[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]                      



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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:]
    
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    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:]
    
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    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:]
    
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    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:]
    
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    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:]
    
    
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    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:]
    
    
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    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.]
    [Material submitted for inclusion in the record follows:]
    
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