have also developed some
training material, so you don't have to train on real PPE. They
will go out to a facility----
Mrs. Ellmers. Um-hum.
Ms. Lurie [continuing]. And let you use other kinds of----
Mrs. Ellmers. Um-hum.
Ms. Lurie [continuing]. Samples to practice.
Mrs. Ellmers. To practice, OK.
Dr. Frieden, in relation to travel, I have been in touch
with my local airport, Raleigh-Durham International, and
obviously, that is not one of the five designated airports, but
I am concerned about our Customs and Border Protection
officers. They are the first line. They would be the first to
come in contact. They are not healthcare professionals. With
this increased threat of Ebola, has the CDC prepared or
dedicated additional funds to those airports outside of the
five designated to help with training and personnel issues?
Mr. Frieden. Part of the emergency funding request is to
ramp up some of the quarantine services. Our focus is working
in the five funneled airports now, and we have worked very
closely with Customs and Border Protection. It has been an
excellent partnership. We have provided training, information,
but we understand that there is a desire for more information.
With the funneling process, we are now able to ensure that
almost all travelers go to those five airports.
Mrs. Ellmers. One last question: Is the CDC working with
OSHA and Department of Labor on helping hospitals to be trained
and up and ready for the preparedness?
Mr. Frieden. Yes, OSHA has been part of the CDC teams and
offers its services and information to hospitals that are
working on preparedness.
Mrs. Ellmers. OK, great. Thank you.
Mr. Frieden. Thank you.
Mrs. Ellmers. And I just want to say also that I wish that
Mr. Klain was here with us today as part of this panel because
I think the information that our new Ebola czar--that he could
provide some very important information, so I just want to
state that. Thank you.
Mr. Murphy. The gentlelady yields back.
I now recognize Mr. Olson for 5 minutes.
Mr. Olson. I thank the Chair. And welcome to our witnesses.
My home is Texas 22. It is a suburban Houston district.
Many folks who live there work down at the Texas Medical
Center, and many live in rural parts of Texas 22. Needville,
Texas, where cotton is still king.
The Ebola case in Dallas spooked them. It spooked them
badly. Two schools in Cleveland, Texas, shut down for days
because two students were on a flight coming back from
Cleveland with that nurse who had been exposed. Cleveland is
closer to Houston than it is to Dallas. Galveston, Texas, had a
cruise ship docked there came home early because a nurse from
Dallas self-imposed-quarantined herself in her cabin. The waste
coming from Dallas is coming down to Galveston UTMB to be
incinerated in 55 gallon drums, 1,800 degree Fahrenheit to
completely burn the waste from treating Ebola cases in Dallas.
Everything that goes to Galveston comes through Texas 22.
One common frustration I have heard over and over back home is
the deluge of information coming from CDC and all of you all.
It is confusing and overwhelming. I have heard that from big
hospital systems and small providers. Emergency centers like
St. Michaels in my own town of Sugarland, Texas. I am worried
about the little guys like St. Michaels.
Now, the question for all three panelists, the first one is
for you, Dr. Frieden. What is your organization doing to ensure
that small guys like St. Michaels are ready if an active Ebola
patient shows up at 2:00 in the morning on Thanksgiving night?
Mr. Frieden. Three things. First, we are working with the
travelers themselves so that they know where to go, they have a
number to call, they are checking their own temperature so that
they can promptly identify if they have symptoms and be cared
for before they become severely infectious. Second, we are
providing information through our Web site, through webinars,
through demonstration and training practices to hospitals
throughout the U.S., as well as hands-on training through our
REP teams and our CERT Teams if there were to be a case. And
third, we are working very closely with State health
departments which we really think are key here. And one of the
critical components of the emergency funding request is
strengthening and providing more resources to state health
departments exactly for this; to strengthen infection control
for Ebola, other deadly threats, and things that are daily
endangering the health of patients throughout the country. And
we think that state health departments and hospitals have a
critical role to play, and to maximize the impact of that, it
will require the resources and it will require taking an
approach that addresses Ebola as well as other deadly threats,
and strengthens our everyday systems of infection control.
Mr. Olson. Dr. Lurie, how about yourself, ma'am? HHS
helping St. Michaels?
Ms. Lurie. Helping St. Michaels? Well, so one of the things
that we have done through our Hospital Preparedness Program is
reach out to all of the hospitals around the country. Hospitals
are now organized into coalitions, which are community-level
collections of hospitals and dialysis facilities and nursing
homes and others. Texas has a very well organized system of
this, and reaching out through them, they are able to reach to
St. Michaels, number one, to say if they needed personal
protective equipment, could they get it through their
coalition. If they needed help with exercises and training,
they could get it through their coalition. Number two, as I
mentioned before, we have had a very aggressive national
outreach and education campaign that has been open to
healthcare providers, including healthcare providers from St.
Michaels and anywhere else around the country. People can take
advantage of numerous phone calls and webinars. They have
reached nurses, they have reached doctors, they have reached
hospital administrators, they have reached EMS professionals
around the country. At this point, we have reached over 360,000
people across the United States with this.
So finally, it is our goal that every hospital, including
hospitals like St. Michaels, will be able, as Dr. Frieden says,
to think Ebola, to recognize a case, to safely isolate a case,
and to be able to get help. And finally, through the state
health departments, and I know you will hear from Dr. Lakey----
Mr. Olson. Yes.
Ms. Lurie [continuing]. In a little while, they call the
state health department, and if they have questions or concerns
about a patient with an Ebola-like syndrome, the state is in a
very good position to help as well.
Mr. Olson. And, Dr. Lushniak, after your question, but one
more question to you, Dr. Frieden. You were quoted on October 2
saying, this is a quote, ``Essentially, any hospital in the
country can take care of Ebola.'' Do you stand by that quote
today? Any hospital.
Mr. Frieden. Clearly, it is much harder to care for Ebola
safely in this country than we had recognized. It is the case
that every hospital in America should be ready to recognize
Ebola, isolate someone safely, and get help so that they can
provide effective care. That is why we established the CERT
Team, CDC Ebola Response Team, that will fly in at a moment's
notice for a highly suspected or confirmed case, to help
hospitals throughout the country.
Mr. Olson. Thank you.
Yield back.
Mr. Murphy. Now I recognize Mr. Johnson for 5 minutes.
Mr. Johnson. Thank you, Mr. Chairman. And I too want to
thank the panel for joining us today. Thank you very much.
Dr. Frieden, have any other States also applied stricter
standards than the CDC has in terms of how to handle Ebola?
Mr. Frieden. CDC guidelines are just that, for States, and
States are free to be stricter than that. We are gratified that
most have followed our standards, and really what we say is
pretty clear----
Mr. Johnson. But do you know if any States have stricter
standards?
Mr. Frieden. Yes, some do.
Mr. Johnson. OK. All right. Why do you think the States are
adopting stricter standards than the CDC? Are you confident
that your standards, the CDC guidelines and standards, are
strong enough?
Mr. Frieden. We believe that our standards, if followed,
are protective of the public. They require that people who may
be at any elevated risk, or some risk, rather, those
individuals have their temperature monitored every day by
direct active monitoring. And that is something that allows us
to interact with the person, to talk with them, and to
determine on an individual basis if they should stay home that
day, or if it might be reasonable to allow them to do other
things.
Mr. Johnson. Have you talked to any of the States that have
stricter standards, to find out their rationale for the
stricter standards?
Mr. Frieden. I have had some communication with some of the
individuals involved, and understand some of their thinking
process. The number of individuals who are subject to those
stricter standards is really quite small, and all of those
individuals, by our standards, should be in what is called
direct active monitoring, which means someone actually watches
them take their temperature each day, has a conversation with
them, and confirms that they are healthy and don't have a
fever.
Mr. Johnson. OK. The last time that you were with us, we
talked about having tested these standards. Have the standards
been fully tested, the guidelines been fully tested across the
country, back to what my colleague from Texas just mentioned,
so that every hospital knows what to do? Have they been tested?
Mr. Frieden. So the standards in monitoring travelers are
being implemented now by every State in the country, or
virtually every State in the country, tracking people coming
back from West Africa, monitoring them for fever----
Mr. Johnson. Have they been tested?
Mr. Frieden. I am not sure I understand your question, but
with respect to the traveling----
Mr. Johnson. Then let me explain the question. You know,
going back to my military experience, and I think some of the
gentlemen here can understand that, we do things called
operational readiness inspections. We don't wait for the
bullets to start flying before we know what we are going to do
when they do start flying. You come to Appalachia, Ohio, there
are lots of little community hospitals that dot our region. Are
those hospitals fully up to speed, have they tested and have
they signed off on any kind of guidelines that they have tested
their Ebola process?
Mr. Frieden. In terms of hospital preparedness, many
hospitals have undertaken drills. We have also----
Mr. Johnson. Has CDC mandated any drills to----
Mr. Frieden. CDC does not mandate that hospitals do drills.
We provide guidance, support, and resources for hospitals to do
that.
Mr. Johnson. Have you recommended that they conduct drills?
Mr. Frieden. Yes, and we have been directly involved with
them in doing that, and we have reviewed for the REP-visited
hospitals, those that are most likely to receive a case, we
have visited those hospitals, we have overseen their drills, we
have overseen their preparedness, and we have worked with them
on advancing their preparedness.
Mr. Johnson. OK. It is my understanding there are several
Ebola centers scattered across the country, also referred to as
infectious disease centers. Most of them have a patient
capacity of one to two people. As of right now, most
individuals with Ebola treated in the United States have been
transported to one of these centers to better manage their
illness.
In the event that a larger number of cases were to show up
in the U.S., how does the CDC plan to treat a patient load that
exceeds the capacity of available bed space in those centers?
Mr. Frieden. The challenge of a cluster of Ebola would be
substantial, and it would be a matter of using all available--
--
Mr. Johnson. Define a cluster.
Mr. Frieden. It would be a handful of cases. It could be 5
or 10 cases.
Mr. Johnson. OK.
Mr. Frieden. In a kind of practical worst case scenario,
this is something that could be seen. In this case, we would
use all available local resources, if need be, surging
healthcare workers in, and we would also transport patients to
facilities around the U.S. where they could be treated.
Mr. Johnson. These centers are set up to handle one or two
patients because of the unique requirements of the disease, the
virus. Do we have transportation systems that are capable of
transporting Ebola patients if that outbreak were to be bigger
than the one or two that we are talking about?
Mr. Frieden. We have some transportation facilities for
Ebola patients in the U.S. We are working with the State
Department and others to increase the capacity to transport
patients.
Mr. Johnson. What about those who might be transported to
other places, would they be receiving lower quality care, in
your mind, than at one of the infectious disease centers?
Mr. Frieden. No, we think the quality of care can be
provided. It is really an intensive care unit care, and CDC
clinicians have consulted on the care of every single patient
cared for in the U.S., and provided to each and every one of
them access to experimental treatments and state-of-the-art
care.
Mr. Johnson. OK.
Mr. Murphy. Gentleman's time has expired.
Mr. Johnson. Thank you. I yield back.
Mr. Murphy. Thank you.
Ms. DeGette, do you have questions that you wanted to ask?
Ms. DeGette. Go ahead.
Mr. Murphy. She is going to yield at this point.
I now recognize Mr. Griffith for 5 minutes.
Mr. Griffith. Thank you, Mr. Chairman. Dr. Frieden, I am
going to try to move through these as quickly as I can, so I
appreciate short answers.
You are aware that the Secretary of HHS is able to transfer
funding from your department to other departments, isn't that
correct? She can take funding from your department and stick it
somewhere else, isn't that correct?
Mr. Frieden. There is limited transfer authority as far as
my understanding goes.
Mr. Griffith. And when that happens, are you notified, is
she required to tell you that she has transferred funds?
Mr. Frieden. As far as I know, yes.
Mr. Griffith. And has the Secretary transferred funds in
2014 from the division of Emerging and Zoonotic Infectious
Disease?
Mr. Frieden. I----
Mr. Griffith. Yes or no?
Mr. Frieden. I don't know the answer to that off-hand. I
could get back to you with that information.
Mr. Griffith. If you could get that information for me?
Mr. Frieden. Yes.
Mr. Griffith. And I believe that that particular division
would be a part of the Ebola response, I am correct in that?
Mr. Frieden. That is correct.
Mr. Griffith. And do you know whether or not the Secretary
has transferred money from the CDC's global health programs?
Mr. Frieden. I would have to get back to you on that as
well.
Mr. Griffith. All right. Likewise, the same would be on the
CDC's Public Health Preparedness and Response Division?
Mr. Frieden. I would have to get back to you.
Mr. Griffith. And both of those also would be a part of
your Ebola response, wouldn't they?
Mr. Frieden. Yes, they would. Yes, they are.
Mr. Griffith. Now, you have indicated that you don't know
about whether these monies were transferred. Do you know if any
monies were transferred at all during 2014? Do you have any
information?
Mr. Frieden. There is a Secretary's transfer, but I don't
know the details of what has been done.
Mr. Griffith. OK, and so you don't know the details. So you
would not know if any of this was transferred to help support
the financial underpinnings of the Obamacare, ACA?
Mr. Frieden. I don't--I do not know.
Mr. Griffith. And likewise, do you know if any transfers
were made by the administration for children and families to
care for increasing number of unaccompanied children who
arrived in the United States?
Mr. Frieden. I am not familiar with that financial----
Mr. Griffith. You are not familiar with that, but would you
get us the answers to all of those?
Mr. Frieden. We can certainly get you those answers.
Mr. Griffith. Likewise, I am curious, the President
apparently has requested a fair amount of money, and part of
that is related to Ebola and part of that is $1.54 billion in
contingency funding. Some of that is supposed to go to HHS, it
says in his letter, to make resources available to respond to
evolving epidemic both domestically and internationally. And I
am looking here and it says that, while $751 million of that is
to go to HHS, it then talks about transferring those funds over
to Homeland Security to increase Customs and Border Control
operations. Have you been in the loop on that? Do you know what
kind of money you all are getting, and what are they talking
about with Customs and Border Control operations?
Mr. Frieden. We work very closely with the CBP, and we
understand the need for contingency funds for Ebola in case,
for example, Ebola would spread to another country that
required a very intensive, extensive response. So that
flexibility is a critical component of the emergency funding
request.
Mr. Griffith. OK, and that funding request is, as was
pointed out in an editorial by David Satcher, and I hope I am
pronouncing that right, a former director of CDC, and a former
Surgeon General. That request by the President is actually
greater than what we have been spending on Alzheimer's, isn't
that correct?
Mr. Frieden. I don't know Alzheimer's funding details off-
hand.
Mr. Griffith. All right, and in regard to Mr. Klain, have
you all had sit-down, face-to-face meetings?
Mr. Frieden. Yes.
Mr. Griffith. And how many of those meetings have you all
been----
Mr. Frieden. Well, I would have to get back to you with the
exact number.
Mr. Griffith. If you could give me that number, I would
greatly appreciate that. That would be very, very helpful.
Now, in some of the outbreaks in the past, historically, in
Ebola that have occurred in Africa, isn't it true that there
are sometimes that we have an outbreak and we don't know where
the disease actually came from, where it was picked up?
Mr. Frieden. We have not identified definitively the animal
reservoir of Ebola. We think it may be bats or bush meat, but
we have not determined that. We have determined it for a
similar virus, Marburg, from research that CDC scientists did.
Mr. Griffith. And the meat, I understand. The bats, would
that be from excrement? I mean how would the bats spread it, or
are they eating the bats as well?
Mr. Frieden. Well, it may be saliva, it may be carried--
bats, as mammals, carry a lot of pathogens that are similar to
the pathogens that infect humans.
Mr. Griffith. But this is just 1 of many areas where we are
not really 100 percent sure of how the disease is spread,
particularly in Africa?
Mr. Frieden. Well, I would clarify. We are not sure of the
animal reservoir. From all of the experience we have had spread
among human populations is from either unsafe care or unsafe
burial in the outbreaks that we have assessed so far.
Mr. Griffith. So that is once there has been an outbreak,
but there are occasions when the outbreak just starts and
nobody had it there before, so it couldn't have come from human
contact, it had to come from this animal reservoir, and we are
not sure exactly what animals carry it, whether or not it is,
you indicated spittle, excrement, what else? We do know that it
is transmitted if you eat a diseased animal, is that correct?
Mr. Frieden. It may be actually not so much the consumption
of bush meat, but the hunting and handling and cleaning of bush
meat where you may get exposed to blood and other body fluids.
Mr. Griffith. OK.
I appreciate it, and yield back.
Mr. Murphy. Now recognize Ms. DeGette for 5 minutes.
Ms. DeGette. Thank you, Mr. Chairman. And I want to
apologize to you and to the panel for running in and out. The
Democratic leadership right now is actually working on who our
next ranking member of this full committee is going to be. It
is not going to be me. Thank you for your vote of confidence.
And so I just want to ask a few questions, and then I am going
to leave you in the capable hands of Mr. Green.
Dr. Frieden, the first thing I wanted to talk to you about
is the contingency fund that has been requested in the
emergency supplemental. What exactly is the purpose of that
fund, and what would it be used for?
Mr. Frieden. The contingency fund is to deal with the
unpredictable nature of Ebola, the possibility that it might
spread to countries where it is not currently in place, and
might require very extensive, expensive control measures there.
Also that we might have new interventions, such as a vaccine,
and need a large and potentially expensive program to implement
a vaccine program in affected communities and for healthcare
workers.
Ms. DeGette. And why would you need to do that through a
contingency fund and not through an additional emergency
supplemental, if either of those situations presented
themselves?
Mr. Frieden. You know, in the words of one of my staff at
CDC, in the case of Ebola, it is the lack of speed that kills.
We need to be able to respond very quickly to changing
conditions on the ground.
Ms. DeGette. And we are seeing that right now in Africa, is
that right?
Mr. Frieden. That is. There----
Ms. DeGette. Everything is changing very quickly in Africa.
Mr. Frieden. Absolutely. We are responding to a cluster in
Mali, we are moving out with CDC disease detectives into very
remote rural areas to address clusters of disease before they
become large outbreaks.
Ms. DeGette. Do you have a sense of why the number of cases
in Liberia has recently dropped?
Mr. Frieden. We believe this is proof of principle, that
the approach that we are recommending can work, but we are
still seeing large numbers of cases in at least 13 of the 15
counties of Liberia. We have seen that decrease taper off so
that we have seen a leveling-off of cases that have been
reported. Every one of those cases needs intensive follow-up,
contact tracing, monitoring of contacts, and we are still
having perhaps between 1,000 and 2,000 new cases per week in
West Africa, so this is still a very large epidemic.
Ms. DeGette. And that kind of leads me to my final
question, which is, you have said repeatedly, and, frankly,
there has been a lot of pushback on this, not just from this
committee but from lots of other folks, you have said
repeatedly that you don't think that travel bans and
quarantines are the way to go about addressing this, and I am
wondering if you can tell us whether that is still your view,
and if so, why, and if it is not, why not?
Mr. Frieden. We are willing to consider anything that will
make the American people safer, any measure that is going to
increase the margin of safety, and one of the things that we
have done is to implement a travel system so that people
leaving these countries are screened for fever, arriving in the
U.S. are monitored for fever, are linked with the local health
department. We are now working with State and local health
departments to monitor each of those individuals each day, and
we are seeing very high adherence rates to that. So we have a
system in place now.
The risk to the U.S. is directly proportional to the amount
of Ebola in West Africa. The more there is, the higher our
risk. The less there is, the lower our risk. We have to reduce
the risk there by attacking it at the source, but whatever we
can do to reduce the risk to this country, we are certainly
willing to consider.
Ms. DeGette. So you would still consider a travel ban if
that seemed like the only solution?
Mr. Frieden. If there were a way to ensure that we didn't
lose that system of tracking people through every step of their
travel, and once here, we would consider any recommendation,
but it is not CDC that sets travel policy for the U.S.
Government.
Ms. DeGette. Right. And what I am concerned about is if
Ebola goes to other countries, and in Africa in general, it
will be harder and harder to trace where people came from.
Mr. Frieden. The spread of Ebola to other places in Africa
is one of the things that we are most concerned about because
it would make it much harder to control. We were able to work
with Nigerian authorities to stop the cluster in Nigeria. Right
now, Mali is in the balance of whether we will be able to stop
the cluster there before it gains a foothold in Mali. But the
longer it continues in the 3 affected countries, the greater
the risk that it will spread to other countries.
Ms. DeGette. OK, thank you.
Thank you very much, Mr. Chairman.
Mr. Murphy. Gentlelady yields back.
Now Mr. Terry is recognized for 5 minutes.
Mr. Terry. I ask unanimous consent to be able to ask
questions.
Mr. Murphy. Yes, you are recognized, yes.
Mr. Terry. Thank you.
Dr. Frieden, from Nebraska, I am really proud of the
efforts of University of Nebraska Med Center. At least we are
top in something. It is not football, but it gives us a sense
of real pride, despite the last patient's outcome, which they
did heroic efforts. But also in that regard, they seemed to
have been the ones that, especially in comparison to the Dallas
Presbyterian Hospital, were setting the standards on the
practices.
And so that begs the question, or at least we should ask
the question, of whether the CDC should develop an
accreditation type of program on infectious disease programs to
ensure that these hospitals maintain a level of competency and
readiness.
Is something like that ongoing?
Mr. Frieden. Well, first, we really appreciate the facility
in Nebraska and their willingness to step forward, and the
phenomenal care they have provided to all the patients who have
come to them, and despite the outcome of the physician
recently, we know that heroic measures really were undertaken,
and the staff there really deserve the gratitude of all of us,
and we appreciate them. We appreciate also their willingness to
consult with other facilities, and to share their experience
because that is critically important.
Mr. Terry. Which they have done, and I----
Mr. Frieden. Yes.
Mr. Terry [continuing]. Again, hospitals like Johns Hopkins
asking them how to do it is a source of pride for us as well.
Mr. Frieden. What we have approached is something called
the REP Team, the Rapid Ebola Preparedness Team, where we send
a team in to work with the facility, to outline every aspect of
their preparedness, and to see how ready they are, and then to
provide recommendations for what more they can do.
We have also worked with the State health departments so
that they can determine which of the facilities within their
State that are most appropriate to take patients with Ebola or
other infectious diseases, because they are really best
prepared for that.
In terms of accreditation, that is something that we have
discussed with the Joint Commission. Whether that makes sense
in the long run or not is something that we are open to
exploring.
Mr. Terry. All right, as a layperson, it seems to make
sense that you would have an area where there is one hospital
that has that level of accreditation. And then it begs the
question that if they are going to be that go-to hospital in a
region or a State, whether there should be maintenance funding
behind that. What do you think?
Mr. Frieden. We certainly believe that they should receive
resources. There is funding within the emergency funding
request, both from CDC and from ASPR, to support specialty
facilities such as the one in Nebraska.
Mr. Terry. And so the question then is, just to clarify,
would that be part of the President's requested dollars?
Mr. Frieden. Yes, it is.
Mr. Terry. Dr. Lurie?
Ms. Lurie. Yes, it is.
Mr. Terry. Very good.
Ms. Lurie. Yes.
Mr. Terry. So, Dr. Frieden and Dr. Lurie, one of the
experiences here is that we know that, let us see, UNMC I think
has 11 units, but the reality is they can probably only have
three patients at a time because of all of the collateral
circumstances. So do we need more bio-containment units like
what Emory and UNMC have? Dr. Frieden?
Mr. Frieden. We think we need some increase in the number
of facilities that can safely care for someone with Ebola, or
another deadly infection. We have been working very closely
with hospitals throughout the country to increase that
capacity, and the emergency funding request would enable us to
really get to the level where we would have a greater degree of
comfort with the facilities out there and the capacities.
Mr. Terry. Well, just to clarify that some of the dollars
that would be in the emergency funding, the President's
request, would be to expand the number of bio-containment
units?
Mr. Frieden. Yes.
Mr. Terry. Very good. And one of the questions about having
three patients at UNMC, these folks don't have any insurance
and they are holding the bag for the funding of those patients.
Is there anything with HHS, Dr. Lurie, or CDC that can
reimburse these facilities for the healthcare costs?
Mr. Frieden. I believe that Secretary Burwell indicated in
the hearing last week that we are very open to mechanisms that
would make them whole for the expenses that they have had.
Mr. Terry. Open to it and doing things--there is a big gap
between those two. Is there any further discussions to
reimbursing, Dr. Lurie?
Ms. Lurie. I think we understand that the cost of caring
for these patients is quite substantial, and as Dr. Frieden
said, Secretary Burwell indicated that she would look forward
to working with Congress on this issue, yes.
I might also just add in terms of the emergency funding
that is necessary, it is clear that hospitals that are going to
take care of Ebola patients need additional training, and we
very much appreciated the fact that University of Nebraska and
Emory have been now working side by side often with the REP
Teams to help with that. Part of our funding request would also
establish something that would look like a national education
and training center that would move to another level, I think,
of preparedness for hospitals that really wanted to obtain that
and to get help with doing that.
Mr. Terry. OK, thank you very much.
My time has expired.
Mr. Murphy. All right, that concludes the questions for
this panel. We thank you. And also Members may have some other
additional questions. I would appreciate your responsiveness to
those. We do appreciate the availability of all of you in
responding to us, so I thank you very much.
Mr. Frieden. Thank you.
Mr. Murphy. As this panel is moving, I will begin to
introduce the second panel so we can move forward here. And I
will introduce two of the panelists, then we will ask Mr. Terry
to introduce one as well.
We will start off here--just a moment here. First, Mr. Ken
Isaacs is the Vice President of Programs and Government
Relations for Samaritan's Purse. Also Dr. David Lakey is the
Commissioner of the Texas Department of State Health Services,
but is here today testifying on behalf of the Association of
State and Territorial Health Officials, correct?
Now, Mr. Terry, if you would like to introduce the other
panelist.
Mr. Terry. I would be honored to introduce Dr. Jeffrey
Gold, the Chancellor of the University of Nebraska Medical
Center and Nebraska Medicine. He is recent to Nebraska, but
certainly making a huge impact, especially with the Biomedical
Containment Center where they have hosted 3 Ebola patients, and
they are setting the standards for how to treat the Ebola
patients, and setting the standards for the employees that come
in contact and work with those. UNMC is a great facility. They
are very forward-thinking. They are ranked very high in a lot
of areas of care, but it is probably the research that is
making them known internationally, and so I am proud to
introduce Dr. Jeffrey Gold.
Mr. Murphy. Thank you. Well, for the panel, you are aware
the committee is holding an investigative hearing, and when
doing so, has had the practice of taking testimony under oath.
Do any of you have any objections to taking testimony under
oath? 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 of you desire to be advised by
counsel during your testimony today? And all the panelists have
said no. In that case, would you please rise and raise your
right hand, and I will swear you in.
[Witnesses sworn]
Mr. Murphy. All have answered affirmatively. You are now
under oath and subject to the penalties set forth in Title
XVIII, section 1001 of the United States Code.
I am going to ask you each to give a 5-minute summary of
your written statement, and we will begin with Mr. Isaacs.
STATEMENTS OF KEN ISAACS, VICE PRESIDENT, PROGRAMS AND
GOVERNMENT RELATIONS, SAMARITAN'S PURSE; JEFF GOLD, CHANCELLOR,
UNIVERSITY OF NEBRASKA MEDICAL CENTER; AND DAVID LAKEY,
COMMISSIONER, TEXAS DEPARTMENT OF STATE HEALTH SERVICES, ON
BEHALF OF THE ASSOCIATION OF STATE AND TERRITORIAL HEALTH
OFFICIALS
STATEMENT OF KEN ISAACS
Mr. Isaacs. Thank you, Chairman Murphy, and esteemed
members of the council and fellow guests of the committee for
letting me testify today. It is a privilege to be before you
regarding the developments of the Ebola outbreak in West
Africa.
Since Ebola entered Liberia in March through its explosion
into the international spotlight in July, and even now, when it
appears that the disease may have crested in Liberia, the world
has learned much about Ebola, but I want to stress today that
we have also discovered that there are many important questions
that we simply do not know the answer to, and we need to know
the answer to them.
I want to run through them quickly. I will say as an
offside that going last means you have to reshuffle everything
you are going to say because it has all been said before.
But I think that a good question to know the answer to is
how are the doctors who are returning to America becoming
infected. Some of those doctors have been our staff, some of
those doctors have been our coworkers that were treated at
Nebraska. And even recently, the gentleman in New York, they
were all wearing level 4 gear. How did they get infected.
Can the virus live in other mammals besides primates, bats,
rodents, and humans. Now, I have worked and lived in Africa for
about 25 years, and I have eaten my share of bush meat. It is
not always bats. It is mostly something like a groundhog. And
so what does it mean, where does the virus live. And the point
is that can it jump into the animal population here. We need to
know that.
As with other viruses, is it possible that Ebola can be
asymptomatic, sort of a Typhoid Mary kind of a thing. We know
for a fact of three situations where blood was drawn on
patients who were non-feeble, who were non-symptomatic, and
they all three tested positive. One of the problems that exists
today in Liberia where Samaritan's Purse is working is that
there is no protocol to move blood from Liberia to Rocky
Mountain Laboratory where these kind of tests would need to be
checked and results found out.
You know, I will just say I am not trying to be a fear
monger, but I think that there are things that we need to look
at critically, and we should not be afraid to ask questions. In
my written testimony, there is one paper from the New England
Journal of Medicine that reports that 95 percent of the cases
of Ebola incubate in 21 days. The inference is 5 percent don't
incubate until 42 days. We need to know what that 5 percent
means.
While the media coverage is already decreasing, and people
maybe feel that Ebola has peaked, we do not think it has. I
totally agree with Dr. Frieden. I think that we need to
vigorously and in a sustained manner fight this disease in
Africa. I think that no card can be taken off the table, and I
think that while we hear from many health experts that we know
how the disease is spread, we know how to fight it and we know
how to stop it, the truth is that lessons come at a great and
expensive and painful price, and when a new lesson comes about,
then all of the policies are changed. So I heard the word
humility used several times today by different Members of the
panel, and I think that that is a good word because Ebola is a
humbling disease.
When you talk to the epidemiologists, they are all over the
place. CDC is saying 1 \1/2\ million people by the middle of
January, and the World Health Organization is saying that in
December maybe 10,000 people a week. The point is we don't
know.
Several things that I want to say right quick is we are
seeing the disease go down in Liberia today as it regards the
empty hospital beds, as it regards deaths, and as it regards
patient loads, but at the same time, we are seeing a
significant increase in Sierra Leone, the country next to it,
so it is clear that the disease has not peaked. Actually, if
anything, I would say that it perhaps has ran its course, and
we don't know what its course is. And if you look at the
epidemiological charts in Sierra Leone, it has peaked two times
before. So the question really is are we at a peak or are we in
a trough before the next up rise?
Practically speaking, I think that a couple of things that
we need to look at is a travel ban, travel restrictions, or I
like to say travel management, should not be taken off the
table. The real threat to the United States I do not feel is
going to be how many people are sick here. The real threat to
the United States is what will happen if the disease spreads
into countries that cannot handle it. And I am not talking
about Africa, I am talking about in a sub-Indian continent, I
am talking about in India and China and Pakistan, Myanmar,
Bangladesh, countries that are highly populated, that have low
public health standards, and have low hygiene standards. You
could see a death toll that would be unimaginable, and the
impact around the globe would affect us as well.
So I think I am out of time there. Thank you.
[The prepared statement of Mr. Isaacs follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you.
And, Dr. Gold, you are recognized for 5 minutes.
STATEMENT OF JEFF GOLD
Mr. Gold. Chairman Murphy, other members of the
subcommittee, thank you so much for the opportunity to discuss
the Ebola outbreak and the Nation's response, and how the
Nation can maintain a state of readiness to respond to future
highly infectious diseases.
I am Jeff Gold, and I have the honor as serving as
Chancellor of the University of Nebraska Medical Center. My
testimony today will focus on the challenges of dealing with
Ebola, and our Nation's readiness to respond to highly
infectious diseases.
This has been said many times earlier today, and well
before, the United States is dealing with a serious public
health crisis with the Ebola outbreak in Africa. It is a crisis
that the United States has both the expertise to contain and to
help resolve.
One of the most pressing goals to accomplish from the Ebola
outbreak is how to best leverage the knowhow to train and to
better prepare the Nation's healthcare system, to combat future
highly infectious threats like Ebola here and around the world.
The University of Nebraska Medical Center is recognized as
a national resource for our readiness to provide care for Ebola
patients, and also our ability to provide training on Ebola and
other highly infectious diseases. We have successfully treated
Ebola now in two patients, and not in one. Most recently,
passed away yesterday. We have provided consultations to many
hospitals, clinics, emergency departments across the United
States, including Bellevue Hospital in New York, on how to deal
with therapies for patients who arrive in their hospitals,
their emergency departments, et cetera.
Our readiness is based upon more than 9 years of
preparation, protocol development, and team training to deal
with highly infectious, deadly diseases. As a result, we are
now responding to literally hundreds of hospital inquiries
across the Nation, asking how to prepare if Ebola arrives in
their community. Emory University Hospital is experiencing
similar inquiries, and we are working closely together.
One step that we took to respond to the immediate national
demand for information and training was to work with Apple
Computer to convert our 9 years of protocols and procedures
into easily accessible and completely downloadable multimedia
materials and videos for healthcare providers. That was
accomplished in 1 week, which is now available through Apple
and through public media, and can be accessed on any personal
computer, with well over thousands and thousands of physicians
and members of the public who are downloading content
specifically about personal protective equipment and others.
You might ask why Nebraska. Why is the bio-containment unit
that we opened in 2005 in existence. This followed the 9/11
attacks. It was built upon concerns about Anthrax on
congressional offices and SARS attacks. We recognize that the
commonest of international travel increased the chance of
global spread of highly infectious diseases. Our unit has
written and rewritten protocols and procedures, and
collaborates consistently with national organizations and other
medical centers. We rigorously train with local emergency
responders, State emergency management, and military units
through our relationships with STRATCOM and others. We spend a
great deal of time considering the response plan if another
highly infectious disease were to occur, and how this could be
scaled.
The university is also a Department of Defense authorized
university affiliated research center, which specializes in
developing medical countermeasures to weapons on mass
destruction, including highly infectious viruses. We have a
history of conducting extensive research in these areas,
including vaccines, antivirals, early detection, et cetera.
What has become obvious from this Ebola crisis is that a
national readiness plan is absolutely necessary. Our bio-
containment unit is one of four in the Nation. The capacity and
the number of units in the Nation must be increased, and a
national readiness plan that trains healthcare providers must
be established. The number of actual beds is under 20, the
number of usable beds is under 10, and I assure you that every
unit such as ours will always maintain at least one bed if it
is ever needed for a staff member that becomes ill. That
immediately knocks the number down by four, five, or six.
The University of Nebraska Medical Center and Emory are
working closely with the CDC and HHS on how training might be
most effectively delivered. It must begin soon, and we have
done so in advance of any funding considerations. As Congress
considers funding, I urge that this include a number of items,
and I will just read them by title as they are contained in my
briefing documents. A national training in Ebola and highly
infectious diseases, to develop a tier training system.
Training should include setting up an accreditation program
that independently nationally accredits organizations,
emergency departments, et cetera, to establish and maintain
their skill level of readiness. An annual maintenance of
funding for increased role of existing bio-containment units to
maintain their readiness. We have funded the readiness of our
unit totally off of internal dollars up to this point. Funds to
expand the number of treatment centers and existing bio-
containment units, specifically, to increase bed and staff
capacity within existing units, as well as new units. And
finally, reimbursement for care for Ebola patients not covered
by insurance.
Ladies and gentlemen, we have the expertise and knowhow to
contain Ebola and other infectious threats, however, in order
to do this, we must ensure that our Nation's healthcare
professionals are adequately trained, properly equipped, and
rigorously drilled.
I thank you so much for this privilege.
[The prepared statement of Mr. Gold follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Dr. Gold.
Now, Dr. Lakey.
STATEMENT OF DAVID LAKEY
Mr. Lakey. Thank you, Chairman Murphy, and members. For the
record, my name is David Lakey, the Commissioner of the Texas
Department of State Health Services, and I have been in that
role now for 8 years. This last month has been one of my most
trying and tough months as the Commissioner of the Department
of State Health Services.
On September 30, 2014, the Texas State Public Health
Laboratory, a laboratory response network laboratory, diagnosed
the first case of Ebola in the United States. The diagnosis of
Mr. Duncan with Ebola set in motion a process we in public
health refine through continued use, tried and true public
health protocols, including identifying those individuals that
have had contact with people that have been infected, making
sure that they are monitored, providing care to those that have
been infected, isolating those individuals, and when needed,
using quarantine.
The magnitude of the situation really was unprecedented.
While Mr. Duncan was one man, staying in one city, in one State
in the country, the outcomes associated with his case could
impact the whole State and possibly other parts of the United
States.
We at the Department of State Health Services, along with
our colleagues in Dallas and our colleagues at the Center for
Disease Control and Prevention took the responsibility to
contain the spread of this disease very seriously. We organized
a local incident command structure to handle the event, and at
a State level, we activated our emergency response management
centers. While our core mission was simple in concept; to
protect the public's health by limiting the number of people
exposed to the virus, the challenges associated with carrying
out that mission were numerous.
The care of Mr. Duncan presented its own challenges.
Identifying the first person in the United States infected with
this disease, the infection control challenges, waste
management and transportation, the availability of experimental
treatments and vaccines, training for healthcare workers on the
higher standards of infection control, and personal protective
equipment guidance and supplies. And when Mr. Duncan
regretfully passed away, we handled issues related to caring of
his human remains, which remained highly infectious with Ebola
for months after death. Unfortunately, during the care of Mr.
Duncan, two nurses became infected. Nurses who had put their
lives and their careers on the line to take care of Mr. Duncan
and to protect the public's health.
Concerns relating to the handling of these three Ebola
patients included questions about decontaminating their homes,
their automobiles, decisions about how to handle their personal
effects, the monitoring of pets, and patient transportation
issues, and addressing the public's concerns. Identifying
potential contacts, and locating them and monitoring those
individuals had some risk of exposure that also involved many
challenges. Decisions about who to quarantine and what level of
quarantine, balancing public health and an individual's rights,
providing accommodations for those confined to one location for
the 21-day monitoring period, quickly processing control
orders, coordinating two symptom checks a day for each person
under monitoring, and managing the transportation and the
testing of laboratory specimens.
Throughout all of these specific challenges, our experience
in Dallas exemplified common requirements for successful
responses to emergency situations. Having clear roles and
responsibilities among the various Government agencies and
entities that are involved, strong lines of communication, and
an incident command structure staffed by trained emergency
management and public health professionals to ensure the
response's cohesive direction. It really requires a partnership
at all levels of Government, and throughout State and Federal
Government.
The outcome in Dallas proved the strength of the public
health's process. Hundreds of people were monitored in the
State. Two cases of Ebola resulted from the direct care of the
index case, and they were detected early in the disease onset,
and they recovered. No cases resulted from community exposure.
At this time, like other States, Texas is providing active
monitoring for individuals who arrive in the United States from
one of the outbreak countries. Texas has monitored
approximately 80 individuals under the airport screening
process. Texas is also, like other States, working to ensure
that capacity exists in the State to care for patients with
high consequence infectious diseases like Ebola. Two centers
currently are able to stand up on a short notice to receive a
patient, and Texas is working to identify additional capacity
within our State.
As Ebola screening and monitoring transitions into our
routine processes, our focus in Texas is now shifting to
include complete evaluation of the response in Dallas, and a
discussion of how to improve the public's health response
system in Texas as a whole, and sharing our experiences and our
lessons learned nationwide.
Governor Perry has put together a task force for infectious
disease preparedness and response to evaluate the Texas system,
and to make recommendations for improvement. We take that
extremely seriously. I believe this discussion among
Governmental and nongovernmental individuals, among varied
stakeholders, and including experts in pertinent fields will
result in a Texas and the Nation being better prepared to
handle the next event.
While we do not know what form the next event will take, we
do know that there will be another event. As I tell my
colleagues at the State and national level, it is my
expectation that, as the Commissioner of Health, that I am
going to have to manage one major disaster each and every year.
One unthinkable event per year. And that is why the funding
that is provided to States through the Hospital Preparedness
Program, in fact, is very important to what we do, and that
partnership is really critical.
And finally, I want to thank my colleagues at both the
Dallas County Health Department and the Center for Disease
Control for their work and their support, and this really was a
team effort.
Thank you, sir.
[The prepared statement of Mr. Lakey follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you.
Dr. Gold, I know you have some travel plans. We have about
20 minutes of questions, will you be able to accommodate that?
Mr. Gold. Yes, sir, whatever your needs are.
Mr. Murphy. Thank you very much. Appreciate that.
And I will recognize myself for 5 minutes.
Dr. Gold, you mentioned a number of comments about what
needs to be done with the administration's request for funding.
I don't know if you have had a chance to read it. Have you?
Mr. Gold. At least in general terms, yes.
Mr. Murphy. OK. So would you know whether or not there is
an adequate plan to support the request yet? I don't want to
put you on the spot.
Mr. Gold. I don't think the granularity is in the written
materials that have been provided.
Mr. Murphy. Would you do us a favor, as someone at a
hospital dealing with this, could you make sure you get to the
committee's specific recommendations? In fact, I would ask that
all the panelists who have all dealt with this, that would be
very, very helpful to have that kind of granularity.
Mr. Gold. Yes.
Mr. Murphy. Thank you.
Dr. Isaacs, you have been to Africa.
Mr. Isaacs. Excuse me?
Mr. Murphy. You have been to Africa?
Mr. Isaacs. Yes, a lot of times.
Mr. Murphy. The CDC has guidelines for health monitoring
and movement for healthcare workers who have been treating
Ebola patients in Africa. Now, they classify as some risk those
professionals who have had direct contact with a person sick
with Ebola while wearing personal protective equipment.
You have cited that some people wearing personal protective
equipment have still----
Mr. Isaacs. Yes.
Mr. Murphy [continuing]. Contracted Ebola.
Mr. Isaacs. Yes, it is an obvious fact, yes.
Mr. Murphy. So these some risk individuals have no
mandatory restrictions on travel or public activities, in fact,
there is no requirement for returning healthcare workers to
self-isolate or avoid public transportation, like subways,
bowling alleys, et cetera. I might want to add, we have done a
survey of Members on this side and every single Member who
asked hospitals in their district has returned comments saying
that all those hospitals said for those first 21 days, those
healthcare workers are not going near a patient. They will be
furloughed, they are to stay home, take their temperature
multiple times a day.
Does Samaritan's Purse healthcare workers follow guidelines
such as this when they return?
Mr. Isaacs. Yes, we have actually written our own protocols
and guidelines back in late July when Dr. Kent Bradley, who has
testified here, was coming back. We were bringing out about 40
people. We contacted CDC and asked them what their protocols
were and, frankly, they told us just to have our staff check
their temperature twice a day, and if they got a fever, go to
the local health department. We didn't feel that that was
adequate because we had just come through a very serious bout
with Ebola, and I think we probably had a more realistic
encounter with it than perhaps other people had, and so we
created our own protocols.
We check our staff through direct monitoring every day,
four times a day. We have a little bit lower threshold, and we
do keep them in a restricted movement, no touch kind of
protocol for 21 days.
Mr. Murphy. So you are saying that your protocol goes
beyond the CDC recommendations.
Mr. Isaacs. There is no question our protocol goes beyond
the CDC.
Mr. Murphy. Well, CDC says that is not necessary. Do you
agree?
Mr. Isaacs. Well, you know, all I can say, I mean there was
a question a minute ago about CDC, you know, disregarding what
we were saying. CDC is a large organization. They create a
policy. So if you call them and say, well, we think we ought to
do this, they say, well, that is not our policy, and then they
don't engage any further. That is just the reality that we have
run into, and I don't mean any disrespect to CDC, I am very
appreciative of them, but for us, we live in a small town, so
our national headquarters is in a town with 40,000 people. What
we have run into is that the spouses of some of our returning
staff don't want them coming home. The returning staff don't
want to be around their children. And we don't want to spook
everybody in our community.
Mr. Murphy. So you are erring on the side of extra safety?
Mr. Isaacs. Yes, sir, we are.
Mr. Murphy. Let me ask another thing. This has to do with
discussions I have had with Franklin Graham----
Mr. Isaacs. Um-hum.
Mr. Murphy [continuing]. Son of Billy Graham, and highly
respected individuals here, but listed that there are some
problems for people, the NGOs, the charitable workers, et
cetera, as well as Government workers traveling back and forth
to Western Africa. Is that a fact that there are difficulties
with travel?
Mr. Isaacs. I think that is one of the greatest
vulnerabilities that the United States has to fight the disease
in West Africa. There is not a dedicated humanitarian bridge.
What has happened, I mean there has been a lot of talk about,
well, a 21-day waiting period would make it onerous for
volunteers and they wouldn't go. I will tell you what will make
it very onerous is for volunteers not to have an assurance that
they can get a flight out. I promise you they will not go.
Mr. Murphy. How many airlines can currently fly in and out
of Western Africa? I heard it is like Sabrina Air and----
Mr. Isaacs. Well, I think it is 150 or 200 a week,
according to what he was saying. That is general population. I
don't know how many relief workers.
Mr. Murphy. But we don't have a bridge for the relief
workers.
Mr. Isaacs. There are two airlines that fly in and out of
Liberia. One is Brussels Air, and by the way, when you get off
in Brussels, you just walk, you can go anywhere, you are not
monitored for anything. And the second one is Air Maroc--Royal
Air Maroc. If they should decide it is not in their commercial
interest to continue flying into Monrovia, then there will
become an effective commercial quarantine on Liberia, then what
is the backup plan?
Mr. Murphy. Plus, as I understand it, getting supplies to
West Africa is a huge problem. We understand that twice they
had to lease planes.
Mr. Isaacs. We had to have two 747s----
Mr. Murphy. At a cost of?
Mr. Isaacs. About $460,000 a piece, and each one can take
about 85 tons. And for cargo logistics in and out. For people,
I think we have a great vulnerability there. There is one
organization that is flying like a nonprofit. They have done
four flights. That is great, but that is not enough.
Mr. Murphy. So let me make sure I understand, what you
would recommend is that the United States Government could help
sponsor a charter flight twice a week from the United States to
Africa, from Africa to the United States, so that Government
workers, volunteers, NGOs, et cetera, would have a clear
bridge, in which case they could be tested before they get on
the flight, tested during the flight, tested when they land at
one point in the United States, would simplify this whole
process. Am I correct?
Mr. Isaacs. I 100 percent support the concept of a
dedicated humanitarian air bridge from the United States
directly to West Africa. Now, there would be 1,000 details to
work out, but we have a vulnerability. If Brussels Air stops
flying for their commercial reasons, we will have no air
access.
Mr. Murphy. Thank you.
I am out of time. I yield to Mr. Green for 5 minutes.
Mr. Green. Thank you, Mr. Chairman. And I thank our panel
for waiting today.
And to follow up, I think that it would also be more
certainty because instead of, like you said, going to Brussels
or somewhere else, and just walking around, it would be the
testing, and I assume these healthcare workers would love to
have that because, like you said, they don't want to infect
their own families.
Dr. Lakey, let me thank you, because I know in October,
there were a lot of--seemed like unusual statements being made
about Ebola, but when the State of Texas made the decision on
how you would develop the protocols right after that, I
appreciate that because it really sounded like everybody was
getting back to normal and saying, ``OK, this is an illness, we
are going to deal with it, and this is how we can do it.'' So I
appreciate the State doing that, but let me go on with some
questions.
Dr. Gold, one of the interests I have, and I said earlier,
is that how did the University of Nebraska develop this
facility? I think it was opened in '05, and was it a
combination of State, local, university funds, Federal, to
develop the largest containment lab in the country?
Mr. Gold. Thank you. The unit was opened in 2005. It was
planned shortly after the 9/11 events, the anthrax scares, and
it was done predominantly on university funds, to some small
extent on State funds, and I believe there were some Federal
Department of Defense dollars involved in the planning as well.
However, very importantly, the maintenance of the staff, which
costs us approximately between \1/4\ and \1/3\ million dollars
a year to maintain the preparedness, has been totally borne by
the university and the medical center.
Mr. Green. Well, I appreciate that leadership, and I am
just surprised that no other university would take that lead,
and I appreciate Nebraska doing that. Now, my colleagues, both
Congressman Terry and Joe Barton, know my daughter is there and
she was recruited to come up there in '09, and I appreciate--
well, and although when she told me back in the '90s she wanted
to be an infectious disease doctor, I said I don't want you to
treat me for anything you know about. But she is like most
medical professionals. That is her job. And we want to make
sure we protect them to do that.
But Nebraska center now has treated several patients, and
what is the spending that is required to prepare the hospital
to treat an Ebola patient?
Mr. Gold. The direct costs that we have experienced, and we
have compared notes pretty closely with Emory and we are not
far apart, is approximately $30,000 per day for each patient
admitted. The average length of stay, I guess it went down over
the weekend a good deal, but for the two patients that went
home, was 18 days----
Mr. Green. Yes.
Mr. Gold [continuing]. And they were both treated in the
relatively early stages of their disease. And that is the
direct cost of equipment, supplies, nursing care, et cetera.
And as I say, that is extremely close to the number that the
folks at Emory have come up with. That does not include the
cost of the preparation, which I just referred to, and it does
not include the cost of what I would call the opportunity cost,
which is this is a 10-bed unit that is otherwise used for
medical, surgical admissions, that would otherwise be
completely full with routine patients receiving their care.
Mr. Green. OK. Are the policies that were in place prior to
the current Ebola outbreak still in use, or has the University
of Nebraska Medical Center made changes to its protocol and
guidelines based on literally real-life experiences?
Mr. Gold. We do evolve our policies and procedures. We
learned a lot from each of the patients, particularly the first
patient that we housed. We, for instance, put a completely
self-contained laboratory unit into the bio-containment unit so
that laboratory specimens are not transported outside of the
unit. We are also very privileged, and I note there has been a
lot of discussion about waste management, is we decontaminate
all of the waste as it leaves the unit so there is no
transportation of any infectious waste material outside of the
unit, which makes it much safer for the community, and it also
makes it much less expensive for us to have that built into the
unit. And this is only because the unit was planned as it was
constructed prior to 2005, understanding that the disposal of
infectious waste would, indeed, be a big problem from
logistical as well as expense, and, therefore, it was self-
contained.
Mr. Green. Mr. Chairman, I know I am out of time, and I
appreciate--because where we were at 6 weeks ago, we have
actually evolved and I am glad the experiences, we are actually
learning from them. And I appreciate our panelists being here
today.
Mr. Murphy. Thank you. Gentleman yields back.
Now I recognize Dr. Burgess for 5 minutes.
Mr. Burgess. Thank you, Mr. Chairman. I want to thank all
of our witnesses for being here today, and bearing with us
through what has been a very long but a very informative
hearing.
Dr. Gold, there is a difference though between the type of
patient you get at your center, because they are referred,
because there is not a direct access where someone thinks, oh,
I have Ebola, I am going to go to Dr. Gold's center in Omaha.
Mr. Duncan came through the Presbyterian emergency room with
all of the other patients that came in that Thursday night, and
his case had to be winnowed out of all of the other load that
was in the emergency room, but in your situation, a patient
only comes after they have been identified, is that correct?
Mr. Gold. Thus far, the patients that we have admitted to
the bio-containment unit have all come with a diagnosis, a PCR
diagnosis of Ebola. However, given our national reputation, the
number of phone calls, emails, even emergency room visits has
actually been quite interesting with people with febrile
illnesses saying please tell me if I have Ebola.
Mr. Burgess. Well, let me just ask you about that then. So
then patients who arrive in your emergency room--I mean, you
outlined how you have almost a dedicated laboratory handling of
the specimens from an Ebola patient, but that is someone you
know about. If somebody comes to the emergency room and they
have fever, they have a headache, and they have all of these
other complaints, I mean in addition, if someone thinks to do
the PCR Ebola test, but in addition, they are going to get a
CBC, they are going to get a urinalysis, they are going to get
any number of other blood tests, and these tests would go
through the normal auto-analyzers in the lab without knowing
that that patient actually had an Ebola possibility, or is
that, in fact, separated out of your emergency room?
Mr. Gold. Yes, sir, we have put protocols in place, and we
have also widely shared them for triage screening in the
emergency department if there is any suspicion that a patient
either has a travel history or a symptom complex, they are
immediately sequestered, there is a specific nursing protocol
with personal protective equipment, et cetera. There is a
notification of the team, and the laboratory specimens are
processed through the bio-containment unit facilities, and then
decontaminated as if they were positive, even before we know
the results of the PCR. And we are doing PCR testing on-site
now, which makes it a lot faster and a lot easier, otherwise it
would have taken days previously.
Mr. Burgess. But again, I would just point out that that is
in a perfect world. In the rough and tumble, Buford, Texas, ER,
all of those protocols would not immediately be available.
And we will get back to that, but, Mr. Isaacs, I just have
to ask you, I mean that Typhoid Mary analogy that you used,
that is the first time I have heard of that. Now, we all
remember Typhoid Mary of lore, and she actually had the ability
to infect people. Do your Typhoid Marys carry the ability to
infect people when they themselves are asymptomatic?
Mr. Isaacs. We don't know. That is the question. Now,
Typhoid Mary, in the case of her, she was dealing with a
bacterial infection----
Mr. Burgess. Right.
Mr. Isaacs [continuing]. But what I do know for a fact is
that there have been a number of asymptomatic, non-feeble
people whose blood had been drawn and it tested positive. And I
think that there is something about the PCR test that, you
know, I heard Dr. Frieden say, in medicine, you never say 100
percent. But the thing with Ebola, if you don't bat 1,000 every
day, somebody dies.
Mr. Burgess. Right.
Mr. Isaacs. And----
Mr. Burgess. And someone else is exposed.
Mr. Isaacs. Yes. My point in saying all of that is not to
raise fear, but it is saying that we need to go to Africa and
beat the disease over there.
Mr. Burgess. Yes, sir.
Mr. Isaacs. We need to keep it contained.
Mr. Burgess. You know, you raise a point of two of your
doctors were infected, and you weren't sure why. We had two
nurses in Dallas who were infected, and we are not sure why.
And, again, that just underscores that there is probably more
not known about this disease than what is known, and that is,
again, why I began this with, we all ought to step back and
have a little bit of humility. I would even extend that to Mr.
Waxman. I mean, he is not known for his humility. We all have
to have a little humility in dealing with this.
Dr. Lakey, I just have to ask you. What you did in Dallas
to sort of restore good order and discipline at a point where
it really almost veered toward being out of control, I mean, it
took a lot of courage to exercise those control orders on the
individuals when you did that, and I will admit to being
somewhat surprised turning on the news and hearing that that
had happened. What were some of the things that went through
your mind as you developed that?
Mr. Lakey. So we don't take control orders lightly, and in
Texas, I can put a control order, it is not enforceable until I
get a judge to enforce it. But we have to get the monitoring
done in an event like this. We have to make sure that people do
not have fever, and if I could not get that done the way that I
needed to protect the public's health, I take protecting the
public's health extremely seriously, and so we put a control
order in place. Now, if you do that, you need to make sure that
you provide the support services around that individual to make
sure that there is food, other support there so you can make
sure it is as humane as possible.
With the nurses following the nurse that became infected
we, again, needed to make sure we had monitoring in place. We
also, as we looked and stratified the risk, it looked to me
like the biggest risk would be inside that room with Mr.
Duncan, and so for those individuals, we said it is best during
this time period that you don't go into large public congregate
settings, movie theaters, churches, et cetera. It becomes a
very large epidemiological evaluation when that occurs, if
unfortunately, somebody becomes infected. And we were able to
work with that staff, and they took this very seriously to be
able to limit their movement for the highest risk in
individuals.
Mr. Burgess. Very good.
And, Dr. Gold, are your patients reimbursed by insurance
or, are you reimbursed by insurance when patients are referred
to you?
Mr. Gold. We are in the process of having those discussions
with the insurance carriers and with their employers, but to
date, we have been unsuccessful in any reimbursement through a
commercial carrier. And I can't really tell you whether
anything has happened in the last 24 to 48 hours, of course,
but they have not responded.
Mr. Burgess. Thank you. I appreciate that.
Mr. Murphy. Now, Mr. Waxman, you are recognized for 5
minutes.
Mr. Waxman. Thank you, Mr. Chairman. I will take five and
maybe take an additional two, like we saw with the other
question there.
Earlier this month, President Obama sent to Congress a $6.2
billion supplemental budget request to enhance the U.S.
Government response to the Ebola outbreak. The President's
request is intended to fund both immediate and long-term needs
in the United States and West Africa.
Dr. Gold and Dr. Lakey, you can both speak to the readiness
of our public health system here in the United States. The
President's budget request designated $621 million to CDC for
domestic response, including funding for State and local
preparedness, enhanced laboratory capacity, and infection
control efforts. It also designates $126 million for hospital
preparedness.
Dr. Lakey, can you comment on the need for additional
funding for State and local public health authorities, what are
the top funding priorities?
Mr. Lakey. Thank you, sir. As I outlined in my comments,
the State public health, local public health, is having to do a
lot of work right now. A laboratory response network, having a
laboratory system out there so we can rapidly diagnose
individuals is essential for us to make the diagnosis and
isolate individuals.
The epidemiologists that contact individuals, talk to them,
figure out the risk, is essential. The hospitals having pre-
designated facilities so we can care for those individuals is
very, very important. This isn't the only event. We have had
multiple events; West Fertilizer explosion, Hurricane Ike, et
cetera. That system, to be able to rapidly respond, is
essential. Now, a lot of that is paid for by HPP funds. My HPP
budget was reduced by 36 percent this last year. And that pays
for the training, the education, the things that take place in
order for the hospital systems to be ready.
Mr. Waxman. Um-hum. I wanted to ask Dr. Gold for his
response. Would additional funding assist in hospital
preparedness, and give us some examples of areas where
additional funding would be helpful.
Mr. Gold. I think the additional funding would be helpful
to build the educational programs, to get the referral centers,
as well as community hospitals completely up-to-speed. The
additional fundings will allow to scale response in event we
need to bring American soldiers or other volunteers back to the
United States. Additional funding will be used to create
preparedness for future infectious crises of this nature, for
which we currently do not have resources, and to build a
sustainable infrastructure such as convalescent serum reserves,
such as core laboratory testing, et cetera----
Mr. Waxman. Um-hum.
Mr. Gold [continuing]. So that we have and sustain a
national preparedness level.
Mr. Waxman. Thank you.
I want to pivot now to the funding for international
efforts. Mr. Isaacs, Samaritan's Purse has been on the ground
in Liberia since March, and understands the environment there.
I want to talk to you about the NGO perspective on continuing
needs and efficient use of resources. What are the main
priorities on the ground in West Africa, and what resources are
needed to accomplish those efforts?
Mr. Isaacs. So if I may just add something to what you
said. We have actually been there for 11 years----
Mr. Waxman. Yes.
Mr. Isaacs [continuing]. And the disease broke out in
March, so we have a large footprint, we have 350 staff, about
20 expatriates, we have aircraft there, we have a lot of
capacity in the country. And when the disease broke out, we
were 100 percent focused on fighting it.
What we are seeing today that we think that other resources
are needed for, this is very practical but you know what,
logistics are everything, and there is a lot of discoordination
and confusion right now between the U.N. players, UNHAS,
UNAMIR, and the DoD about gaining access to airlift. There are
no protocols in place about moving blood samples, so if CDC
goes out into an area and identifies a new village, and there
are 10 or 12 people who test positive, they call us in because
we have assembled rapid response teams. We are not able----
Mr. Waxman. Um-hum.
Mr. Isaacs. --to take the blood samples out to other
aircraft, we have to move them out by land. A rapid diagnostic
test is one of the greatest things that are needed there, and I
think, frankly, that if the U.S. Military was running the
coordination cell, things would----
Mr. Waxman. OK.
Mr. Isaacs [continuing]. Be done quicker.
Mr. Waxman. Well, the U.S. is committed to helping in
Liberia, and has provided personnel, resources, and funding. As
we continue our aid efforts, we must also keep in mind the need
for a flexible response. Initial reports indicate that there
are empty beds in Ebola treatment units in Liberia, so the aid
efforts have adjusted accordingly to monitor occupancy and only
build additional ETUs as needed.
Mr. Chairman, I hope that we can join together to quickly
pass the President's budget request. We heard from this panel
and we heard from our first panel about the urgency of the task
at hand, and the public health catastrophe that will occur in
West Africa if we fail to do so.
Thank you very much, and yield back the balance of my time.
Mr. Murphy. I appreciate that. Certainly, I would like to
see that happen, too, and I hope you also take a careful look
what Mr. Isaacs' group is also looking at. They need a bridge
to move people back and forth because that is a struggle right
now.
Mr. Waxman. Um-hum.
Mr. Murphy. Now I recognize Mr. Long for 5 minutes.
Mr. Long. Thank you, Mr. Chairman. And I thank you all for
being here, and not only that, but what you do on a day-to-day
basis because I for one really appreciate it.
Dr. Gold, you said--well, let me ask you something before
that. Dr. Martin Sali, is that how it is pronounced?
Mr. Gold. Yes, Salia.
Mr. Long. Salia. Dr. Salia was taken to your facility,
correct?
Mr. Gold. Yes.
Mr. Long. And the reports that we got on the news, turned
on the radio and they said that there was a doctor with Ebola
that was very critical, was the first thing I thought, and I
probably had the same thought as a lot of people that that is
probably not a good thing when they say that he is very
critical. He later deceased just a few days later. I apologize,
I had to step out of the room for a few minutes, which I
normally don't do, I am usually here for the whole duration of
these hearings, but was there a reason that he was delayed
coming to this country for assistance, for help? Do we know,
because that seems strange that he would be that far gone, so
to speak, before they would think about flying him out?
Mr. Gold. It is unclear to us what the logistics were that
might have delayed it. As we were told, that he had an initial
blood test for Ebola that was negative, and only three days
later did he test positive. And when he tested positive, there
was a period of time before at least we were contacted, I don't
know whether the transportation organizations or the State
Department were contacted, but from the time we were contacted,
the plans for transfer were put into place virtually
immediately.
There was also a good deal of uncertainty how stable he was
immediately prior to transfer, but once the decision was made
to transfer him, rest assured that he got every conceivable
treatment.
Mr. Long. I am sure he did, and I wasn't implying that at
all, but I was just curious as to why they waited as long to
try and get him a--because when I heard that first radio
report----
Mr. Gold. I am told----
Mr. Long [continuing]. And they said he was very critical--
--
Mr. Gold [continuing]. That is not uncommon for people to
test negative even when they are symptomatic. We have heard
about other people who have tested positive who were
asymptomatic. This is not 100 percent certainty disease, and we
are learning an awful lot about the spectrum of how symptomatic
people get, versus their viral levels, et cetera.
Mr. Long. Let me stay with you, Dr. Gold, and switch up the
topic just a little bit. You said in your written testimony
that you have coordinated extensively with the CDC and HHS on
readiness and treatment. Can you tell us more about that
collaboration, on what specific issues have you advised the
administration?
Mr. Gold. We are working with Emory, with the CDC and with
ASPR on standing up educational protocols, visiting other
institutions across the United States to help them enhance
their readiness, hosting teams from other institutions across
the United States. In Nebraska, we have recently had a team of
9 or 10 people from Johns Hopkins University, as well as
putting together a series of protocols that would be used for,
if you will, accreditation or certification of readiness, and
maintenance of readiness.
Mr. Long. And when you say you have advised the
administration, have you spoken with Mr. Klain, the new czar--
the Ebola czar?
Mr. Gold. Yes, sir, several times.
Mr. Long. OK, and did the administration, did they
incorporate or accept your recommendations, and did they reject
any of your recommendations?
Mr. Gold. We are working specifically with Dr. Lurie, who
was your guest here a little bit earlier, and we speak probably
daily on the development of these protocols. There is a
conference call that is scheduled for Friday----
Mr. Long. So you feel they are accepting your
recommendations?
Mr. Gold. Thus far, yes, sir.
Mr. Long. Good, OK. And, Mr. Isaacs, we were talking about
earlier, or you were in your testimony, people traveling on
planes and being checked temperature-wise every so often, three
times a day, did you say, or what were----
Mr. Isaacs. Our staff are under protocol to take their
temperature four times a day.
Mr. Long. Their own personal temperature?
Mr. Isaacs. No. We actually have staff in our Ebola task
force that call them every day, and we keep a log of it. I
could call my office right now and tell you where every one of
our people are----
Mr. Long. But you are talking about your staff, not their
patients?
Mr. Isaacs. Yes, our staff.
Mr. Long. OK.
Mr. Isaacs. Not----
Mr. Long. OK. I got you, OK.
Mr. Isaacs. We are just monitoring their health.
Mr. Long. Right. OK, good. OK, I misunderstood earlier
because you hear these reports about, well, we will check their
temperature when they get off the plane. I think we need to do
a travel ban, as I have mentioned before, but if they say,
well, take their temperature, and then they say they cannot be
symptomatic, not have a temperature and still have Ebola, so my
question is probably invalid since you are talking about your
staff.
But anyway, thank you all again for your service and what
you do, and for being here today.
Mr. Chairman, I yield back.
Mr. Murphy. Thank you.
Mr. Griffith, you are recognized for 5 minutes.
Mr. Griffith. Thank you, Mr. Chairman, I appreciate that.
Thank you all for being here, and thank you, Mr. Isaacs, for
the work that you all have been doing there for 11 years.
Samaritan's Purse----
Mr. Isaacs. Thank you.
Mr. Griffith [continuing]. Is a good organization, and
appreciate what you all have done----
Mr. Isaacs. Thank you.
Mr. Griffith [continuing]. Not just there, but around the
world. Speaking of that, in your written comments, you said
many public health experts are telling us that we know the
disease, how to fight it, and how to stop it. Everything we had
seen in this current outbreak, however, suggests we do not know
the science of Ebola as well as we think we do. I touched on
this earlier in the previous testimony related to, I believe,
the reservoir species is what Dr. Frieden was talking about,
and that we don't know the full extent of the reservoir
species. And you touched on that in your written testimony as
well, and you asked questions can the virus live in other
mammals besides primates, bats, rodents, and humans, and you
attached a study that related to pigs. Do you ask this question
because your people on the ground have some questions, or just
because it is a blank slate and we really don't have much
research on it?
Mr. Isaacs. I think that Ebola is potentially a much more
serious disease than it is given respect for. What we are
seeing is that it is flexible, it is deceptive, it is sneaky,
it is agile, and every time somebody thinks they have it
figured out, it shows us something new. And I think that we as
a society cannot make assumptions that we know what it is and
what it will do. I think that we need to be extraordinarily
careful about letting it come onto this shore. And while it is
true that when it has come here, we quickly identified it and
isolated it, the truth is, as these doctors could tell you,
particularly the gentleman from Texas, that if he had 10 or 20
or 50 cases down there, it would consume his capacity to
isolate it. And so while we can isolate it, if it were to get
out from under us, it would quickly exceed our capabilities,
and that is why I think it is so extremely important to invest
resources to fight and stop this disease in Africa before it
gets off that continent in a major way.
Mr. Griffith. And I appreciate that. Have any of your
people there in Africa indicated to you that they are concerned
about animals that might be carrying the disease, or is that
just a question----
Mr. Isaacs. We live Ebola 24 hours a day. It is all we talk
about. We talk about it all.
Mr. Griffith. Right.
Mr. Isaacs. And, yes, we are worried about it. We don't
know. Evidently, in Spain, they thought the little dog--they
killed it. In Texas, you put it in isolation, and I am glad the
lady got her dog back, I am a big dog guy, but who knows if
it--maybe there is some science on this, but I think that we
don't know.
Mr. Griffith. Well, I would refer you to a study that came
out in March of 2005 in the Emerging Infectious Disease--I
guess that is the name of the publication, but it is a CDC
publication. I would be happy to get you a copy of it, and it
is available, where they talk about the potential of dogs, and
it says that although dogs can be asymptomatically infected--in
other words, they don't get the disease, and sometimes the
science gets confused on television, they don't get the
disease--but they are carrying the antibodies for the disease,
and this study says asymptomatically infected dogs could--
doesn't say they are, could--be a potential source of human
Ebola outbreaks and a virus spread during human outbreaks,
which would explain some epidemiologically unrelated human
cases. And it goes on, and it talks about there are cases in
the past in Africa where they don't have any idea where the
disease came from. And I asked Dr. Frieden about that, and he
said that maybe bats, but they still don't know what all the
reservoir species are.
In a prior hearing before today, when we were here in
October, I said, what are we doing about animals coming into
this country, and it was more or less laughed off, but it is a
concern, wouldn't you agree, Mr. Isaacs?
Mr. Isaacs. I do agree, and I will tell you why it is so
important. This is not the flu, this isn't influenza, this is a
disease that kills 70 percent of the people that get it. And,
if you look at what the disease has done this year--5,550
people dead, 13,000 cases--that is extraordinary. And none of
us have swum in these waters before, and I don't think that we
can use case studies that come from 1976 today to make
assumptions about an unprecedented event that crosses national
boundaries. It is now in Mali. When you look at the disease,
the caseload may be going down in Liberia, but the disease is,
in fact, spreading geographically. We fear that very soon we
will see it in Sierra Leone, and it has already been identified
in Mali.
Mr. Griffith. Well, and I appreciate your comments on that,
and I liked your term ``travel management`` because I do
believe we want people to be able to get there to provide
humanitarian relief, like your organization does. At the same
time, I think we have to be very, very careful.
And with that, Mr. Chairman, I yield back.
Mr. Murphy. Gentleman yields back.
Now I recognize Mr. Tonko for 5 minutes.
Mr. Tonko. Thank you, Mr. Chair.
State and local health departments and local hospitals
serve at the frontlines for treatment and containment of
infectious diseases in the United States. In the case of Thomas
Duncan in Dallas, the country saw the challenges faced by local
health departments and local hospitals dealing with an
unexpected infectious disease.
So, Dr. Lakey, now that you have had some time to reflect
on Mr. Duncan's case and how it was handled, can you talk about
some of the challenges Texas Health Presbyterian Hospital faced
in terms of preparedness?
Mr. Lakey. Yes, sir. I think the first challenge was to
recognize the first case ever in the United States. A rare
disease in the United States. Everyone was watching what was
occurring in Africa, but to think that that was going to occur
in your emergency room on a busy night was a challenge. I think
there was a challenge related to the national strategy, and I
say national because there are experts outside of Government
that review those strategies on infection control. But the
assumption that any community hospital can care for an
individual that has that much diarrhea, that much vomiting,
with that much virus in those fluids I think was a faulty
assumption, that it took a really dedicated team to be able to
care for that individual.
I think one of the lessons learned was healthcare nurses,
physicians, they take their responsibility extremely seriously,
and they showed up to take care of Mr. Duncan and their
colleagues. I think a lot of people were worried that
healthcare wouldn't show up, that healthcare providers would
not show up, but they showed up.
Mr. Tonko. Um-hum.
Mr. Lakey. I think there was a lesson related to the level
of personal protective equip. And that was changed, and so the
higher-level personal protective equip, and I think we learned
that you don't have to wait for a temperature of 101.5 to
diagnose the individuals. We lowered that temperature threshold
just because we wanted to make sure we identified individuals
early, and we identified them with temperatures of about 100.6,
100.8, which, by the previous guidelines, wouldn't have met the
criteria for testing. So those are just some of the lessons,
sir.
Mr. Tonko. And in what ways could the Dallas and the Texas
State Public Health Departments have been better prepared to
handle an unexpected case of Ebola or any infectious disease?
Mr. Lakey. Yes. So I think there are several components to
that. I think the, you know, necessity to train, you know, I
think health departments across Texas and across the Nation had
been preparing. There was a lot of information that we had been
sending out, but that is different than saying this is a real
event and I have to be ready right now. I think one of the
things that we are doing right now to make sure we improve our
preparedness is not only making sure that all hospitals are
ready to think that Ebola is possible, and in the differential
diagnosis, isolating those individuals and informing
individuals, but make sure that there is a system across the
State where those individuals then can be seen and be tested
before you get to a level of a hospital that can care for those
individuals. No hospital wants to be an Ebola hospital. You
know, it is just hard on getting other individuals into your
emergency room if you are labeled the Ebola hospital. And so
there is some reluctance across the United States to step up
and be that facility, but that is one of the things that we are
working on right now.
Mr. Tonko. Thank you.
Dr. Gold, as you said in your testimony, University of
Nebraska Medical Center is recognized as a national resource
for your readiness to provide care for Ebola patients. You have
successfully treated Ebola patients, and just last week another
patient who sadly passed away was brought to your facility for
treatment. Can you briefly describe the protocols and
procedures UNMC had in place that ensured staff was
appropriately prepared to care for Ebola patients?
Mr. Gold. Yes, sir. Since the unit was stood up in 2005,
the staff of between 40 and 50 people has been sustained. And
that staff meets on a monthly basis to go over policies and
procedures, emerging trends in Africa and South America, et
cetera, and as well as works closely with the military through
STRATCOM and the Offutt Base. But that team also drills 4 times
a year, and they do real exercises in the community with waste
disposal, with paramedic transport, et cetera.
We also practice donning and doffing, use of various types
of personal protective equipment, dialysis, respiratory
management, et cetera. So all of the typical procedures and
protocols are not only learned but actually practiced hands-on,
real-time--at a minimum four times a year for every staff
member.
Mr. Tonko. Thank you very much. Mr. Chair, I yield back.
Mr. Murphy. Thank you.
Mr. Terry, 5 minutes.
Mr. Terry. Thank you.
Dr. Gold, what are the costs and impacts of being prepared
when you are preparing and practicing four times a year, when
all of those pieces within the community are also
participating?
Mr. Gold. The actual out-of-pocket costs have been
calculated to be between $250,000 and $350,000 a year to
maintain the core team of nursing support, techs, respiratory
therapists, et cetera. That does not count the in-kind time
that our physicians and other leaders put into it, as well as
does not count the time of the maintenance of the unit, the air
handlers, water supply, autoclaves, maintenance of stock of
equipment, et cetera. That is just the personnel time that goes
into maintaining the readiness.
Mr. Terry. In your opening statement, and I hinted this in
one of my questions to the CDC, is that for the level of
facilities that UNMC and Emory are, and when you train and
practice like this, there should be some maintenance funds to
offset those costs.
Mr. Gold. Well, we certainly agree with that. I believe
that the CDC over time has had a relationship with the Emory
organization, predominantly to protect the employees of the CDC
that work with highly infectious agents in their testing
laboratories and around the world.
We have not had that type of relationship, and would think
it would be appropriate perhaps through the UR instructor or
through some other vehicle that exists.
Mr. Terry. Are you being homered?
Mr. Gold. Sorry?
Mr. Terry. Emory being in Atlanta and CDC being there, are
they just giving money to the hometown hospital----
Mr. Gold. I think they needed a----
Mr. Terry [continuing]. Or is there some contractual----
Mr. Gold [continuing]. Just like we need a way to take care
of our employees if something tragic were to happen and they
were to become ill, they need a way to manage their employees
as well, and I think that was the original basis of the
relationship. We would----
Mr. Terry. OK.
Mr. Gold [continuing]. Very much enjoy a similar
relationship.
Mr. Terry. And I think you are on equal, if not better,
footing, medically speaking, at least.
Speaking of that, just to pick your brain a little bit
here, and maybe someone has already done this, but you have had
two successful patients that got to hug all the doctors and
nurses that helped them, and then we had the last patient that
came in that appeared from the TV video to be in supercritical
condition. What, in your opinion, is the reason that perhaps
this physician, the latest patient, passed away? Any takeaways
from being how you were able to treat the first patients versus
this one that came in a more critical condition? Any lessons
learned?
Mr. Gold. I think the most important lesson learned is that
the early we have access to treat any patient here or in
Africa, the better the yield is going to be.
This particular patient had renal failure, liver failure,
was unconscious when he arrived in the United States, and what
we have learned is that those are all very bad predictors of
outcome. The earlier patients that we cared for did have early
organ failure, but were reversible through good supportive
care, and they all received experimental medication, as did
this patient, but I believe that the organ system failure we
dealt with over the weekend was just far too extreme.
Mr. Terry. So I mean with just this one example, it is
probably not certain, but is there just a point of no return
with an Ebola patient, their organs have already shut down, is
there a way of treating them so they can survive, or is it just
at that point not survivable?
Mr. Gold. I don't think it is possible to predict. Young
people, this gentleman was in his early 40s, and the thinking
was that it was worth an all-out effort to attempt to save him.
And I don't think, if you could take the exact same patient
twice, that you could predict the outcome.
Mr. Terry. Yes. Very good. Appreciate it. And, Dr. Gold,
you and Nebraska Medicine and UNMC make us proud. I appreciate
all of your efforts.
Mr. Gold. We have a great team. Thank you, sir.
Mr. Terry. You do. With Mr. Green's daughter.
Mr. Murphy. Gentleman yielding back?
Mr. Terry. I yield back.
Mr. Murphy. All right, I will recognize Mr. Green for 1
minute of wrap-up.
Mr. Green. Thank you, Mr. Chairman. I ask unanimous consent
to place in the record a statement by the AFSCME, the American
Federation of State, County and Municipal Employees, urging
Congress to support the President's emergency funding of $6.18
billion.
Mr. Murphy. Without objection.
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Mr. Green. And, Mr. Chairman, I want to thank both panels
today. I know the first one is gone--
Mr. Murphy. Can't hear you.
Mr. Green. I just appreciate our witnesses being here, but
also for the panel that was put together, and that is what our
Oversight and Investigations Subcommittee is supposed to be
doing, and I appreciate it. But to follow up on my colleague, I
am the first time in history that the intelligence from your
children went back down the tree, and so I just appreciate that
the first time in many times. Thank you.
Mr. Murphy. So noted for the record.
I want to thank this panel--you can have 30 seconds here.
Go ahead. Dr. Burgess.
Mr. Burgess. Well, I was going to thank the panel, too. I
mean I have been through a number of these hearings. Our
committee, of course, has done hearings. I was allowed to sit
in Homeland Security when they did a field hearing in Dallas. I
sat through the hearing on foreign affairs last September. This
has been the most informative panel that I have had the
pleasure to hear from, and I really appreciate--I know it was a
long day and I know we made you wait a long time, but I really
appreciate you guys sticking with us and sharing with us the
information that you shared because it has been absolutely
critical.
And I will yield back.
Mr. Murphy. Thank you, Doctor.
I want to add to that. I almost had the feeling that the
first panel we had today was spiking the ball. ``We got this,
and we can be confident.'' And I don't agree. After we had our
hearing several weeks ago, we put forth several
recommendations, among them we needed some level of travel
restrictions. People ought to be isolated for 21 days, and what
I hear, Mr. Isaacs, Dr. Lakey, I don't know if it is the same
for Dr. Gold, not only did you do that along with the hospitals
of so many colleagues, but your employees didn't complain. They
recognized they don't leave their compassion at the borders of
Africa.
I thank them for that selflessness of all, not only while
they are there, but in returning home. From this, several
takeaways. That people with level 4 gear can still get Ebola.
We don't know all the routes. And what we don't want to have is
a false sense of security that everything is fine. I worry that
the first hearing, this room was packed with cameras and people
in the Press. At this point in the hearing, what you have told
us should still tell us we have to keep our radar up full alert
here. We have a major battle for this taking place in Africa.
We have a very difficult time for getting people in and out of
there, and if any of those airlines stopped their flights,
could happen at any moment, we are at a loss for moving people
and supplies in and out of there.
So along those lines, I hold to it that we should still
have people do 21-day restrictions from touching patients when
they come back. I am glad that hospitals are doing that
anyways. I hate to think what would happen if that did not
occur. And, quite frankly, I think the hospital would have to
tell other patients if they did have some employees who were
recently with Ebola patients. But I also want to echo what Mr.
Isaacs said, I am going to try and work this out, that we ought
to have a bridge for people going to and from Africa, for all
your selfless workers, from so many charities, Catholic Relief
and Methodist and so many other groups I have heard from--
Doctors Without Borders--we need a way for them easily to go
and easily come back, and we can help monitor them, so this is
one less thing to worry about. With the amount of money we are
talking about going through this, I, quite frankly, especially
when you look at $20 million going to New York City just to
monitor the people exposed to that doctor, that would pay for a
heck of lot of flights, and we could have a charter system to
do that.
Please stay in touch with us. Committee members will have
10 days to get other comments of the committee, and they will
also have questions for you, and we ask that you respond in a
timely manner with any questions for the committee.
And with that, again, thank you to the panel, and this
committee hearing is adjourned.
[Whereupon, at 5:08 p.m., the subcommittee was adjourned.]
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