[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]




 
CONFRONTING THE CORONAVIRUS: PERSPECTIVES ON THE RESPONSE TO A PANDEMIC 
                                 THREAT

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


                                HEARING

                               before the

                     COMMITTEE ON HOMELAND SECURITY
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 4, 2020

                               __________

                           Serial No. 116-65

                               __________

       Printed for the use of the Committee on Homeland Security
       
                                     

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


                                     

        Available via the World Wide Web: http://www.govinfo.gov

                               __________
                               
                               
               U.S. GOVERNMENT PUBLISHING OFFICE 
41-985 PDF               WASHINGTON : 2021                                
                               
                               

                     COMMITTEE ON HOMELAND SECURITY

               Bennie G. Thompson, Mississippi, Chairman
Sheila Jackson Lee, Texas            Mike Rogers, Alabama
James R. Langevin, Rhode Island      Peter T. King, New York
Cedric L. Richmond, Louisiana        Michael T. McCaul, Texas
Donald M. Payne, Jr., New Jersey     John Katko, New York
Kathleen M. Rice, New York           Mark Walker, North Carolina
J. Luis Correa, California           Clay Higgins, Louisiana
Xochitl Torres Small, New Mexico     Debbie Lesko, Arizona
Max Rose, New York                   Mark Green, Tennessee
Lauren Underwood, Illinois           John Joyce, Pennsylvania
Elissa Slotkin, Michigan             Dan Crenshaw, Texas
Emanuel Cleaver, Missouri            Michael Guest, Mississippi
Al Green, Texas                      Dan Bishop, North Carolina
Yvette D. Clarke, New York           Jefferson Van Drew, New Jersey
Dina Titus, Nevada
Bonnie Watson Coleman, New Jersey
Nanette Diaz Barragan, California
Val Butler Demings, Florida
                       Hope Goins, Staff Director
                 Chris Vieson, Minority Staff Director
                 
                            C O N T E N T S

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                                                                   Page

                               Statements

The Honorable Bennie G. Thompson, a Representative in Congress 
  From the State of Mississippi, and Chairman, Committee on 
  Homeland Security:
  Oral Statement.................................................     1
  Prepared Statement.............................................     2
The Honorable Mike Rogers, a Representative in Congress From the 
  State of Alabama, and Ranking Member, Committee on Homeland 
  Security:
  Oral Statement.................................................     3
  Prepared Statement.............................................     4

                               Witnesses

Dr. Tom Inglesby, Director, Center for Health Security, Johns 
  Hopkins University, Bloomberg School of Public Health:
  Oral Statement.................................................     4
  Prepared Statement.............................................     6
Dr. Ngozi O. Ezike, Director, Illinois Department of Public 
  Health:
  Oral Statement.................................................    10
  Prepared Statement.............................................    11
Dr. Julie Louise Gerberding, Co-Chair, Commission on 
  Strengthening America's Health Security, Center for Strategic 
  and International Studies (Former Director of The Centers for 
  Disease Control and Prevention):
  Oral Statement.................................................    13
  Prepared Statement.............................................    15

                             For the Record

The Honorable Sheila Jackson Lee, a Representative in Congress 
  From the State of Texas:
  Article, Washington Post.......................................    44
  Article, Washington Post.......................................    46
  Article, National Geographic...................................    49


CONFRONTING THE CORONAVIRUS: PERSPECTIVES ON THE RESPONSE TO A PANDEMIC 
                                 THREAT

                              ----------                              


                        Wednesday, March 4, 2020

                     U.S. House of Representatives,
                            Committee on Homeland Security,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:05 a.m., in 
Room 310, Cannon House Office Building, Hon. Bennie G. Thompson 
(Chairman of the committee) presiding.
    Present: Representatives Thompson, Jackson Lee, Langevin, 
Richmond, Correa, Rose, Underwood, Slotkin, Clarke; Rogers, 
King, Katko, Walker, Higgins, Lesko, Green of Tennessee, Joyce, 
Crenshaw, and Bishop.
    Chairman Thompson. The Committee on Homeland Security will 
come to order.
    The committee is meeting today to receive testimony on 
confronting the coronavirus.
    Without objection, the Chair is authorized to declare the 
committee in recess at any point.
    Good morning. Today the committee is meeting to hear from 
medical experts about how our country can best confront the 
coronavirus. Americans are justifiably concerned about the 
virus, which has spread around the world, and claimed the lives 
of thousands. Understandably, they have questions about how it 
may affect them, their loved ones, and their communities.
    How concerned do we need to be about the virus? Who is most 
at risk? What can communities do to prepare? What can Americans 
do to protect themselves and their families? What is the 
Federal Government doing? What more should it be doing? When 
might we have a vaccine or other treatment? My constituents are 
looking to the Federal Government for leadership, guidance, and 
expertise, and I am sure my colleagues' constituents are, too.
    I am concerned the Trump administration has downplayed the 
threat, overstated how close scientists are developing a 
vaccine, and silenced experts who disagree with him. Instead, 
we must acknowledge the threat and allow doctors and scientists 
to offer candid assessments of the situation, and direct the 
Federal response.
    We are fortunate to have a distinguished panel of 
physicians to offer their expert opinion today. I look forward 
to hearing from them about what the Federal Government must do 
to support State and local efforts, help hospitals and health 
care providers, and protect the lives of Americans. Input like 
theirs will absolutely be essential to confronting this threat. 
I appreciate their willingness to join us today.
    [The statement of Chairman Thompson follows:]
                Statement of Chairman Bennie G. Thompson
                             March 4, 2020
    Today, the committee is meeting to hear from medical experts about 
how our country can best confront the coronavirus.
    Americans are justifiably concerned about the virus, which has 
spread around the world and claimed the lives of thousands, including 
at least 9 people here at home.
    Understandably, they have questions about how it may affect them, 
their loved ones, and their communities:
   How concerned do we need to be about the coronavirus?
   Who is most at risk?
   What can communities do to prepare?
   What can Americans do to protect themselves and their 
        families?
   What is the Federal Government doing?
   What more should it be doing?
   When might we have a vaccine or other treatment?
    My constituents are looking to the Federal Government for 
leadership, guidance, and expertise, and am sure my colleagues' 
constituents are too.
    I am concerned the Trump administration has downplayed the threat, 
overstated how close scientists are to developing a vaccine, and 
silenced experts in his own administration who disagree with him.
    Instead, we must acknowledge the threat and allow doctors and 
scientists to offer candid assessments of the situation and direct the 
Federal response.
    We are fortunate to have a distinguished panel of physicians to 
offer their expert opinions today.
    I look forward to hearing from them about what the Federal 
Government must do to support State and local efforts, help hospitals 
and health care providers, and protect the lives of Americans.
    Input like theirs will be absolutely essential to confronting the 
threat posed by the coronavirus, and I appreciate their willingness to 
join us here today.

    Chairman Thompson. When the Ranking Member comes, we will 
allow him an opportunity to read his statement into the record. 
We will go forward.
    I welcome our panel of witnesses.
    Our first witness, Dr. Tom Inglesby, is the director of the 
Center for--you want to----
    Mr. Rogers. Go ahead.
    Chairman Thompson. OK--is the director of the Center for 
Health Security of the Johns Hopkins Bloomberg School of Public 
Health. His work is internationally recognized in the fields of 
public health preparedness, pandemic and emerging infectious 
disease, and prevention and response to biological threats.
    I now recognize the gentlelady from Illinois, Ms. 
Underwood, to introduce our next witness.
    Ms. Underwood. Thank you, Mr. Chairman. I want to welcome 
Dr. Ngozi Ezike, the director of the Illinois Department of 
Public Health. Dr. Ezike is a board-certified internist and 
pediatrician who has dedicated her career to improving health 
outcomes and health care access for the people of Illinois. She 
has served in public health roles for the past 15 years in my 
home State of Illinois.
    Dr. Ezike received her undergraduate degree from Harvard, 
and her medical degree from the University of California, San 
Diego. She completed her internship and residency at Rush 
Medical Center, where she is an assistant professor of 
pediatrics.
    I want to thank Dr. Ezike and her team for working around 
the clock to respond to the recent coronavirus outbreaks in 
Illinois, and sincerely appreciate her taking the time to share 
her expertise with us today.
    Thank you.
    Chairman Thompson. Thank you very much.
    Finally, we have Dr. Julie Gerberding, who has served as 
the director of the Centers for Disease Control and Prevention 
from 2002 to 2008. She currently serves as executive vice 
president and chief patent officer for strategic 
communications, global public policy, and population health at 
Merck. She is also co-chair of the Center for Strategic and 
International Studies Commission on Strengthening America's 
Health Security.
    Without objection, the witnesses' full statements will be 
inserted in the record.
    At this point I would like to defer to the Ranking Member 
for an opening statement.
    Mr. Rogers. Thank you, Mr. Chairman. I apologize for being 
late, I got 2 hearings going on simultaneously. But this is a 
great panel, and I look forward to their testimony.
    As I said yesterday, our hearts go out to those who have 
lost their loved ones, and those who are currently undergoing 
treatment.
    This is a global event that requires global response. I 
know many of our international partners are working diligently 
as part of a united effort to understand and address COVID-19's 
spread. Unfortunately, some of the actions taken by other 
countries may have hindered a comprehensive response to this 
new virus. I remain concerned that Chinese officials knowingly 
withheld essential information from both the public and 
international health community in the most critical stages of 
this outbreak. I am sure that the early days of this outbreak 
will be under intense scrutiny, once this crisis is over.
    My deepest concern for the moment is the level of 
preparedness at the State and local level. I have heard 
directly from State and local responders, medical 
professionals, and emergency managers that are dealing with an 
increasingly concerned public.
    We have a very distinguished panel of medical professionals 
here today. I am interested in hearing from them on what 
assistance front-line health professionals need from the 
Federal Government to effectively deal with this crisis.
    I am also pleased that Dr. Gerberding is here today. Dr. 
Gerberding was director of CDC for most of the Bush 
administration. She has led a very effective response to the 
anthrax attacks and the outbreak of SARS, and managed more than 
40 other emergency responses. I am very interested in hearing 
about her experience, and how lessons learned from managing 
those public health emergencies can be applied to the COVID-19 
outbreak.
    Finally, I am interested in the panel's honest assessment 
of the risk from the virus. Your expert medical opinion is 
invaluable in reassuring the public during times like this.
    It is also very important for political leaders to avoid 
fanning the flames of hysteria. Our job should be to support 
the medical community, and provide them with the resources they 
need to handle this and future outbreaks. That is why I am very 
pleased we will be considering a supplemental appropriations 
bill today. Hopefully, this funding will help speed along these 
important diagnostic treatment and vaccination resources that 
will alleviate this crisis.
    Thank you, Mr. Chairman.
    [The statement of Ranking Member Rogers follows:]
                Statement of Ranking Member Mike Rogers
                              Mar. 4, 2020
    As I said yesterday, our hearts go out to those who have lost their 
loved ones and those who are currently undergoing treatment.
    This is a global event that requires a global response.
    I know many of our international partners are working diligently as 
part of a united effort to understand and address Covid-19's spread.
    Unfortunately, some of the actions taken by other countries may 
have hindered a comprehensive response to this new virus.
    I remain concerned that Chinese officials knowingly withheld 
essential information from both the public and the international health 
community in the most critical stages of this outbreak.
    I'm sure that the early days of this outbreak will be under intense 
scrutiny once the crisis is over.
    My deepest concern for the moment is the level of preparedness at 
the State and local level.
    I've heard directly from State and local responders, medical 
professionals, and emergency managers that are dealing with an 
increasingly concerned public.
    We have a very distinguished panel of medical professionals here 
today.
    I am interested in hearing from them what assistance front-line 
health professionals need from the Federal Government to effectively 
deal with this crisis.
    I am also very pleased to have Dr. Gerberding here today. Dr. 
Gerberding was the director of the CDC for most of the Bush 
administration. She led a very effective response to the Anthrax 
attacks, and the outbreak of SARS and managed more than 40 other 
emergency responses.
    I'm very interested in hearing about her experience and how lessons 
learned from managing those public health emergencies can be applied to 
the Covid-19 outbreak.
    Finally, I am interested in the panel's honest assessment of the 
risk from this virus. Your expert medical opinion is invaluable in 
reassuring the public during times like this.
    It is also very important for political leaders to avoid fanning 
the flames of hysteria.
    Our job should be to support the medical community and provide them 
with the resources they need to handle this and future outbreaks.
    That's why I am very pleased we will be considering a supplemental 
appropriations bill today. Hopefully, this funding will help speed 
along important diagnostic, treatment, and vaccination resources that 
will alleviate this crisis.
    Thank you, Mr. Chairman.

    Mr. Rogers. I do have one UC request we enter this into the 
record.
    Chairman Thompson. Without objection.*
---------------------------------------------------------------------------
    * The document has been retained in committee files.
---------------------------------------------------------------------------
    Mr. Rogers. Thank you, sir. I yield.
    Chairman Thompson. I now ask each witness to summarize his 
or her statement for 5 minutes, beginning with Dr. Inglesby.

  STATEMENT OF TOM INGLESBY, MD, DIRECTOR, CENTER FOR HEALTH 
SECURITY, JOHNS HOPKINS UNIVERSITY, BLOOMBERG SCHOOL OF PUBLIC 
                             HEALTH

    Dr. Inglesby. Chairman Thompson, Ranking Member Rogers, and 
Members of the committee, thank you for the chance to testify 
today about COVID-19. My name is Tom Inglesby, and I am the 
director of the Johns Hopkins Center for Health Security.
    COVID-19 was first recognized in Wuhan, China at the end of 
last year and, as of yesterday, has infected somewhere between 
85,000 and 90,000 cases world-wide, and killed over 3,100 
people across 65 countries. Patients who become sick with 
COVID-19 most often have cough, fever, and in the more serious 
cases underlying viral pneumonia. In China approximately 80 
percent of those with this illness had mild symptoms, 15 
percent required hospitalization, and 5 percent develop 
critical illness. The virus has a 1-14-day incubation period, 
and is spread primarily via respiratory droplets between 
persons at close contact. The elderly and those with underlying 
medical conditions are at highest risk.
    As of yesterday, the United States had confirmed 118 cases 
of COVID-19, including 8 deaths. The majority of those cases 
are returning travelers or repatriated persons from China. But 
for about 20 cases, there is no connection between any known 
case of COVID-19, which suggests that in those places there is 
some level of community transmission of COVID going on.
    An emergency supplemental appropriation is currently being 
negotiated between Congress and the administration. In 2014/
2015 Congress appropriated $5.4 billion for the Ebola response. 
In my view, COVID-19 will require perhaps twice as much or 
more, given its respiratory transmission and the likelihood 
that it is going to be wide-spread around the country, and so 
all jurisdictions will need to prepare and respond.
    Health care systems should be planning to provide care for 
large numbers of critically ill patients, as we have seen has 
been required in China and in South Korea and Italy. They will 
also need very strong infection control strategies, including 
access to personal protective equipment, as well as other kinds 
of engineering and administrative controls and hospitals.
    The Federal Government should be engaging at the highest 
level of industry regarding PPE manufacturing and maximizing 
the supply of this critical medical material.
    Steps should be taken to make sure that routine medical 
care is not disrupted, as it has been in China, where we saw 
that clinics entirely unrelated to COVID-19 were disrupted, 
including cancer clinics, dialysis clinics, and other important 
medical facilities.
    Public health agencies are working to isolate suspected 
cases around the country, and to help ensure isolation of high-
risk contacts. If cases increase significantly, it may not--may 
no longer be possible to isolate all cases and contacts. There 
may need to be a shift, probably will need to be a shift in 
strategy. At that point public health agencies will need to 
focus on surveying the population for the overall level of 
COVID-19, advising how the public can be tested, and how it 
needs to be isolated when sick, and working with political 
leaders at the State and local level to consider social 
distancing policies that will be--that will do more good than 
harm.
    CDC has been doing all lab testing until this week, but 
testing is now getting going in public health labs around the 
country. I believe we will see considerably more cases 
diagnosed around the United States in the coming days, as we 
have seen in the last week. Large-scale testing at clinical 
sites around the country will require clinical diagnostics 
companies to create high-throughput clinical tests because CDC 
and public health labs were not designed for the kind of high-
throughput clinical testing that will ultimately need to take 
place.
    Vaccine development is likely to take at least 12 to 18 
months. One of the world's experts is to our left, so you will 
hear more about that. We should be developing--as we develop an 
effective vaccine, we should also be developing means to mass 
manufacture it, which is not necessarily the normal process for 
vaccine manufacturing. Ideally, that should be occurring at 
multiple sites around the world. Even if the United States is 
the country to develop the vaccine, there will be huge demand 
for the vaccine around the world.
    Antiviral or antibody-based medications could also be 
developed far sooner than a vaccine. Similarly, plans for mass 
manufacture of those products should also be under way, should 
those be successful.
    One of themes of our preparedness in this country needs to 
be close partnership between Government and industry, because 
industry is the place where diagnostics on a large scale--PPE, 
medicines, vaccines, hospital equipment--are being 
manufactured. So there is no way around having a very close 
effective partnership, and making sure that those industries 
are well aware of the support that they will receive from the 
Government to do that work.
    Finally, I would say that it is very important from this 
point forward for the Federal Government to be speaking in a 
single consistent voice about what is happening. I think a 
daily briefing, as we did in 2009 H1N1, about what is known, 
what is unknown, how we are learning to fill the gaps in 
information should come out of the Government on a daily basis. 
I do think that should come from our health officials, either 
at HHS or CDC, because they are closest to the science and to 
local and public health agencies around the country.
    Thank you for the chance to testify today, and I look 
forward to your questions.
    [The prepared statement of Dr. Inglesby follows:]
                   Prepared Statement of Tom Inglesby
                             March 4, 2020
    Chairman Thompson, Ranking Member Rogers, and Members of the 
committee, thank you for the chance to speak with you today about 
COVID-19 and the Federal Government's response to it. My name is Tom 
Inglesby. I am the director of the Center for Health Security of the 
Johns Hopkins Bloomberg School of Public Health and a professor of 
public health and jointly in medicine at Johns Hopkins University. The 
opinions expressed herein are my own and do not necessarily reflect the 
views of The Johns Hopkins University.
    Our Center's mission is to protect people's health from major 
epidemics and disasters and build resilience. We study the 
organizations, systems, and tools needed to prepare and respond. Today, 
I will provide comments on the status of the COVID-19 pandemic and the 
U.S. Government's response efforts. My testimony will provide 
recommendations regarding what I believe should be top priorities of 
the U.S. Government.\1\
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    \1\ Please see https://www.nytimes.com/2020/03/02/opinion/
coronavirus-prepare-test.html and https://jamanetwork.com/journals/
jama/fullarticle/2762690 which were the basis of a good portion of this 
testimony.
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    The COVID-19 pandemic presents the United States and the world with 
a serious health security threat. As such, it is critical that the U.S. 
Federal Government continue to lead a robust response effort that 
supports State and local governments, public health agencies, health 
care systems, industry, and the public in order to prevent the worst 
case outcomes in terms of health effects, economic damage, and societal 
impacts.
                         epidemiological update
    As you know, coronavirus disease 2019 (COVID-19) was first 
recognized by astute clinicians in the Chinese city of Wuhan at the end 
of last year. As of March 3 it had infected over 92,000 people and 
killed over 3,100 across 65 countries.\2\ On January 30, the World 
Health Organization declared a Public Health Emergency of International 
Concern (PHEIC).\3\
---------------------------------------------------------------------------
    \2\ https://www.who.int/docs/default-source/coronaviruse/situation-
reports/20200229-sitrep-40-covid-19.pdf?sfvrsn=7203e653_2.
    \3\ https://www.who.int/news-room/detail/30-01-2020-statement-on-
the-second-meeting-of-the-international-health-regulations-(2005)-
emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-
ncov).
---------------------------------------------------------------------------
    Patients who become sick with COVID-19 most often present with a 
cough, fever, and in the more serious cases, an underlying viral 
pneumonia. In China, approximately 80 percent of those with illness 
developed mild symptoms, 15 percent require hospitalization and 5 
percent became critically ill.\4\ The virus has a 1-14-day incubation 
period, most often in the range of 5 days. We know that before China 
put in place its many efforts to slow the spread of the disease, each 
infected person infected between 2 and 3 others, an epidemiological 
parameter known as R0. That number will be different in different 
places and conditions over the course of the outbreak. The primary 
route of transmission is via respiratory droplets between persons at 
close contact (within 6 feet).
---------------------------------------------------------------------------
    \4\ https://jamanetwork.com/journals/jama/fullarticle/2762130.
---------------------------------------------------------------------------
    Some people who get infected have no symptoms--it will take time to 
understand the proportion of people who are infected that do develop 
illness as compared to those who do not. Tests called serology studies 
will need to be created for that, and the CDC and other labs are 
working to get those tests ready. There is some evidence that some 
people who are infected but do not develop symptoms can pass along 
their infection to others--a phenomenon referred to as asymptomatic 
transmission, which complicates public health's ability to control the 
disease.\5\ There are many uncertainties at this point, including how 
severe the disease will be in the United States (it has a case fatality 
rate of about 2 percent in China), what percent of the population will 
be affected (also known as the attack rate), who develops severe 
disease, and how quickly it will spread in the face of public health 
interventions intended to slow it. In China the median age of the 
infected is about 51, and the case fatality rate increases with people 
in their 70's and 80's, and in those with pre-existing conditions.
---------------------------------------------------------------------------
    \5\ https://jamanetwork.com/journals/jama/fullarticle/2762510.
---------------------------------------------------------------------------
    As of March 3, the United States has 100 recognized confirmed cases 
of COVID-19, including 6 deaths in 15 States. That number includes 
evacuees from the Diamond Princess cruise ship. The total includes 
returned travelers and their close contacts, as well as cases of people 
recognized in California and Washington State who do not appear to be 
related to those Americans who traveled in China or their close 
contacts. When a patient tests positive, and no known contacts with 
previously identified cases are found, this mean that there is likely 
at least some level of transmission happening in those communities.
    Public health laboratories have now been given the go-ahead to 
begin using the CDC developed diagnostic test, and they are beginning 
to start testing patients around the county. We should now expect to 
see new cases confirmed in different States as diagnostic testing is 
expanded around the country this week. New cases confirmed in the next 
week or so could feasibly be in the hundreds and will likely continue 
to grow as more testing is performed.
                         u.s. response efforts
    An emergency supplemental appropriation is currently being 
negotiated between the administration and Congress to fund the COVID-19 
response. In terms of an appropriate funding level, comparisons to past 
infectious disease responses might be useful. In 2009, Congress 
appropriated $7.7 billion for the H1N1 influenza pandemic, and in 2014, 
$5.4 billion was appropriated for the Ebola response. COVID-19 will 
require perhaps twice as much money as Ebola or more. On February 28, 
our Center sent a letter signed by 32 leading public health and health 
care organizations and individuals to the Chairs and Ranking Members of 
the House and Senate Appropriations Committees urging them to act 
swiftly to pass emergency supplemental funding sufficient for a 
comprehensive National and international response.
    HHS will have major responsibilities for COVID-19. The CDC is 
leading the public health response, including the development, conduct, 
and promulgation of diagnostic testing; issuing technical guidance; and 
supporting Federal, State, and local partners in screening and contact 
tracing. The NIH's National Institute for Allergy and Infectious 
Diseases (NIAID) is supporting medical countermeasure development, 
along with efforts at BARDA and FDA. The assistant secretary for 
preparedness and response (ASPR) is responsible for ensuring that the 
U.S. health care system, including hospitals, EMS, health care supply 
chains, and others are well-prepared and able to provide care.
    DHS has responsibilities related to Customs and Border Patrol, 
working with CDC personnel to screen incoming travelers to the United 
States, including assessing travelers who self-report illness and 
conducting fever screening at airports. Last weekend, the New York 
Times reported that 47,000 travelers have been screened at airports 
across the country.\6\ It is worth noting, though, that those efforts 
have yet to identify a confirmed case of COVID-19. The provision of 
educational messaging and materials at points of entry probably has had 
value in getting returned travelers to self-identify and bring 
themselves to medical and public health attention.
---------------------------------------------------------------------------
    \6\ https://www.nytimes.com/2020/02/29/health/coronavirus-
preparation-united-states.html.
---------------------------------------------------------------------------
    In addition, the National Biodefense Analysis and Countermeasures 
Center (NBACC) is conducting research intended to provide answers to 
some operationally relevant questions, including the stability of the 
SARS-COV-2 virus in different media and characterizing the best 
decontamination methods.
    The Department of State has major responsibilities related to 
international agreements we have with other countries in terms of 
travel and trade, and it will need to navigate their disruptions. The 
Department of Commerce too will be involved in that work, given the 
interruption of supply chains that have already emerged.
    The Department of Defense will have responsibility for protecting 
the health of the military from COVID-19 and dealing with the 
operational implications of the epidemic and has had responsibilities 
for working with those persons who have been repatriated and kept on 
military bases.
                          response priorities
    Health care systems should be planning to provide care for large 
numbers of critically ill patients. Measures that could be taken 
include the cancellation of elective surgeries if critical care demands 
rise to the point when ventilators or ICU space becomes limited, 
changing staffing patterns to accommodate for higher patient volumes in 
these units, and seeking additional ventilators from the National 
stockpile if necessary.
    Health care institutions will also need very strong infection 
control strategies and responses. In China there have been thousands of 
health care workers infected, although it is unclear to what extent 
those infections occurred before HCWs were properly trained or whether 
they were properly equipped. To prevent that in the United States there 
will need to be good administrative and engineering controls, and ready 
access to personal protective equipment by all staff that interact with 
patients. The manufacturers that make personal protective equipment 
should be assured by the Federal Government that they will be 
compensated for increasing their output to the maximum extent possible, 
even if hospitals do not end up needing all supplies that are produced.
    In addition, readiness at other health care facilities will need to 
be strengthened. In China, there have been disruptions to dialysis 
centers and cancer clinics caused by COVID-19, and it will be important 
in the United States for planning to ensure that routine medical and 
surgical care is not grossly disrupted by this disease.
    In particular, it will be important to prevent infections in long-
term care facilities, given the risks faced by the elderly and those 
with pre-existing conditions, and the propensity for this disease to 
spread within closed systems, such as the Diamond Princess cruise ship, 
which had over 600 cases and in prisons in China, where they have been 
reported large outbreaks. We have already seen the consequences of this 
disease in a long-term care facility in Washington State where a number 
of people have died and a number of others are potential or confirmed 
cases.
    Public Health agencies around the country will also play a pivotal 
role throughout the course of COVID-19. They are now working to isolate 
suspected cases, and track and help ensure the isolation of high-risk 
contacts. If the numbers of cases increase significantly, it may not be 
possible to find and isolate all cases and contacts, any more than that 
is possible with seasonal influenza. At that point, public health 
agencies will need to focus on surveying the extent of COVID-19 in the 
larger population, advising how the public can be tested, and 
communicating to the public about the importance of staying isolated 
when sick, including having positive cases stay home when not sick 
enough to be in the hospital.
    Public health professionals will also need to work with political 
leaders to decide whether and under what conditions social distancing 
plans should be put in place--for example, whether large events should 
be canceled, workers should telecommute, or schools should close. 
Public health agencies typically run on shoestring budgets and have no 
cash surpluses on hand. This work is expensive and will require some 
24/7 work, all of which will need to be supported by Federal and State 
governments.
    Up until this week, the CDC has been doing all the lab testing for 
this virus which has limited the National capacity. Technical 
challenges have slowed the distribution of this test around the 
country, but 54 public health labs had the capacity to do testing as of 
March 3, with all of the more than 100 public health labs around the 
country being likely ready to start testing by the end of the week. 
Testing should ideally be available now for those who have a clinical 
picture consistent with coronavirus infection, but bandwidth limits on 
testing mean that for the immediate future we should be focusing on the 
sickest hospitalized patients who might have this disease.
    Large-scale testing will ultimately require clinical diagnostics 
companies to develop testing in the way that they have done for high 
throughput testing for other diseases. The Federal Government should 
make commitments to these companies that will ensure their development 
and manufacturing work will be fully compensated. These companies 
should not be wondering about the market size or if they will be left 
holding the bag for the costs of development. They should be working 
full-speed ahead in making clinical diagnostics that can be used on 
large scale.
                   medical countermeasure development
    Leading vaccine scientists have said that in a good-case scenario 
it will take 12 to 18 months to develop a vaccine against COVID-19. 
Even as all possible actions are being taken to develop a safe and 
effective vaccine in a highly-funded Federal Government effort, the 
Federal Government and its industry partners should be planning to mass 
manufacture the vaccine when it is developed, ideally in multiple sites 
around the world. Vaccine will need to be made on large scale in a 
short period of time, and the developers of the successful vaccine(s) 
will have enormous pressure to share it around the world.
    Antiviral or antibody-based medicines could be developed far 
sooner. Some candidate antiviral products are already in use or were 
developed for other purposes. It is too soon to say if they will be 
effective. There are a number of companies that are proposing to 
develop antibody-based therapies. Such therapies, if able to diminish 
the morbidity and mortality of the very sickest patients could be very 
valuable. As with vaccines, the Federal Government should be strongly 
supporting the development and testing of a full range of candidate 
therapies, and it should be planning for the rapid and mass production 
of these therapies--should they prove safe and effective.
                     communication with the public
    Given the quickly changing and complex daily developments around 
COVID-19, it will be important for the Federal Government to speak with 
a consistent voice. It will be important for the Federal Government on 
a daily basis to describe what is new, describe what new uncertainties 
or problems have developed, and explain what the Federal Government is 
doing in response. It is important that the White House is involved in 
coordinating the efforts of the various agencies of government involved 
in the COVID-19 response. However, it should be HHS/CDC that are 
responsible for the daily public briefing, given their many overriding 
responsibilities in this public health emergency and their strong 
connections to the public health and health care organizations and 
leaders that are running the response locally around the country.
    It is also important to say that the response to COVID-19 will be 
stronger if it is nonpartisan and highly inclusive. Epidemics can 
result in division and in scapegoating. The country will get through 
this with less damage if we are all pulling in the same direction.
    In conclusion, the United States has many tools at its disposal to 
slow and reduce the overall impact of COVID-19. What is needed now is 
to bring our substantial resources and expertise to bear quickly and 
decisively. Thank you for the opportunity to testify today, and I would 
be happy to answer your questions.

    Chairman Thompson. Thank you for your testimony.
    I now recognize Dr. Ezike to summarize her statement for 5 
minutes.

STATEMENT OF NGOZI O. EZIKE, MD, DIRECTOR, ILLINOIS DEPARTMENT 
                        OF PUBLIC HEALTH

    Dr. Ezike. Chairman Thompson, Vice Chair Underwood, Ranking 
Member Rogers, and distinguished Members of the committee, my 
name is Ngozi Ezike, I am the director of the Illinois 
Department of Public Health, and I thank you for inviting me to 
speak about the novel coronavirus and the preparedness and 
response efforts of the Illinois Department of Public Health.
    Even before our first Illinois case was identified in 
January, a strong Federal, State, county, and local coordinated 
effort was enacted, and enabled our State to be a leader in 
addressing this rapidly-developing outbreak. The CDC quickly 
deployed a team to Illinois after our first case was announced, 
and was essential in partnering with us through the response. 
They have been equally responsive with our recently-announced 
third and fourth cases.
    The Illinois Congressional delegation supported our request 
for immediate approval of an emergency use authorization for 
the COVID-19 test, which has been invaluable in the effort to 
containing illness. Illinois was the first State in the United 
States to validate this test, and to begin testing in-house, a 
capability that we have had for the last 3 to 4 weeks.
    We began sentinel surveillance testing this week, enabling 
Illinois to better determine how much COVID-19 is circulating 
within our community. Our success in testing raises a new 
concern, however: Will we have enough reagent to maintain and 
increase our testing?
    We are requesting that CDC provide an uninterrupted supply 
of testing materials. The ability of States like Illinois to 
test samples lessens the burden on the CDC. We encourage CDC to 
expedite additional reagent shipments to Illinois and other 
States.
    Illinois has utilized and proven its capabilities in the 
past when responding to the domestic cases of SARS, H1N1, Zika, 
and Ebola. IDPH recently participated in Crimson Contagion. 
This is a National tabletop exercise that used a COVID-19-like 
outbreak that was said to have originated in China in the 
United States. However, surge capacity remains something that 
is not able to be sustained for extended periods of time.
    Therefore, emergency supplemental funding is necessary. 
Illinois encourages Congress to appropriate funds enough to 
reimburse Illinois and other States for the costs associated 
with this aggressive response. Public health infrastructure 
such as data management, information sharing, and operations 
management are essential just for day-to-day function, but they 
are vital in the settings of public health emergencies.
    For example, during this response the State health 
department is closely monitoring the availability of airborne 
infection isolation rooms. These isolation rooms are 
providing--are proving critical in the treatment of these 
patients by controlling the spread of the virus to the public 
and health care workers. We inventory these beds daily as an 
indicator of disease rates, and to adjust surge capacity 
estimates. An important support for this capability came from 
ASPR's Hospital Preparedness Program.
    Given the transmissibility of COVID-19, isolation sites are 
required to house affected persons. It is challenging to find 
establishments willing to take on isolation or quarantined 
patients. When COVID-19 began in Illinois, the city of Chicago 
was given very little time to set up screening operations at 
O'Hare and establish a requisite quarantine site. Chicago has 
continued to maintain both its screening operation and 
quarantine site at an enormous cost. Without reimbursement and 
on-going money for future expenses, governments will likely 
struggle to maintain these critical public health 
interventions.
    Additional attention must be given to mitigation strategies 
of the State. We are also working closely with long-term care 
facilities to implement mitigation strategies aimed at 
protecting what would be our most vulnerable citizens.
    In addition to these community mitigation approaches, we 
encourage the public to employ their own strategies to keep 
themselves healthy. We have said it over and over: The frequent 
hand-washing, the staying home when ill, sanitizing frequently 
touched services--surfaces. Individuals should take care to 
rely on trusted sources of information such as the CDC.
    Public health security is homeland security. Our country is 
nothing without the health of its people. We can all work 
together to ensure that we continue to support this response, 
and decrease the potential negative effect and impact on the 
people of this country.
    In closing, I wish to again thank the committee for its 
invitation and the attentiveness to Illinois's successes and 
opportunities in responding to COVID-19. Thank you.
    [The prepared statement of Dr. Ezike follows:]
                  Prepared Statement of Ngozi O. Ezike
                             March 4, 2020
    Chairman Thompson, Vice Chair Underwood, Ranking Member Rodgers, 
and distinguished Members of the committee thank you for the inviting 
me to speak about the novel coronavirus or COVID-19 the preparedness 
and response efforts of the Illinois Department of Public Health 
(IDPH).
    Since the first Illinois case was identified in January a strong 
Federal, State, county, and local coordinated effort ensued and enabled 
our State to be a leader in addressing this rapidly-developing 
outbreak.
    In the aftermath of 9/11 Illinois steadily built a remarkable 
emergency response network, including a comprehensive public health 
emergency response system lead by IDPH and inclusive of our certified 
local health departments and Illinois' hospitals. With on-going Federal 
support, Illinois has been able to conduct exercises such as last 
year's Crimson Contagion, that prepared Illinois for outbreaks like 
COVID-19. A true reflection of our preparedness is found in the 
containment efforts at Chicago's O'Hare airport and contact tracing of 
potentially exposed citizens; Illinois has demonstrated that its public 
health infrastructure is strong and prepared. We encourage Congress to 
continue and increase its financial support of State-lead preparedness 
and response through Federal emergency supplemental legislation.
    Resources are essential to any response effort. Human and financial 
support are irreplaceable and necessary to protect the lives of all 
Americans. Understanding the costs and where extra support is needed is 
integral. As an example of this, IDPH and the Illinois Emergency 
Management Agency began tracking the costs of the outbreak at its 
inception. Similarly, local health departments, like the city of 
Chicago and Cook County are doing the same. While preliminary, the 
Illinois combined spending tops $20 million dollars for the first 5 
weeks of the outbreak. This committee may know that Illinois is a State 
with serious financial concerns; not unexpectedly, COVID-19 response 
was not in any of our budgets. Under the leadership of Governor JB 
Pritzker, IDPH has been able to take every step necessary to address 
COVID-19 recognizing that we would need to figure out how to pay for 
the response efforts at a later date, but our priority at the moment is 
protecting the health of the people in our State. The State of Illinois 
encourages Congress to appropriate funds enough to reimburse Illinois 
and other States, territories, and local health departments for the 
cost associated with COVID-19 response.
    With respect to IDPH's working relationship with the Federal 
Government, Illinois is pleased with the responsiveness and 
collaboration with Federal agencies including the Centers for Disease 
Control and Prevention (CDC) and the U.S. Food and Drug Administration 
(FDA). Illinois is grateful that CDC quickly deployed resources to 
Illinois in response to the first 2 cases in the State and has been 
equally supportive now that there are third and fourth cases. The FDA's 
prompt response when Illinois' Congressional delegation requested 
immediate approval of an Emergency Use Authorization for the COVID-19 
Rapid PCR test has been invaluable in the State's approach to 
containing illness. Illinois was the first State in the United States 
to validate CDC's COVID-19 test and now has all 3 of its State 
laboratories running samples. These 3 laboratories began State-wide 
sentinel surveillance testing this week, enabling Illinois to determine 
if COVID-19 is circulating in the community among persons with no 
travel exposures and no known exposures to confirmed cases.
    Our success in testing raises a new concern, whether we will have 
enough reagent to maintain or increase our testing in Illinois. Even 
so, Illinois has a finite amount of reagent on hand and needs assurance 
that CDC can provide an uninterrupted supply of testing materials. The 
ability of States like Illinois to test samples lessens the burden on 
the CDC, especially at this moment when not every State is able to test 
samples. To support this, the State of Illinois encourages CDC to 
expedite additional reagent shipments to Illinois and other States.
    Federal funding to Illinois, and other States, territories, and 
local health departments supported us in our current ability. 
Preparedness funding ensures that Illinois has plans in place that are 
exercised and ready to deploy when necessary. From both virtual and 
actual exercising of the State's public health emergency response, 
there was immediate action to address COVID-19. Historically, Illinois 
has utilized and proven its capabilities in the past when responding to 
the domestic cases of, SARS (2002), H1N1 (2009), MERS (2014), Ebola 
(2014), Zika (2016), and other high-profile diseases. IDPH recently 
participated in Crimson Contagion, a National exercise that used a 
COVID-19-like outbreak in the United States. The training and 
preparation have been decades in the making and Illinois is capably 
managing the current and anticipated workload. However, surge capacity 
remains something that States like Illinois are not able to sustain for 
extended periods of time and therefore emergency supplemental funding 
is necessary.
    Public health infrastructure such as data management, information 
sharing, and operations management are essential for day-to-day 
function in public health, but vital in a public health emergency. 
Illinois can now resource public health emergencies and track key 
indicators. For example, during this response, the State health 
department is closely monitoring the availability of airborne infection 
isolation rooms or AIIR beds. These isolation rooms are proving 
critical in the treatment of COVID-19 patients by controlling the 
spread of COVID-19 to the public and health care workers. IDPH 
inventories AIIR beds daily as an indicator of disease rates and to 
adjust surge capacity estimates. An important support for this 
capability comes from the Assistant Secretary of Preparedness and 
Response Hospital Preparedness Program (HPP). The department of health 
has partnered with Illinois' health care industry over the years in a 
way that was not there 20 years ago. Understanding where to send 
patients, and adjust accordingly, in a cohesive response, saves time, 
lives, and valuable resources.
    Available isolation and quarantine space are another area where 
Federal support is needed. When a person under investigation is put in 
isolation or quarantine, it is sometimes not possible to house that 
person in their home. It is incumbent upon the local and State health 
departments to find housing for the person until they are cleared. 
Given the transmissibility of COVID-19, quarantine sites are required 
to house these persons. It has been challenging to find commercial 
establishments willing to take quarantine patients for the required 14-
day period. When COVID-19 began in Illinois, the city of Chicago was 
given very little time to set up screening operations at O'Hare and 
establish a requisite quarantine site. Chicago has continued to 
maintain both its screening operation and quarantine site at an 
enormous cost to the city. Without reimbursement and on-going money for 
future expenses, Chicago and governments like it will struggle to 
maintain these critical public health interventions. The Federal 
Government should increase its assistance to States in meeting the 
housing and isolation needs of citizens exposed to COVID-19.
    IDPH partners with State-certified local health departments and 
hospitals to ensure Illinois has a robust and effective health care 
system. That relationship requires IDPH to provide personal protective 
equipment (PPE) to its partners when usage rates drain normal 
inventories. This highlights another concern that Federal authorities 
should soon act upon, the PPE Shelf Life Extension Program (SLEP). 
Illinois and perhaps all other States have significant stores of 
Federally-supported PPE. As a recipient from the Strategic National 
Stockpile (SNS), Illinois is required by law to preserve outdated PPE 
until dispositioned by the Federal Government. In most cases, the 
original manufacturer's expiration date has past, rendering the PPE 
unusable. The SLEP allows the Federal Government to test certain lot 
numbers for efficacy and then extend the expiration date of successful 
lots allowing the PPE to be used. Let me be clear, IDPH has not 
exhausted its stores of in date PPE, however, usage rates could change. 
We urge the Federal Government to evaluate the SNS and provide States 
with extensions for COVID-19-intensive supplies, namely N95 
respirators, isolation gowns, latex gloves, and eye shields.
    As COVID-19 is anticipated to spread throughout the country, 
additional attention must be given to mitigation strategies that State 
and local public health employ. Illinois for example has a pandemic flu 
plan that IDPH will utilize during the upcoming month. Illinois is 
evaluating triggers for changing public behaviors and implementing 
community mitigation strategies. We understand that these triggers may 
be local or regional based upon population and other factors, making a 
one-size-fits-all approach infeasible for Illinois. COVID-19 appears to 
impact the elderly population with co-morbidities and therefore we are 
working with long-term care facilities to implement mitigation 
strategies aimed at protecting our most vulnerable citizens.
    In addition to community mitigation approaches we encourage the 
public to employ their own strategies to keep themselves healthy such 
as frequent handwashing, staying home when ill, eating and sleeping 
well. Individuals should take care to rely on trusted sources of 
information such as CDC or their State and local health department in 
order to get the most up-to-date and accurate information as possible. 
In the public health community we are gravely concerned that 
misinformation and fear will spread faster than the illness itself.
    Public health security is homeland security. Our country is nothing 
without the health of its people and we can all work together to ensure 
that we continue to support this response and decrease the potential 
negative impact on Americans.
    In closing, I wish to again thank the committee for its invitation 
and attentiveness to Illinois' successes and challenges in responding 
to COVID-19.

    Chairman Thompson. Thank you for your testimony.
    I now recognize Dr. Gerberding to summarize her statement 
for 5 minutes.

   STATEMENT OF JULIE LOUISE GERBERDING, MD, MPH, CO-CHAIR, 
 COMMISSION ON STRENGTHENING AMERICA'S HEALTH SECURITY, CENTER 
FOR STRATEGIC AND INTERNATIONAL STUDIES (FORMER DIRECTOR OF THE 
          CENTERS FOR DISEASE CONTROL AND PREVENTION)

    Dr. Gerberding. Thank you, Chairman. I am very honored to 
be here, and also to testify with such distinguished experts at 
the table.
    I am here wearing several hats. I am currently the chief 
patient officer at Merck, where I have served as the president 
of the vaccine business for a number of years, and more 
recently as the chief patient officer who contributed to the 
development and deployment of the Ebola vaccine in the 
Democratic Republic of the Congo, which is now licensed, even 
though it was created on the fastest possible track. So far we 
have been able to contribute about 300,000 doses of the 
vaccine. This week the director general of the WHO indicated 
his optimism that that outbreak has finally come under control.
    I am also witnessing, as the co-chair of the CSIS 
Commission on Global Health Security, which submitted this 
report to the record--the commission is a bipartisan--it 
includes bipartisan Members of the Senate and the House, and 
has the stated purpose to advise the Congress on steps that can 
be taken to improve our global health security. The report was 
written before coronavirus was recognized, but I think many of 
the recommendations which are summarized in my written 
testimony are prescient, and really apply to the situation that 
we are experiencing today.
    I would be remiss if I didn't mention that I am also on the 
executive committee of BIO, the Biotechnology Innovation 
Organization. Today many of the CEOs of BIO are here in 
Washington to brief Members of Congress. About 40 of these 
companies have innovations and molecules and platforms, and are 
stepping up to try to contribute to the prevention and 
treatment of this coronavirus outbreak. So we are lucky that we 
live in a country that has such a vital biotechnology 
organization.
    Finally, I am the former CDC director. In past life, where 
we were dealing with anthrax and SARS and many other outbreaks, 
the first coronavirus outbreak, SARS, challenged the United 
States and challenged the world. I think we learned many, many 
lessons which are relevant to where we are today.
    I don't have time to give the full picture of the U.S. 
public health situation, and I think my colleague has expressed 
it from a State view very eloquently. But I would say that it 
is important to remember where we are in the outbreak right 
now, from a U.S. perspective.
    There are really 3 main phases of outbreak response.
    The first is detection, and that happened in China, and was 
reported fairly early in the process, but we don't have full 
detection because we haven't had full testing, and we still 
don't know whether the cases we are detecting represent the tip 
of the iceberg, and how much of the iceberg is undetected yet 
because we haven't tested, or because many patients are 
asymptomatic, which I, in fact, suspect.
    The second phase is the phase of trying to contain the 
outbreak where it starts. I don't think, in the history of the 
world, we have seen a more dramatic demonstration of that than 
what occurred in China, and then what has occurred in countries 
around the world who attempted to keep the virus out of the 
country. It was a heroic effort. It wasn't perfect, but it 
probably did buy us some time, and for that I think we should 
all be grateful.
    Where we are now is in the phase of slowing the spread of 
the virus. It is here. We are doing everything we can on the 
front lines of public health to identify and isolate cases, to 
quarantine people who may be exposed or incubating, and to 
managing the social system that promotes spread.
    But we have to balance that effort to slow things down by 
recognizing that we also need to sustain our essential 
services. Our businesses need to run, our medical supply chain 
needs to operate, and our security and safety need to be also 
part of our overall response capability. So we are going to be 
seeing a lot of local decision making. If you are looking at it 
from a high-level view, what is going on in Chicago might look 
different from what is going on in some other part of the 
country. But you know that each individual location has to make 
decisions in the best interests, given the state of the 
outbreak in their particular community.
    One of the most important lessons that I wanted to 
emphasize in my opening statement is something we have learned 
in every outbreak, and that has to do with the importance of 
trust. We must have credible leadership at every level: 
Federal, State, and local. We must have clear and consistent 
communication from trusted individuals who are knowledgeable 
about public health, health care, and the science and evidence 
of public health interventions. We must have a spirit of 
collaboration, not combat, a spirit of health protection, and 
not politics.
    Thank you.
    [The prepared statement of Dr. Gerberding follows:]
                  Statement of Julie Louise Gerberding
                             March 4, 2020
    Chairman Thompson, Ranking Member Rogers, and other distinguished 
Members of the committee--I am truly grateful for the opportunity to 
appear before you today on the topic of ``Confronting the Coronavirus: 
Perspectives on the Response to a Pandemic Threat''.
    I have been engaged in professional activities related to the 
prevention and control of infectious disease threats throughout my 
entire career, from the early response to AIDS during my tenure as a 
faculty member at the University of California, San Francisco, to years 
as CDC director during the anthrax, SARS, West Nile virus, avian 
influenza, and other outbreaks, and now as the chief patient officer at 
Merck & Co., Inc. where I led the Vaccine Division for several years 
and more recently supported the development and deployment of Ervebo, 
our Ebola vaccine that is currently deployed in the Democratic Republic 
of the Congo outbreak.
    I also co-chair with former Senator Kelly Ayotte the Center for 
Strategic International Studies (CSIS) Commission on Strengthening 
America's Health Security, which recently released a report entitled 
Ending the Cycle of Crisis and Complacency in U.S. Global Health 
Security. Members of Congress who also serve on the Commission include: 
Senators Murray and Young, and Representatives Bera, Brooks, Cole, and 
Eshoo, in addition to several security experts. I am pleased to review 
the recommendations of the full report and its implications for the 
COVID-19 outbreak that we are dealing with now and pandemics that will 
inevitably strike in the future.
    We began the Commission's work with a simple understanding: Health 
security is National security, in a world that is increasingly 
dangerous and interdependent. Biological threats--outbreaks from 
natural, intentional, and accidental causes--are occurring more often, 
and at the same time, the world is increasingly insecure, violent, and 
disordered, and it is exactly in these danger zones where an increasing 
number of biological outbreaks occur.
    Globalization and the rise of international trade and travel mean 
that an outbreak in a disordered setting with a compromised health 
system can quickly become a pandemic, threatening the United States and 
the rest of the world. Policy makers increasingly recognize these 
threats can undermine the social, economic, and political security of 
nations.
    Unfortunately, this recognition occurs when a health crisis 
strikes--coronavirus, measles, MERS, Zika, dengue, Ebola, pandemic 
flu--and U.S. policy makers rush to allocate resources in response. 
Yet, all too often, when the crisis fades and public attention 
subsides, urgency morphs into complacency. Investments dry up, 
attention shifts, and a false sense of security takes hold.
    That realization led us to conclude that the U.S. Government needs 
to break the cycle of crisis and complacency and replace it with a 
doctrine that can guarantee continuous prevention, protection, and 
resilience. Accordingly, the Commission advocates for a package of 
strategic, affordable actions to advance U.S. health security.
    The Commission commends the recent advances in U.S. health security 
and biodefense policy, including the release of the National Biodefense 
Strategy last fall and the Global Health Security Strategy this year. 
These are positive steps forward, which we should build upon.
    1. We recommend that health security leadership at the White House 
National Security Council (NSC) be restored.--Health security is 
National security. Strong, coherent, senior-level leadership at the NSC 
is essential to guarantee effective oversight of global health security 
and biodefense policy and spending, speed, and rigor in decision 
making, and reliable White House engagement and coordination when 
dangerous pandemics inevitably strike. Leadership on the NSC can bring 
about key, targeted new investments while achieving much-needed reform 
of fragmented programs and higher efficiencies in the use of scarce 
resources.
    2. We need to invest directly and consistently, over the next 
decade, in the capacities of low-income countries.--The best approach 
to protect the American people is to stop outbreaks at the source. The 
Global Health Security Agenda has a proven track record in building 
health systems and health security preparedness in low- and middle-
income countries, financed through a $1 billion Ebola emergency 
supplemental funding. We recommend sustaining that success, not 
disrupting or curtailing it.
    We recommend that the U.S. Government expand the Defense Threat 
Reduction Agency's (DTRA) geographic authorities to operate in all 
continents where health security threats exist. Furthermore, support 
for military overseas infectious research laboratories should be 
sustained. The Department of Defense's (DOD) biological research and 
development programs often focus on diseases not studied in other 
venues and result in medical countermeasures that would otherwise be 
delayed or not developed at all.
    3. We need to exercise multilateral leadership to persuade partner 
countries to invest more of their own resources in preparedness.--We 
recommend that Congress advocate for U.S. leadership to launch a 5-year 
challenge at the World Bank that would incentivize long-term investment 
by fragile and conflict-affected countries in their own basic health 
security capacities.
    The Commission recommends that Congress increase contingency 
funding levels for the CDC and the United States Agency for 
International Development (USAID), and that the U.S. Government make 
annual contributions to the World Health Organization's (WHO) 
Contingency Fund for Emergencies so we can access adequate, quick-
disbursing resources when a health or biosecurity crisis strikes.
    4. The Commission advocates for the establishment of a U.S. Global 
Health Crises Response Corps.--This organization would build upon and 
integrate existing CDC and USAID capabilities, and work with local 
partners to respond early to outbreaks and biosecurity incidents in 
disordered and insecure settings.
    5. The Commission also advocates for the U.S. Government to 
strengthen and adapt programs and capacities to deliver health services 
in fragile settings that meet the special needs of acutely vulnerable 
populations, especially women and children.--This means ensuring the 
continuity of immunization programs, the protection against and 
response to gender-based violence (GBV), and the strengthening of the 
delivery of maternal and reproductive health and family planning 
assistance.
    6. The last area of priority concern is to plan strategically, with 
strong private-sector partners, to support targeted investments that 
will accelerate the development of new technologies for epidemic 
preparedness and response.--We assert that the U.S. Government should 
directly invest in the Coalition for Epidemic Preparedness Innovations, 
or CEPI, an international alliance that finances and coordinates the 
development of new vaccines to prevent and contain epidemics. The U.S. 
Government should also redouble its efforts to develop a universal flu 
vaccine.
    In addition, to ensure that the United States has a sufficient 
arsenal to treat the secondary infections that will occur from the 
coronavirus now and similar public health threats in the future, 
Congress should advance reimbursement reforms to incentivize the 
development of new antibiotics. The current antibiotic market is 
broken; if Congress does not act to ensure that antibiotics are valued 
appropriately, we will continue to see small biotechnology companies 
declaring bankruptcy and large pharmaceutical manufacturers exiting 
this arena.
    Thank you for the opportunity to address you today, and I look 
forward to hearing your perspective. It is my sincere hope that we can 
work closely together to advance the U.S. health security agenda.

    Chairman Thompson. Thank you very much. I must add we hear 
from a lot of witnesses on this committee, and what you have 
told us has been quite sobering, to say the least, but quite 
informative. So I would like to compliment you at the beginning 
of the questions.
    But one other thing that each one of you talked about was 
the need in a situation like this to have effective 
communication. There seems to be mixed messages to the public 
from the administration at this point regarding the severity of 
this outbreak. Many of my constituents have repeatedly called, 
asking for clarity on many issues, citing inconsistency, 
inconsistencies made by the high-level administrative 
officials.
    How would you assess the U.S. Government's communication 
with the public regarding the risks presented by this outbreak? 
What can the Federal Government do better?
    Dr. Inglesby, we will start with you.
    Dr. Inglesby. I think that the state of the outbreak has 
changed a lot in the last month, and we have a very big Federal 
Government with many different people working on this. So there 
have been days when, within the Government, there have been 
different messages issued. I don't think that was necessarily 
intentional. I think that is partly its people kind of catching 
up to where we are in the outbreak. But I do think it will be 
very valuable for the Government to be speaking with as much 
as--of a single and consistent voice as they can, as is 
possible in a big government.
    I do think it is--on the one hand, I think it is very 
important to say what the risk is at this moment. I think many 
of the risk statements have been said from the Government, 
``Today the risk is very low for any particular American,'' and 
that may be accurate for today.
    But I think it would be helpful for Americans to understand 
risk going forward. What do health officials believe is likely 
to happen in their communities? Not in an alarmist way, but 
just so that people can be informed to begin to take measures, 
as we heard--my colleagues talked about, to try and diminish 
their own risks, to make sure that they are staying home when 
sick, to make sure that they are washing their hands properly, 
disinfecting after they touch public services--public surfaces.
    So I think consistent messages that empower the public 
would be useful. Even if we don't know exactly what will happen 
next, we do expect this disease to continue to spread in the 
country at this point. It would be useful for people to know 
that.
    Chairman Thompson. Dr. Ezike.
    Dr. Ezike. In Illinois our intersection with the Federal 
Government has been primarily with the CDC, and we have had 
intense communication and collaboration. We are on hours of 
calls together every day, 7 days a week. We have had Federal 
CDC staff come on-site to help us directly with our 
investigations.
    So--and then, with the FDA, they were the ones that gave us 
the authorization to be able to test, and that ability to test, 
and being the first State being able to do that, has been very 
instrumental in being able to quickly identify our positive 
versus our negative cases.
    So we have seen how good communication, collaboration, and 
coordination between the Federal, State, and our local health 
departments, how that integration has been successful in giving 
us a pretty good response in Illinois.
    Chairman Thompson. Dr. Gerberding, you have gone through 
this in another life. Can you kind-of talk about that, the same 
issue as it relates to communication and the public needing to 
hear a consistent voice?
    Dr. Gerberding. Sure, I will try to share a couple of 
things that I think I learned along the way.
    The one that was the hardest for me was that you can't 
communicate enough, that it really does take, like you said, 
daily, regular, what do we know today that we didn't know 
yesterday? What don't we know? What are we doing to find out? 
Then, what can you expect going forward?
    One of the hardest things about being in the very early 
phases of an outbreak like this is that we don't really know 
what to expect. This is new, and we are learning as we go. So 
preparing people for change, for decisions that we make today, 
might be different from decisions that we make next week. These 
are very important things, and we should just acknowledge them. 
People don't panic if they are given straightforward 
information. They panic when they hear confusing and 
conflicting information, and they don't know who to trust or 
who to believe.
    I think the other important lesson that I learned was the 
importance of Governors in the communication. We tend to think 
that everything is Washington and Federal and, if we do our job 
right, it will just automatically flow through the system. But, 
as you know, Governors have a great deal of authority in their 
States, and they need to be brought into the communication and 
information flow, because they influence a whole number of 
important decisions at the State and local level. So making 
sure that they are connected to the Federal response is 
critical.
    Chairman Thompson. Well, and I thank all of you for saying 
that, because yesterday the administration's coronavirus task 
force held a press briefing that was closed to cameras and 
audio recordings. That is troubling in a time like this, 
because information is very important. So if you hold 
briefings, I think they should be public, they--recordings to 
be--should be made, because it is the consistency of the 
message that provides the confidence that is so important 
during these troubling times.
    So my plea to the administration is, going forward, please 
allow at the briefings to have the press there, have the 
cameras rolling, have the recordings being made, because all 
this adds to a--strengthening the level of communication 
required in a situation that we are in now. So I wanted to make 
sure that the administration hear us so future press briefings 
will be open, from a transparency standpoint, to the public. I 
think all three of you have kind-of said that that is so 
important in situations like this.
    I yield to the Ranking Member.
    Mr. Rogers. Thank you, Mr. Chairman.
    Dr. Gerberding, you made a, in your opening statement, a 
reference to the fact of lessons learned from your time in your 
previous life. What lesson have we most learned from this 
outbreak, given that it is in its early stages, that we need to 
take heed of? Can you think of one, in particular, that stands 
out?
    Dr. Gerberding. I will say the global lesson is that we are 
going to see infectious diseases spill over from the animal 
kingdom on an increasing basis for a number of reasons, and 
that there are common-sense things that the global community 
needs to rally behind, like not having wet markets, where live 
animals are congregated together and create the opportunity for 
this spillover to occur.
    I think, from a U.S. response perspective, the lessons are 
summarized in this report, and that is that we do a pretty good 
job of stepping up when there is a crisis. Our response 
machinery takes time to get in place, but eventually we get 
there, and we do a pretty good job of managing an outbreak. But 
we shouldn't have to do it in a crisis mode. We need to invest, 
we need to take our counter-measures across the finish line.
    We still don't have a SARS vaccine, we do not have a MERS 
vaccine, we do not have a Zika vaccine. We are partially there, 
but then the effort gets abandoned. So we need to stay the 
course, and complete the job so that we can take some of these 
threats off the table.
    Mr. Rogers. Dr. Ezike, you talked about quarantine, and--
tell me more about what you think the appropriate facility 
would be styled like to be a good quarantine facility.
    Dr. Ezike. So thank you for the question, and let me start 
by distinguishing the quarantine sites versus the isolation 
sites. So----
    Mr. Rogers. Define those two.
    Dr. Ezike. Yes. So ``quarantine'' we use to talk about 
people who don't have symptoms, who are asymptomatic. When I 
talk about isolating people--maybe we needed some sites for 
home isolation for people who maybe are already showing 
symptoms--the goal would be for people who are already sick, to 
actually keep them out of the hospital. If they don't require 
hospital-level care, ICU care, we really want to keep those 
people out of the hospital, so that we don't pose that 
additional risk to the health care workers and sicker people in 
the hospital.
    Mr. Rogers. They need to be exposed in any way to other 
individuals who have no symptoms?
    Dr. Ezike. Please--can you please repeat the question?
    Mr. Rogers. Do those individuals who are starting to show 
symptoms need to be exposed to anybody else that doesn't have--
--
    Dr. Ezike. We would--that is what we are trying to avoid.
    Mr. Rogers. Right.
    Dr. Ezike. So, in cases where a person has contracted the 
virus but they are not sick enough to require hospitalization, 
we would like to have a space, an isolation location, where 
that person could be safely housed until they were no longer 
infectious.
    Mr. Rogers. What are the characteristics of a place that 
would safely house somebody who is showing symptoms?
    Dr. Ezike. Right. So if someone lived alone, there would be 
no problem, they would just be in their home. But if someone 
had a family, we wouldn't want to infect them. We wouldn't want 
to expose them to their family.
    So we are--the settings that we have used or looked to use 
are--we need a, like, motel, where you have individual rooms 
with their own entrance, where the air is not shared, where 
there is not a common lobby where people would have to 
congregate. So you want individual settings where they can 
minimize exposure to other people.
    Mr. Rogers. What if somebody had to go to the hospital? 
What should a hospital prepare for, as far as rooms or 
capacity, that does not expose people to other emergency room 
personnel or patients?
    Dr. Ezike. Yes. So again, it comes around coordination. 
Ideally, if you knew someone was concerned, or the clinician 
who had talked to the person, hopefully by phone, and 
identified them as an--at risk for having the virus, that we 
would have a system in place where they could be safely 
transported to the ED, and--or whatever location, but not be 
exposed to people, where the initial people who are interacting 
with this suspected person could already be in full personal 
protective equipment.
    We have had, you know, hundreds of people who were just 
taking--doing business as usual, and then after the fact found 
out that the patient they were taking care of had the 
coronavirus. That has resulted in them having to be at home for 
14 days, waiting to see if they developed symptoms.
    So ideally, we would have robust communication, be able to 
bring them into a safe space--ideally, not even into the 
hospital. If we could create some kind of, you know, drive-
through testing sites that are away from the hospital, if there 
was some off-site location where you avoid contact with, you 
know, sick people in the hospital and health care workers, we 
don't want to do anything to compromise our capacity, in terms 
of health care workers, where they are all home, waiting to see 
if they contracted something, and not able to provide front-
line services.
    Mr. Rogers. Thank you. I yield back.
    Chairman Thompson. Thank you very much. The Chair 
recognizes the gentleman from Rhode Island, Mr. Langevin, for 5 
minutes.
    Mr. Langevin. Thank you, Mr. Chairman. I want to welcome 
our witnesses here today. Thank you for your testimony.
    Dr. Gerberding, in particular, welcome back before the 
committee. You testified before us many times when you were the 
head of the CDC, including hosting me and a Congressional 
delegation at CDC for a site visit there. So I deeply 
appreciate your leadership.
    I would like to continue on this line of State preparedness 
and what States should be thinking about right now.
    Yesterday I spoke with the Governor of Rhode Island, 
Governor Raimondo, about the emerging public health threat to 
our State, which has already seen one confirmed case of 
coronavirus and several presumptive cases. So any additional 
thoughts, in terms of States' preparedness right now, what they 
should be thinking of right now, in terms of surge or 
alternative sites? Because that has been my concern, is that 
people are sick, they are going to go to the hospital, that 
could very easily overwhelm the public health system, in 
addition to infecting sick patients already that are at the 
hospital, or, equally important, the health care providers that 
are caring for people.
    So any additional thoughts, in terms of what States can be 
thinking of right now, preparing for the eventuality that this 
might become community spread, and that we should have 
alternative sites?
    Dr. Ezike. So that is, of course, exactly what we are 
working on throughout our agency. We are trying to develop--we 
are developing guidance for different locales. We are 
developing guidance for our local health departments, so that 
they can advise schools. We want schools to start thinking 
about contingency plans.
    So we can't be over-prepared. I think the adage is if you 
fail to prepare, you are preparing to fail. So just thinking 
through possibilities, thinking through the options for 
telework, looking at your agency, your company, and seeing 
which people in your agency, if this surge--could stay home and 
still maintain the operations of the company or the business, 
which people don't have to come in. How do we minimize those 
situations?
    So going through different scenarios, looking at our--
again, worried--have a top-of-mind--our long-term care 
facilities, because there is a very high-risk population, and 
making sure that all the long-term care facilities, assisted 
livings, that they are looking at their infection control 
programs, that they are making sure that they are following 
them, that they teach and re-educate their staff on infection 
control measures.
    Think now about how--what are the appropriate ways to co-
house people if there is more than a person in a room. So 
thinking through all the possibilities, that is the 
preparedness part.
    Mr. Langevin. Let me ask you this, if I could. As we know, 
of course, the workplace is an area of particular concern with 
respect to bio-transmission. To that end, the CDC and State 
leaders, including our Governor, strongly recommend that people 
stay home from work who are sick, which is common sense.
    However, for many people, especially hourly workers, 
staying at home can mean choosing between putting food on the 
table or paying bills or stopping the spread of the virus. So I 
know Governor Raimondo is trying to look at creative solutions 
to make sure that the Rhode Islanders are not forced to make 
this impossible choice.
    But Dr. Ezike, how is Illinois addressing this problem, and 
what should the Federal Government be doing to help?
    Dr. Ezike. Yes, that is a really--real concern. I am 
thinking of one person in particular who actually wanted to 
leave the hospital before we had test results, because they 
expressed that exact concern, that ``I only get paid when I 
show up to work, and being here is costing me, and I am the 
primary breadwinner for the family.''
    So we know in the hospital setting we have had great 
collaboration with our hospital leadership. So when they have 
told employees to stay at home, they know that they will be 
paid. But we need to have some kind of pay-back for people who 
are set up to stay home. If we want people to comply with our 
public health interventions, it can't be at a detrimental cost 
to them and their family, in terms of their economic 
subsistence.
    So making funds available to reimburse people for the time 
that they have to be at home to comply with our public health 
measures will help people to follow our public health measures, 
as opposed to avoiding being tested because they don't want to 
incur the resultant isolation.
    Mr. Langevin. Hopefully, that is going to be addressed in 
the supplemental that Congress is dealing with, and we will 
have a mechanism for that.
    Dr. Gerberding, any thoughts before my time runs out?
    Dr. Gerberding. I just wanted to say one thing about 
schools, because we learned, in studying the previous influenza 
pandemics, that early school closure was a critical component 
to helping to slow down spread in many communities.
    This outbreak is somewhat puzzling, because less than 1 
percent of the cases are in kids. So that may be because they 
have very mild disease, and they don't get tested, or they are 
not noticed to have the disease, or perhaps they have some 
immunity from prior normal coronavirus, common cold-type 
exposures. We really don't understand that. Until we have 
serologic testing we won't really understand that whole tip of 
the iceberg.
    But I think we will see situations where school closure 
makes sense, in the short run. But we very quickly need to 
learn what is the role of children in spreading the diseases 
with this coronavirus, because it makes a huge difference 
whether or not schools are closed. Closing schools is extremely 
disruptive. It may be necessary, but we need to, I think, build 
the evidence base to understand how to use that tool.
    Mr. Langevin. Very good. Thank you all.
    Chairman Thompson. Thank you very much. The Chair 
recognizes the gentleman from New York for 5 minutes, Mr. King.
    Mr. King. Thank you, Mr. Chairman. Let me thank all the 
witnesses for your testimony today.
    There is a report from New York this morning, which, I 
think, shows the rolling impact of this disease. It was a 
lawyer from Westchester County who was diagnosed yesterday. 
This morning it turns out that his wife and 2 children and the 
neighbor who drove him to the hospital for the test all have 
it. One of the sons is a student at Yeshiva University, and the 
school is being shut down now because of that. So this is, you 
know, the growing impact it can have.
    In a metropolitan area like New York or Chicago, Los 
Angeles, Boston, any of them, how quickly could this spread?
    I am not trying to spread fear here, because I think this 
can be controlled. But when you just see that one impact of one 
person and one family, and his neighbor and students, how 
quickly that could spread--and I assume he took--he may have 
taken the train or the subway to--you know, to work that day. 
He works in lower Manhattan, where he, just by being on an 
elevator, walking through a hallway, he runs into hundreds of 
people.
    Dr. Inglesby. So in Wuhan, where this first occurred, the 
estimate by some of the most prominent modelers in the world 
was that the epidemic was doubling every week. We don't know 
whether that will be the same here. But we do see most--we saw 
very prominent clustering in families and in people who have 
close contact.
    So I think we should presume that there will be relatively 
rapid spread in our communities. We are beginning to take 
measures to try and change that. But I think it could spread 
rapidly in communities around the country.
    Fortunately, I think this--that many of the cases that you 
just described will have very mild illness. They won't even 
have--if they didn't have a contact with their father, they may 
never have been recognized. They might have had the illness and 
then never had it diagnosed. So we are going to learn a lot 
about the illness, and what it looks like in America in the 
coming weeks, and we should be prepared to kind-of move in 
different directions.
    I do think that some of the social distancing measures need 
to be considered in places where we have high exposure and loss 
of cases recognized, such as the communities in Washington 
State, which are having a lot of disease recognized.
    But at some point I don't believe those measures will--some 
of those measures will scale any further. We won't be able to 
quarantine and isolate in the way that we are doing now. It 
will be too many people to do that. So we will have to shift 
strategies to things that are more community-based.
    Mr. King. Doctor.
    Dr. Ezike. So, in the cases that we have seen in Illinois, 
we have seen how a single individual, after being diagnosed, 
when we try to look back at the time that they could have been 
incubating, the places they would have been, the different 
settings, you know, maybe if they interacted with the health 
care system as an outpatient, and then, you know, was sent 
home, and then maybe came back, one person could have contacted 
up to, I mean, in our cases--and I am just thinking of specific 
examples--150 people. So then those people are all looked at.
    But--and that--you know, if someone happened to have, you 
know, flown or gone to, you know, a mass gathering, then the 
numbers could be a lot. So absolutely to your point, a single 
case can spread to many people.
    But we have also seen, as the doctor mentioned, that it has 
been the closest contacts that we have seen so far--you know, 
we have not had any of the health care workers who have been 
exposed to the patients before they were detected, before they 
were in full personal protective equipment, none of those 
people have come back positive.
    So we hope that that is a sign that will continue. But the 
idea is to minimize the number of cases, because it does have 
the potential to spread exponentially.
    Mr. King. Doctor.
    Dr. Gerberding. Just think about the very first patient 
diagnosed in the United States who had traveled to China and 
came back with the virus, and was a good citizen and stepped 
forward when he just didn't feel well, long before he had fever 
or pneumonia. So they were able to sample his respiratory tract 
as he was developing progressive illness, and learned that 
early on, when you might not have even recognized that you were 
very sick, his upper airway was full of virus. So he was 
probably potentially quite infectious early--even early in the 
course of his disease.
    Later he went on to develop pneumonia and, of course, with 
pneumonia, with your coughing or you are getting procedures in 
a health care setting, you have the risk of becoming a super-
spreader, which means that your respiratory secretions are 
being disseminated into the environment. We saw that with SARS 
and with MERS.
    The good thing about that in the United States is that we 
are pretty good at hospital infection control, and we can 
usually minimize that kind of spread.
    But stepping back and thinking about the transmissibility 
of this coronavirus versus the community transmission of SARS, 
this is a much more transmissible situation. We saw very little 
community transmission.
    Another way of thinking about it is in SARS, in 8 months, 
we had 8,000 global cases. With coronavirus there were 8,000 
cases in 2 weeks.
    Mr. King. I just feel sorry for the guy who drove him to 
the hospital for the test. He ended up--I guess no good deed 
goes unpunished. You know, the neighbor who drove him to the 
hospital has come down with it now, too, so----
    Dr. Gerberding. Yes.
    Mr. King. Anyway, thank you very much for your testimony. I 
appreciate it very much.
    Chairman Thompson. Thank you. The Chair recognizes the 
gentleman from California, Mr. Correa, for 5 minutes.
    Mr. Correa. Thank you, Mr. Chairman. I want to thank you 
for holding this most important and timely hearing.
    In January, Orange County--my county--the first patients 
who tested positive for coronavirus in the United States, one 
of the first ones--now we have 43 of these cases in California. 
I was looking at my phone right now, we just reported the 
second case in Orange County.
    Yesterday, in response to the news report, I wrote to the 
Center of Disease Control and Prevention, asking them to please 
share clinical information on the coronavirus patients with 
medical professionals to help doctors diagnose, evaluate, and 
treat coronavirus.
    I would presume that, right now, we don't know how many 
folks are infected out there, so we really don't know the death 
rate out there. We don't know if this is worse than flu--yes or 
no? Am I correct on that?
    Dr. Inglesby. You are correct. At this point, in China, the 
overall number of people who have died have been about 3 
percent, close to 3 percent, between 2 and 3. We don't think 
that that will be, ultimately, the case fatality rate of this 
disease, because there are, as Dr. Gerberding said, probably a 
substantial number of people who haven't been diagnosed, who 
have mild illness, which would mean the case fatality rate will 
go down. But we don't have any surety about that yet.
    So we believe it is--and, as a comparison, seasonal 
influenza is somewhere on the order of 1 in 1,000 people die 
from that disease or less, depending on the year.
    Mr. Correa. So, as we get more information, we have a 
better picture and----
    Dr. Inglesby. Yes.
    Mr. Correa [continuing]. Therefore, possibly this is a 
better evaluation, a better handle on this emergency.
    Dr. Inglesby. Right.
    Mr. Correa. So Dr. Ezike, are we doing enough at the 
Federal level? Are we working--Homeland Security, with local 
States, to address this issue? Are the resources, 
communication--they can do a better job to get a handle on this 
crisis?
    Dr. Ezike. I think, at the forefront of what you just 
mentioned, and in terms of identifying the details and the full 
picture is the ability to broadly test. We can't know what the 
rates of infection are if we don't diagnose the infection.
    So I think that that is so critical. The sentinel 
surveillance that would be a helpful tool involves looking at 
people, just generally in the community, to see if there are--
what the levels are in the community without a known travel 
history, without a known exposure to a confirmed case.
    Currently in Illinois, we are trying to start that process, 
but we have to tread lightly, because we don't want to run out 
of testing supplies that--and we need also test the people who 
are connected to the last 2 cases that we just recently 
identified.
    So I think making sure that testing supplies are available 
broadly, where people can test without reservation, I think, is 
an important thing that the Federal Government needs to give 
the States and hospitals the ability to do. I think that is 
pretty central to the effort, being able to diagnose in the 
first place.
    Mr. Correa. Dr. Gerberding, you said something that really 
bothered me, which is we have had past pass similar crises, 
similar situations, yet we don't finish the job. We haven't 
developed vaccines, treatments for these other cases in the 
past. Yet, as you said, we are going to continue to have these 
kinds of situations and jump from animal infections to humans.
    What can we do at the Federal level to compare and be very 
consistent, in terms of addressing these crises so they don't 
turn out to be such a major challenge, as we move forward?
    Dr. Gerberding. Thank you. You know, I am so grateful that 
the Congress is going to provide an emergency supplemental for 
this. But if we were investing properly for our broad homeland 
security and the issue of health threats, infectious disease 
threats, we would not need emergency supplementals anywhere 
near the scope and magnitude that you are facing right now.
    So we need to improve the support for the CDC's 
surveillance capability. I think we have learned that we also 
need to make sure that they can scale testing as quickly as 
necessary to avoid the bottlenecks that we have seen. I think 
we need to make sure that our State and local health 
departments have the capacity. They will soon run out of 
laboratory time, space, and people to be able to do all of 
these tests, and they will need support from the Federal 
Government to scale their capabilities. They will be working 
24/7, literally.
    So we haven't built into our system of preparedness that 
surge capability. It might be fine if this were a rare 
situation, but let's just think back for a few years. We have 
had SARS, we had avian influenza. We had a pandemic in 2009. We 
have had Zika. We have had to worry about Ebola. And now, here 
we are with this new coronavirus. This is not a one-off 
situation; this is going to be our new reality, and we need to 
upgrade the investment that we are making in the front line of 
public health.
    Mr. Correa. Thank you.
    Mr. Chair.
    Chairman Thompson. Thank you. The Chair recognizes the 
gentleman from North Carolina, Mr. Walker.
    Mr. Walker. Thank you, Chairman Thompson.
    Dr. Ezike--first of all, let me thank you, panel, for being 
here today. But Dr. Ezike, yesterday my home State of North 
Carolina announced its first case of coronavirus. The patient 
in North Carolina had recently returned from Washington State, 
where an outbreak had occurred. How is your State monitoring 
patients arriving from areas that have many confirmed cases?
    Dr. Ezike. So right now, for interstate travel within the 
United States, there is not a specific mechanism, a formalized 
mechanism to say, oh, this person came from California. Where 
that information would be used is if the person developed 
symptoms and, hopefully, a very astute clinician is taking a 
travel history, and then would notice, in asking questions 
about where you have been recently, somebody would say, ``I was 
in Washington,'' or, ``I was in California,'' and so that would 
raise the level of suspicion, the index of suspicion, that, oh, 
that could be maybe a higher risk.
    So, at that point, they would, you know, reach out to the 
local health department to get the PUI number to get the 
authorization to test.
    So we have, you know, more formalized processes that--where 
we--through the, you know, Customs and Border Control, and the 
Department of Global Migration and Quarantine, where they come 
from, you know, China or Iran, certain countries that we would 
get that and automatically do the monitoring. But for 
interstate, that is not in place now.
    Mr. Walker. Yes, and I am--anybody on the panel can speak 
to this--is it--I believe it is my understanding that the 
deaths that we have seen in Washington State, for the most 
part, are senior adults with maybe some respiratory issues. Is 
that your understanding?
    Dr. Ezike. I don't know of all of them, but I think the 
majority--I know for a fact the majority of them are. I can't 
speak for every single case.
    Mr. Walker. All right. And Illinois, successfully what are 
you doing to maybe limit the spread of viruses that States like 
North Carolina can emulate?
    Dr. Ezike. So we--again, the--right now, some of the--we 
don't have other counter-measures besides the standard public 
health measures, in terms of, you know, self--you know, self-
quarantine, or staying home when you are sick and, you know, 
using hand sanitizer, and washing your hands. So we are giving 
that message out broadly.
    But I think, again, our sentinel surveillance will be 
helpful, so that we can identify if there are pockets of the 
State that actually have circulating virus that we are not 
aware of. I know that the whole State might not see some kind 
of surge at the same time, it is going to be focal and local in 
certain communities. So we just want the ability to identify 
that----
    Mr. Walker. All right, thank you.
    Dr. Ezike [continuing]. As soon as possible.
    Mr. Walker. Dr. Inglesby, you discussed the incubation 
period as 5 days, and someone who gets infected has no 
symptoms. The question is this: What do you suggest the 
Government does to minimize the risk of asymptomatic 
transmission?
    Dr. Inglesby. I think that is a very difficult question. I 
am not sure there is anything in specific that we can do about 
asymptomatic transmission, because all of us are asymptomatic--
I don't believe any of us are necessarily infected with 
coronavirus, but we wouldn't know.
    I think, ultimately, the goal of communities, as this virus 
begins to spread, is to try to lower the peak of the epidemic, 
to slow it down, so our health care system is not over-burdened 
with very sick people. So some of the measures that public 
health agencies and local governments are going to start to 
consider will be should we cancel public gatherings, where 
people--where thousands of people get together for a sports 
event, or a concert, or something else. Should we begin to 
recommend to our communities that they telecommute, if they 
can?
    Mr. Walker. OK.
    Dr. Inglesby. Those kinds of things.
    Mr. Walker. Well, a lot has been talked about the 
quarantine time period of 14 days. Is that a sufficient amount 
of time? How did medical professionals come to that number? 
Should patients stay in quarantine any longer?
    Dr. Inglesby. I think that number was based on what we have 
seen from China and the World Health Organization, and 
supported by CDC, and it is based on the longest we have seen, 
in terms of incubation.
    I do think, when people come out of isolation, that local 
health authorities are working with them directly to make sure 
that they are safely coming out of isolation if they have 
actually been infected.
    Mr. Walker. One last question for you. There have been a 
few reports of people testing positive after having recovered 
from an earlier infection, which is very troubling. That 
means--that brings in other things we won't get into today, as 
far as concerns, as far as where it was actually based, or how 
it was created.
    If you become infected and recover, is it possible to be 
infected again? Or is this a larger issue with testing, such as 
false positives?
    Being married to a nurse--family nurse practitioner, we--
this has been part of our discussion this past week. Would you 
address that?
    Dr. Inglesby. I think it is the latter. I don't--I think 
the numbers are too small to say anything about reinfection. 
Our judgment is that it is probably a testing phenomenon: Test 
1 day, and then the next, and the test picks it up the next 
day, but the person was consistently recovering for that whole 
time.
    Mr. Walker. Last question, just real--yes or no. This is 
something we are debating at home. Washing your hands, of 
course, is crucial. With anti-bacterial soap, is that better 
than hand sanitizer?
    Dr. Inglesby. I don't think there is any evidence that it 
is.
    Mr. Walker. OK, all right. Thank you.
    Chairman Thompson. Thank you. The Chair recognizes the 
gentlelady from Illinois, Ms. Underwood.
    Ms. Underwood. Thank you, Mr. Chairman, and thank you to 
all of our witnesses for being here today.
    Coronavirus requires a whole-of-Government response, which 
means Federal, State, and local governments must work closely 
together to fulfill their different roles. But it also requires 
a public health approach, one that prioritizes risk 
communication, as you all both--or all 3 of you just clearly 
expressed. It uses smart strategies to minimize the impacts of 
the virus, and keeps communities that we all serve educated and 
safe.
    Dr. Ezike, can you tell us more about your Department's 
day-to-day work with the CDC in response to the coronavirus?
    Dr. Ezike. So we have lots of interaction with the CDC. 
There are hours of calls per day, where we get updates, where 
they will interact with--whether it is the State health 
officials, or the State epidemiologist, or the State 
preparedness and response, there are all departments of the CDC 
talking to all departments at State and local government.
    We have on-site support, in terms of Epidemiologic 
Intelligence Service officers, we have go-teams that have been 
deployed to help us with the actual investigations. They have 
guidance that they are continually putting out and updating to 
help us disseminate information to our communities, in terms of 
ways that they can get prepared.
    So there is a robust coordination and collaboration. They 
are listening--the calls--they are listening to us to identify 
what our needs are. When we say, ``Oh, we are missing a 
guidance related to this,'' then they say, ``Yes, we will take 
that back,'' and then they work with their teams, and solicit 
our input, and put out guidance in as timely a manner as 
possible. So there has been a robust coordination, and we are 
happy to partner with the CDC.
    Ms. Underwood. Then, is IDPH working with any other Federal 
agencies in this response?
    Dr. Ezike. That is--at my level, that is the primary point 
of contact. I know that my Governor has been--we are in contact 
constantly, and he is also in contact with the Federal 
Government. They have--they outreach directly to him, as well, 
to give him the overview, and the summaries. So there is 
communication directly with the Governor, as well as with the 
different parts of the public health department.
    Ms. Underwood. Are there any areas where additional 
assistance would be helpful, from your perspective?
    Dr. Ezike. Sure. So we can't reiterate enough the need for 
funding, both to make sure that we can accommodate all the 
employee--whether it is the overtime, whether it is--we had 
to--in one instance in our State we had to rent an RV, because 
we couldn't find a motel that would agree to take one of the 
people that needed to be isolated. So we need assistance to pay 
for the housing options for people who don't have it. I think 
funds for people who are displaced from work temporarily, 
assistance with that.
    So there are--you know, our lab, you know, the--to run the 
lab, the lab equipment, a single piece of lab machinery is up 
to $500,000 or more. So there is a list of resources that need 
financial support to maintain our operations.
    Ms. Underwood. In your testimony you wrote that Illinois 
conducted an exercise last year, the Crimson Contagion. Can you 
tell us more about those kinds of exercises, and why they are 
such an important part of your preparation to respond to 
potential outbreaks?
    Dr. Ezike. So in the aftermath of 9/11, we started getting 
funding for what our offices call the Office of Preparedness 
and Response. So, in that office, it is gearing up, as the 
doctor mentioned, trying to prepare for what are the eventual 
situations that can arise.
    So, table-top exercises, where you convene with the Federal 
Government, multiple States, local health departments, 
businesses, schools, communities, all--you know, we had a 
almost week-long exercise, where the event, which was created, 
was a novel virus that came from China, and was spreading 
throughout the world. So that was the scenario that was played 
out with all these partners at the table.
    So, thinking through the what-ifs, if you will, is part of 
the preparedness. So, when you--the more prepared you are, then 
when you see something similar to that, then you switch into 
response.
    Ms. Underwood. Sure. So in your testimony you wrote that 
responding to the coronavirus has cost the State more than $20 
million in the first 5 weeks. We have heard from our local 
public health officials the importance of stable, long-term 
funding. So we are so pleased to be able to, you know, at least 
have a supplemental to get a downpayment, and hope to continue 
to work with our colleagues to make sure that these efforts are 
well-funded.
    We know that too many Americans have chosen to skip a visit 
to the doctor because their costs are too high, their out-of-
pocket costs are too high. So, when dealing with an unknown 
infectious disease, that decision making has consequences, not 
only for their patient and their family, but for the entire 
community. So it is our hope that addressing those kind of out-
of-pocket costs, in addition to your public health costs, is 
going to be an important solution to this epidemic.
    Thank you for being here. I yield back.
    Chairman Thompson. Thank you very much. The Chair 
recognizes the gentleman from Pennsylvania for 5 minutes, Mr. 
Joyce.
    Mr. Joyce. Thank you, Mr. Chairman, and thank you for the 
esteemed panel for being with--here with us today.
    Of utmost importance, it is imperative that we work 
together, as you have stated, on a Federal, local, and every 
level to fight this problem that we are facing with the 
coronavirus.
    To briefly review the time line, President Trump has taken 
action, decisive action, to protect Americans and to prevent 
the spread of COVID-19. In January President Trump declared a 
public health emergency, initiated travel restrictions, and 
mandated quarantines for those returning from affected areas. 
He also formed the Corona Task Force to ensure a coordinated 
response among all U.S. agencies and experts. Since then the 
Trump administration has expanded travel restrictions, explored 
innovative medical solutions, and requested additional funding 
for COVID-19 response resources.
    Vice President Pence has also been elevated to lead the 
response, and has been appointed corona response coordinator. 
Vice President Pence also announced just yesterday that 
Medicare and Medicaid will be covering the coronavirus testing.
    The most important questions we need to be asking are where 
do we go from here, and what can be done to mitigate the future 
threats of the same nature?
    Dr. Gerberding, your expertise and extensive experience in 
this field, serving as CDC director during the anthrax, the 
SARS--which is also a coronavirus--the West Nile virus, and the 
avian flu outbreaks, if you could, please prioritize and talk 
to us about the development of a vaccine. Specifically, you had 
mentioned that we had not yet completed the SARS evaluation for 
vaccines, but yet that process has been initiated. SARS, too, 
is a coronavirus. Does that put us steps ahead in the vaccine 
development?
    Dr. Gerberding. One optimistic point of view is that 
science has actually evolved considerably since 2003, when the 
first SARS outbreak occurred, so that the time line and the 
ability to have the molecular tools and the immunology tools to 
speed up manufacturing has significantly improved.
    At the WHO leadership meeting on vaccines for this 
coronavirus there were 31 innovators there talking about their 
approach to vaccine development. Unfortunately, all of that 
development was pre-clinical. None of those vaccine candidates 
were in people yet. But the ability to have that much 
innovation already on the table really speaks to the importance 
of our biotechnology industry and capability. I think that is a 
positive perspective.
    The reality check--and I know this from the experience we 
have had at Merck, working on the Ebola vaccine--is that 
getting a candidate vaccine is somewhat straightforward; 
getting it through the safety testing, through the clinical 
testing, and front-line conditions, getting those data 
together, getting it through several regulatory processes, 
manufacturing it and, in this case, not just for a relatively 
small number of people in a localized Ebola outbreak, but for 
the world, that is a daunting task.
    There are 7.7 billion people in the world, and I am not 
sure who is going to be left out of access to the vaccine. So 
it is a big undertaking to have the full completed preparedness 
accomplished in the vaccine arena, and what concerns me about 
our current outlook is that we are seeing some over-promising, 
and we need not to alarm people when those promises don't 
actually come to fruition on the time line people are 
expecting. We need to be straightforward about the challenge 
ahead. Work hard, invest, support the people who are doing 
innovative work, but at the same time be cognizant that this 
vaccine is not going to be in people's arms for a long time.
    Mr. Joyce. I have always been impressed by American know-
how, innovation, our approach to science, and specifically to 
medicine. Dr. Gerberding, and could you please comment to us 
what immediate actions can we be taking in Congress to assist 
and to inform our constituents while we are still awaiting the 
results of negotiations on the emergency funding package?
    Dr. Gerberding. Well, obviously, funding is a big piece of 
the effort in almost any direction that you look.
    But I also think that there is an opportunity here for 
Congress to provide its own leadership on the communications 
front. You are members of State delegations. You do interact 
with Governors and State leaders. Really, coming together as a 
unified whole-of-Government opportunity to get on the same 
page, for you all to understand what is needed at the State and 
local level, that creates an informed platform for decision 
making. I think, as we have heard from our colleague in 
Illinois, you will learn a lot about what is really needed at 
the local level.
    Mr. Joyce. I thank all the panelists for being here today, 
and I yield my time.
    Chairman Thompson. Thank you. The Chair recognizes the 
gentlelady from New York for 5 minutes, Ms. Clarke.
    Ms. Clarke. I thank you, Mr. Chairman. I thank our expert 
panelists for bringing your expertise to bear today. It is 
refreshing to hear facts.
    So let me start by saying that yesterday in New York it was 
confirmed that we had a second COVID-19 coronavirus case. As 
Mr. King has stated, we are now dealing with sort-of the 
fallout and the rapid spread of this illness as a result of a 
gentleman who had traveled from Westchester County into the 
city of New York. We can expect more to come.
    But this is not the time for fear. It is time for facts. 
That is why I am so happy you are here today.
    This crisis is serious, but we can mitigate the coronavirus 
if we put science over scoring points. Doctors, not 
politicians, need to be in the driver's seat as we combat this 
global outbreak. This isn't a hoax, in the words of the White 
House. It is not an apocalypse, either. It is a public health 
emergency, but one we can address with funding resources and 
sound science.
    As of yesterday, we know of 105 cases, and a death toll of 
9 persons in the United States. As testing is expanded, the 
numbers will continue to rise. The Federal Government and the 
State and local partners must also rise to the occasion and 
give each American not only the care they need if infected, but 
also the knowledge they need to avoid infection. I look forward 
to our continued conversation as we guide the American people 
through this impending crisis.
    So, Dr. Gerberding, according to the recent article in May 
2018, Donald Trump ordered the NSC's entire global health 
security unit shut down, calling for reassignment of Rear 
Admiral Timothy Ziemer, and dissolution of his team inside the 
agency. What were the consequences of this action?
    Dr. Gerberding. Thank you for the question. I honestly 
don't know the answer to your question. I am a champion of a 
whole-of-Government approach. I know Dr. Ziemer, he is an 
amazing leader, and served us well first in malaria, and then 
in subsequent public health emergencies. So he was 
extraordinarily effective, a whole-of-Government leader, and I 
was sorry to see him go.
    Ms. Clarke. Yes, it is important that we have institutional 
knowledge, and that, as you have stated in your testimony, we 
follow the course to its natural end. Unfortunately, when we 
dismantle or disrupt, we don't benefit from that institutional 
knowledge.
    The Center for Strategic and International Studies 
established the Commission on Strengthening America's Health 
Security to examine the U.S. preparedness to respond to global 
health threats. The commission published in its final report 
last year--Dr. Gerberding, you served as co-chair of the 
commission. The commission's first recommendation was, ``to 
restore health security leadership at the White House National 
Security Council.''
    Why did you believe that restoring senior-level leadership 
at the National Security Council is so important to ensuring 
our Nation is prepared to combat a potential pandemic?
    Dr. Gerberding. Let me share my personal experience while 
we were involved in a very serious whole-of-Government effort 
to prepare for an influenza pandemic.
    At the time, the Secretary of Health and Human Services was 
Secretary Mike Leavitt, and Secretary Leavitt believed that we 
needed to have all of the cabinets of the Federal Government 
participating in the preparedness. So he took us, all of us, as 
leaders of parts of HHS, to every Cabinet. We sat down with 
every Cabinet Secretary with the book on the 1918 pandemic, and 
we went through, highlighted sections, and asked the question, 
``What will your Cabinet need to do in the context of a serious 
emergency?''
    What that really taught me was that the Federal Government 
in every Cabinet level has something to contribute, whether it 
is education and school closures, or commerce and keeping our 
businesses operational, or transportation. Whatever the Cabinet 
has authority over, it is relevant in a serious public health 
crisis, and we need to have the whole-of-Government 
collaborating. The only way to really do that is to bring an 
uber-leader, somebody who really sits above and has the 
authority of the President.
    Now, I will also acknowledge that there is a bipartisan 
blue-ribbon panel on biodefense that Secretary Ridge--former 
Governor Ridge and Senator Lieberman have co-chaired for 
several years. That panel's recommendation, sort-of parallel to 
what CSIS recommended, is that the Vice President should chair 
that whole-of-Government process. So I think what that tells 
you is the idea is the same. You need an empowered person to 
oversee complex, inter-Government--inter-Governmental agencies 
and the Government strategy. But how you go about doing that 
may vary from one administration to another.
    Ms. Clarke. Very well. Mr. Chairman, thank you. My time has 
run out. I yield back.
    Chairman Thompson. Thank you very much. The Chair 
recognizes the gentleman from North Carolina, Mr. Bishop.
    Mr. Bishop. Thank you, Mr. Chairman.
    Dr. Ezike, you mentioned in your written and spoken 
testimony the phrase ``sentinel surveillance testing.'' What is 
that, ma'am?
    Dr. Ezike. Thank you for the question. So sentinel 
surveillance, once you have the ability to test, involves 
testing people who don't have a direct connection to a 
confirmed case, do not have a direct travel to a specific place 
that would put them in a--in our higher risk to be a 
coronavirus suspect.
    So this is going to your average person with no connection 
to a case or to a hotbed, if you will, and then them developing 
a flu-like illness, an influenza-like illness, and going to 
their doctor, and the doctor identifying that, ``Oh, you don't 
have the flu, you don't have any of the other common viruses on 
the respiratory virus panel. Maybe this is coronavirus, despite 
you having no connection.''
    So testing people with no connection, and seeing what the 
ground percentage of coronavirus--if it is there and, if so, 
how much. So, if you can do that broadly, you can see if there 
are pockets within your State that have coronavirus in people 
that you wouldn't specifically suspect to have.
    Mr. Bishop. Thank you, ma'am.
    Dr. Gerberding, the CDC, after initially, I understand, in 
early February releasing test kits, determined that there was a 
flaw in them. I have understood, from speaking to someone else, 
that those tests are referred to as an RT-PCR test, and there 
are 3 components, and what was flawed was the--what is called 
the negative control component.
    Do you have any information about that, or how that came to 
pass? Because that is sort-of alarming if we need to respond 
quickly. If somewhere in CDC's function this test kit was 
created and then didn't work because of what I understand to be 
a very basic error, how does that take place? Do you have any 
insights about that?
    Dr. Gerberding. I don't have insight into the specifics.
    I can tell you that, long before I was part of the CDC, the 
one thing I understood and saw from my front line at San 
Francisco General Hospital was that the CDC is the best at 
testing. Their diagnostics are usually gold standard. So it 
just seems to represent a highly unusual and exceptional 
situation, and I am sure they will get to the bottom of it. I 
know they have had a great deal of consternation about their 
inability to be out there with a--not just an accurate test, 
but with the volume of tests that people really need.
    Mr. Bishop. Following up with that, Dr. Gerberding, or 
whoever else may want to comment, my understanding is that 
there was a question about who had access to this test. Could a 
line doctor, an emergency room doctor, decide to administer 
this test?
    It was limited to--at some point to public labs, perhaps 
because of supply. But now the Vice President has made it clear 
that anyone will be allowed to order a test, any doctor, and 
that there is a distribution going on of, like, 2,500 or 25,000 
kits that will enable testing of up to 1,000,000 people, 
something like that.
    Can you speak to those details?
    Dr. Gerberding. Yes, this is not unusual at the very 
beginning of a situation with a new pathogen that we have never 
seen before. You know, we don't have a test on the shelf for 
it, so it is being invented in real time. So it does not 
surprise me that early on there was a limited number of tests 
that were available.
    We typically use what is known as the Laboratory Response 
Network, because those people are highly trained. They have the 
standardized equipment. Part of our public health system. They 
are best able to judge in their own communities who should be 
tested.
    The State health officers also contribute to the decisions 
about what is a case definition and who should be tested. So it 
is not just an order from above, it is a collaborative process. 
But, you know, when we are sitting in the United States, and 
the disease is in China, and we are not suspecting a large 
number of cases, it makes sense that you would focus your 
testing, your limited testing, on a traveler who had just come 
back from China.
    Obviously, we are in a very different situation now, where 
we are seeing community spread. So it is normal that we would 
expand the indications for testing.
    I completely agree with the notion that, if a doctor 
suspects coronavirus, they ought to be able to order the test.
    Mr. Bishop. I--given the limited time--my friend, Ms. 
Clarke, made a comment that the President called the 
coronavirus a hoax. I guess, since that was said in public, I 
wanted to say that he didn't say any such thing. But--and I 
don't want to alter what I think has been a very good tenor of 
this hearing.
    I guess my last question, having said that, is I understand 
that, for the testing to be done rapidly enough, we need to be 
able to empower or bring in private lab infrastructure into 
that picture. I don't know who met--Dr. Gerberding, I am not 
trying to pick on you, but just--given I have got a couple of 
seconds left, if you could, comment on what is needed to make 
that happen.
    Dr. Gerberding. I think that is well under way. I am going 
to be spending some time this afternoon with colleagues, 
including the CEO of one of the important diagnostic companies, 
so I will have a better answer by the end of the day.
    But I think the first thing is that FDA, through the years, 
has really liberalized the process for getting an emergency 
authorization for new tests to get out there into the 
community. You know, compared to 20 years ago, our ability to 
do this fast has significantly improved.
    Once we know what we are looking for, it is a simple matter 
for diagnostic companies to pick up on that. They have the 
scale and the capacity to ultimately build much larger capacity 
than the public health system. But they do have to demonstrate 
the sensitivity and specificity of their tests. When you don't 
have the disease, it is a little bit harder to do that, because 
you don't have enough case material to really know if you are 
accurate in the results that you are receiving.
    Mr. Bishop. Thank you, ma'am.
    Chairman Thompson. Thank you very much. The Chair now 
recognizes the gentleman from Staten Island, Mr. Rose.
    Mr. Rose. Mr. Chairman, thank you.
    Thank you all so much for being here. I want to start off 
just with what I am seeing, some business leaders making 
decisions around employee travel, halting international 
flights, halting domestic flights, really getting ahead of 
unnecessary or necessary--that is my question here--ahead of 
guidance from the Federal Government.
    So what should our business leaders be doing, people 
running global companies?
    Dr. Gerberding. I can share what our philosophy has been. 
We are a global company, and we have 8,200 people in China, and 
many of them were on lockdown for an extended period of time. I 
am so glad that our offices are back open, and our systems are 
operational there.
    But we recognize that, when we have people in several of 
the hotspots where community transmission is occurring, and we 
are responsible for essential medicines and vaccines, that we 
have to keep our supply chain open and running. So people need 
to be coming to work. Those critical employees are especially 
cautioned about non-business essential travel, and to self-
quarantine if they have any recent travel to a hotspot, and to 
not come to work if they are sick.
    So we don't have a decision that you can't travel. We are 
just simply saying, while we are working on slowing spread and 
understanding what is going on here, let's err on the side of 
caution----
    Mr. Rose. Well, what about----
    Ms. Gerberding [continuing]. And minimize unnecessary 
travel.
    Mr. Rose. What about domestic travel?
    Dr. Gerberding. Domestic travel is more in this--in the 
spirit of the slowing down the spread that Dr. Inglesby was 
talking about, that if we are in a situation where we really 
can't isolate and quarantine each individual, and we are trying 
to reduce the peak of transmission, it does make sense that we 
begin to think about avoiding crowds and minimizing our 
movement and our----
    Mr. Rose. And flying?
    Ms. Gerberding [continuing]. Maintaining our distance----
    Mr. Rose. Flying, as well?
    Dr. Gerberding. Flying, as well. So we are just, you know, 
trying to use some common sense. I am flying, we are on the 
move when we think it is important to our business. But we are 
certainly emphasizing now is a good time to be more comfortable 
using digital communication, and being more thoughtful about 
how we travel.
    Mr. Rose. Sure. Would anyone else like to speak to that?
    Dr. Inglesby. Yes, I think the CDC guidance on travel at 
this point seems logical. It is now describing what--countries 
where they think there is elevated risk, and making 
recommendations to Americans about where they should travel 
internationally. That seems sensible.
    I think one of the challenges is that we have seen things 
change very rapidly in a week. So 10 days ago Italy had 0 
cases. Now it is kind of among the countries with the highest 
cases. So it is challenging for business leaders to think ahead 
about a conference in 3 weeks or 4 weeks, where things can 
change quite a bit.
    So at this point, I think the best recommendation is to 
follow U.S. Government guidance, but also be aware that 
something could change, literally, in a day or 2, as countries 
begin to start testing.
    Mr. Rose. Understood. Would you like to add something, 
ma'am?
    Dr. Ezike. I think I echo what these two experts are 
saying, that this is an emerging situation, and advice and 
counsel given today may not be applicable tomorrow. So, 
continuing to follow the most recent guidance----
    Mr. Rose. Sure. So I want to move on to our lower-wage, 
hourly workers. I am very concerned that they will not--
rightfully so, or at least rationally--respond to quarantine 
suggestions because of immediate economic concerns.
    What can the Federal Government do to step in, to support 
people so that they respond to quarantines?
    Dr. Inglesby. One thing that can be done, which I know is 
being discussed actively here, is to make sure that there are 
no barriers to testing or to getting medical care or isolation, 
and that--we have already begun to refer to that. I think that 
that is--that sounds like that is beginning to occur through 
your CMS----
    Mr. Rose. Sure.
    Mr. Inglesby [continuing]. Or discussions with insurance 
companies.
    So that is really important, because we have seen actual 
evidence of people who have had $3,000 bills after they went in 
to get a test, and that has been publicized, and people will 
potentially avoid getting tested.
    I think it is a harder challenge--and that maybe Congress 
and the administration can solve together about workplace----
    Mr. Rose. Should we consider expanding unemployment 
insurance?
    Dr. Inglesby. I think if that is a way of helping people in 
the gig economy or lower-wage workers make good decisions, 
public health decisions, I think that should be considered.
    Mr. Rose. Anything else?
    Dr. Ezike. I would agree that there should be a mechanism 
for people who would be economically disadvantaged if they 
don't have any benefit time, if they don't have any kind of 
paid leave, that there should be a way for them to be 
compensated so that they don't have to make the decision 
between following public health measures that will help the 
entire community versus being able to pay their next month's 
rent.
    Dr. Gerberding. I just want to add something, because it 
hasn't come up yet, but in the context of this conversation we 
also have to be mindful of stigma. This happened during SARS, 
where the Chinese community----
    Mr. Rose. Yes.
    Ms. Gerberding [continuing]. Was profoundly stigmatized. I 
think it is an opportunity for leaders and House Members, as 
well, to really stand up and make sure that we are including 
everyone in the benefits that we can provide to help protect 
Americans, but also that we speak out against the 
stigmatization that often follows in the wake of an outbreak.
    Mr. Rose. Great. Thank you very much.
    Chairman Thompson. Thank you. The Chair recognizes the 
gentleman from Tennessee, Mr. Green.
    Mr. Green. Thank you, Mr. Chairman, and thank you to all of 
you guys for being here today. It is--I greatly appreciated 
your involvement in this process.
    Very quick, my questions, I am going to try--because I got 
lots of them--mortality rate, it appears to be about 3 percent 
in China. Outside of China it appears to be about 0.7 percent 
is what I saw in a JAMA article that was just published.
    You know, what are your thoughts about that delta? The 
Journal of the American Medical Association seemed to imply 
that it was attributable to China's smoking rate, other 
reasons. But why is their mortality 3 percent, and outside of 
China it is 0.7? In South Korea it was .12 percent. So your 
thoughts on that?
    Dr. Inglesby. It is too soon to say, because things are 
changing rapidly in other countries, and they don't have as 
much data being published as there is in China.
    One of the factors--and Wuhan does seem to be--the surge in 
hospitals, it does seem like some of the people who could have 
used ventilators did not get them because they ran out of 
ventilators. So that is one possibility.
    There is a possibility that there is some underlying health 
conditions, or pollution, or smoking, or something else that 
will fall out in analysis. But I don't think we have strong 
understanding of that yet.
    Mr. Green. OK.
    Dr. Inglesby. It also--the other thing that is important is 
that there is a time lag from when countries discover cases and 
begin to see them, and the time that people begin to die from 
this illness, sometimes as long as 2 weeks. So if it is a 
country just beginning to report illnesses and deaths, it is 
really two----
    Mr. Green. OK.
    Dr. Inglesby [continuing]. Weeks later when we see----
    Mr. Green. That makes sense.
    Dr. Inglesby [continuing]. A real--a better sense of 
deaths.
    Mr. Green. Sure, that makes sense. I just know the end is, 
like, well over 3,000 now for outside the country. So you would 
think that that would give you some degree of confidence. But--
and there is such a huge delta between 3 percent and 0.7 
percent.
    This, obviously, based on the way it is hitting the--you 
know, those who have co-morbidities, and the elderly, probably 
a very good virus to tackle with the vaccine, but I am--you 
know, I am also aware that this attacks the lung tissue 
directly, so that makes it concerning. We need to be very safe 
as we develop this vaccine.
    Sort-of in the interim time frame, there is remdesivir and 
the monoclonal antibodies. I just wondered if either--anyone 
could comment first on remdesivir and some of the other 
antivirals that we developed for Ebola and their usefulness. I 
know there is a test in Nebraska. Then, on monoclonal 
antibodies, because of the ability to blunt the tissue--the 
lung tissue's damage with monoclonal antibodies, and they can 
be spun up so much more quickly than a vaccine.
    Dr. Gerberding. So I will start with the anti-viral 
question. Yes, I am hopeful. I really want these antivirals to 
work. But at the same time, you got to think about what we have 
learned about respiratory infections and antivirals so far. I 
mean we have several antivirals for influenza, and they might--
--
    Mr. Green. Sure.
    Dr. Gerberding [continuing]. Mitigate a little bit, but 
they are not curative. So we need to not over-promise on what 
we might ultimately see. So hope for the best, but I won't be 
surprised if we are a little bit disappointed.
    In terms of monoclonals, again, almost every outbreak that 
I have dealt with, the first thing people do is use serum from 
recovered people, and try to see if it is helpful. So that is 
the, you know, the intellectual background for using 
monoclonals. They may very well be useful, but on this kind of 
situation, where the severe pulmonary disease is caused by a 
cytokine storm----
    Mr. Green. Right.
    Dr. Gerberding [continuing]. Which basically means broad 
inflammation that is very tissue-damaging, you have to test the 
safety of the monoclonals very carefully, because what you 
wouldn't want to have happen is put an antibody in there and 
actually make that cytokine storm worse.
    Mr. Green. Sure, sure.
    Dr. Gerberding. So it has got to be tested. I hope, again, 
but--and I agree with you, these approaches to treatment can 
happen much faster than a vaccine. So they are definitely a 
high priority.
    Mr. Green. Well, thank you for that.
    One of the things that concerns me, there is lots of 
legislation in Congress about price fixing for pharmaceuticals. 
I know Merck is one of those companies that would be hurt by 
that. My concern is, particularly those smaller companies, the 
bio, you know, companies, biomed companies that, you know, when 
they have an idea, they have to go get capital in order to 
advance that idea. They are not going to get capital if we 
price-fix.
    So I wondered if someone, particularly ma'am, you, because 
you are from the industry, could comment about how damaging 
price-fixing might be on some of the innovation that is out 
there----
    Dr. Gerberding. I----
    Mr. Green [continuing]. That could address this issue.
    Dr. Gerberding. Yes. You know, first of all, as I said 
earlier, 40 biotech companies have stepped up on coronavirus. 
But understandably, the entrepreneurs are very apprehensive 
about what this will mean to investors. Price-fixing is the 
thing that investors hate the most. They made that very clear 
when the subject came up on another topic.
    I live it in the world of antimicrobial resistance, because 
we don't have a market for antibiotics. There is no 
reimbursement appropriate to the danger of multi-drug-resistant 
infections. Last year we saw three companies that had new 
antibiotics that failed, and went out of business because their 
investors pulled back.
    Mr. Green. Right.
    Dr. Gerberding. So it is a real issue, and we need to keep 
our biotech industry alive.
    Mr. Green. Thank you for sharing that.
    Thank you, Mr. Chairman, I yield.
    Chairman Thompson. Thank you. The Chair recognizes the 
gentlelady from Texas Ms. Jackson Lee, for 5 minutes.
    Ms. Jackson Lee. Mr. Chairman, thank you so very much. 
Thank you very much for your hearing yesterday. I was detained 
in my district for civic matters that occurred on that date. In 
tribute to my constituents and the necessity for America to 
ensure that people can vote, I was at a college voting precinct 
at 1 a.m. in the morning, where people had remained on-line to 
vote at 1:29 because they could not vote because of shortages 
of machines and broke-down machines.
    I say that because this is the greatest country in the 
world, and I am disappointed you are not Government witnesses. 
I am disappointed in the slow response to the coronavirus.
    We have dealt with Ebola, one of the first cases was in the 
Dallas hospital in Texas. We dealt with H1N1. So I am going to 
pose the question and hope--as straightforward as possible.
    There were two briefings, unclassified. One briefing was 
complete denial, everything was fine, top-level leaders of our 
government in health and emergency issues. Shortly--as the 
first Member, I think, to do a press conference questioning 
everything was fine with airport personnel and others, at that 
time TSA officers had no gloves, they had mismatched gloves and 
mis-matched masks. I know there is a discussion about masks.
    But I would like to ask Dr. Ezike--and am I close to the 
pronunciation--the need for preparedness and awareness when the 
obvious is occurring, I would like to be prepared months or a 
year out, or regularly having a preparation for this to occur. 
When I say ``this,'' an infectious episode to occur. But the 
fact that China was quite public, they couldn't hold it any 
longer--can you comment on the preparedness of this Nation?
    Dr. Ezike. I think Dr. Gerberding also has eloquently 
described the situation, and has highlighted the importance of 
having increased surveillance capacity for the CDC.
    We have been--as a State health officer, every year we try 
to come to Washington and encourage increased funding for the 
CDC to keep up with these surveillance efforts, to keep up with 
our preparedness and response. All of our preparedness and 
response----
    Ms. Jackson Lee. So do you have an assessment of whether or 
not we were prepared on the Federal level for the coronavirus?
    Dr. Ezike. I think we can always be more prepared. I think 
there is levels of preparation, and the more prepared we are, 
the better.
    Ms. Jackson Lee. I am going to go to Mr. Inglesby--forgive 
me as I watch my time go out, and I appreciate it.
    Is that Inglesby, Doctor?
    I meet regularly with my local health agencies, and I 
appreciate the director of the Illinois Department of Health. I 
understand that you are always lobbying to make sure that there 
is direct funding to both State and local. This is a particular 
instance where that would be important. I understand our 
appropriations is something that we have all requested, is 
going to enhance dollars going to State and local entities.
    How do you translate that into helping you and your local 
communities be prepared for something that appears now to come 
from CDC, that it is either an epidemic or a pandemic? Now they 
are willing to say that.
    How are you doing with the test kits, and how would that 
help you with the test kits? My community does not have them 
yet, and that is a real problem. Most communities, I think, do 
not.
    Dr. Inglesby. Yes, I think, first of all, that every year 
there are public health emergency preparedness grants that are 
given to States from CDC, and they are very important grants 
for States and locals, and need to be supported by Congress and 
the administration. They are crucial for long-term 
preparedness. They are separate and distinct from the emergency 
response funding that is coming out through--that we hope will 
come out through these appropriations. You can't build a 
firehouse the day before the fire, you have to build it a long 
time ahead of time. That is what those preparedness grants do.
    In terms of expanding diagnostic capacity testing, that is 
now happening over the course of this week, and State health 
labs around the country are going to be able to start testing, 
hopefully within Texas, as well. But ultimately, to really 
expand into clinics and hospitals, we are going to need 
diagnostic companies to be fully invested, just like----
    Ms. Jackson Lee. That is very important, right?
    Dr. Inglesby. [Nonverbal response.]
    Ms. Jackson Lee. And the preparation of our hospitals, as 
well.
    Dr. Inglesby. Yes.
    Ms. Jackson Lee. Quickly, can I--if we go into a moment in 
time of quarantine, closing schools, restaurants, et cetera, do 
you think we should also be concerned about, in this instance, 
hourly wages--hourly wage workers who would be caught up in 
that quarantine who don't get paid, and may have a devastating 
impact on the family?
    So that would be a part of what we need to do in this 
moment to be able to provide for people's livelihood and 
survival, if they are quarantined for a period of time.
    Dr. Inglesby. I do agree with that. I think people could 
be--especially if a quarantine is prolonged, if--there are many 
people in the country who receive a check every week, and they 
need that check that week. So if we are telling people they 
cannot go to work, or cannot go to school, and have to stay 
home to take care of their kids, we need to make sure the 
incentives for doing that are aligned with what we want done, 
and that people aren't having to, basically, not be able to 
provide for their families.
    Ms. Jackson Lee. I thank the Chairman. I thank the 
witnesses very much for your----
    Chairman Thompson. Thank you very much. The Chair 
recognizes the gentlelady from Arizona for 5 minutes, Mrs. 
Lesko.
    Mrs. Lesko. Thank you, Mr. Chairman. Thank you, Mr. 
Chairman, for having this meeting, an important issue, and 
thank you, all of you, for being here.
    Debbie Lesko from Arizona. Our State--Dr. Christ heads up 
our Arizona Department of Health Services, and she is very 
competent. We just started testing with--in-house, ourselves.
    It is very important, obviously, that we are prepared. But 
also, we have to balance that with panicking people. I think it 
may be a little bit too late, because you turn on the news and 
this is all you hear about, right? My husband went to Sam's 
Club last night, and said that all of the, you know, Purell, or 
whatever brand of the hand sanitizers totally sold out. I mean 
all that was sold out.
    So my question is kind-of a basic one. So many people die 
from the flu, more than I even realized until just recently. 
So, is this worse than the flu? I mean we need to be concerned, 
but I am concerned about people panicking.
    So I guess I will ask Dr. Gerberding--if that is how you 
pronounce your name--is this worse than the flu? Should we be 
more panicked than the flu? Tell me about that.
    Dr. Gerberding. I think we are learning that this is 
probably as transmissible as the flu. The rate of transmission 
seems to vary, depending on how much testing goes on in the 
background to really figure that out. So we still have to learn 
what the true transmissibility dynamics are. But it is, 
obviously, spreading from person to person, especially in 
families, and on cruise ships, and other closed environments 
with a great degree of efficiency.
    The question is, how fatal is it? And who is vulnerable? I 
think Dr. Inglesby has pointed out earlier that we don't know 
the true case fatality rate yet. Part of that is because of the 
differences in medical care that influence that. Part of that 
is because we don't know the denominator of the less-sick 
people. Part of it is because the testing is just not available 
to sort out who is actually a case. So we will learn more about 
that.
    But I think what we could say today is that it looks very 
much like the case fatality rate is significantly greater than 
the fatality rate for seasonal flu. I think that is the 
distinguishing issue here that makes me so concerned, that it 
is the death rate that is high. The death rate is highest, the 
older you are, and the more underlying disease, particularly 
respiratory disease, that you have.
    So this nursing home outbreak, for example, that is a 
significant concern, and we need to prioritize getting 
infection control precautions and other things to slow down or 
prevent spread in those settings as one of our highest public 
health priorities right now.
    Mrs. Lesko. Thank you very much. My next question has to do 
with face masks, so anybody can answer this.
    What is the answer? Should people that don't have a cold or 
aren't coughing, should they wear face masks?
    I have been--I have Googled it, and said no, you shouldn't 
wear a face mask unless you are coughing. It won't help. But 
then why is it that health care workers wear it? So that is my 
question to anyone.
    Dr. Inglesby. In hospitals people are exposed to the 
sickest people, and we do see a correlation between level of 
illness and the ability to spread the disease. So walking 
around in the community, most of the people are well in the 
community. Even if they are asymptomatic, we don't think they 
are the fundamental largest drivers of infection.
    Also, when you wear a mask in the public, you know, you end 
up fussing with it a lot, you end up touching your face often. 
You are untying the strings, moving it around. It may be that 
you are actually touching your face even more often than you 
are normally.
    So the bottom line is that we don't have evidence that face 
masks in public are going to do any good, and we are worried 
that, if everyone goes out and buys a mask, that that will 
diminish the number of masks that are available in the 
hospital, where the people are the sickest, and are 
transmitting at the highest levels. We need our health care 
workers to stay healthy, because they are going to be--it is 
going to be a long period of time--a marathon, probably--of 
high COVID patients in hospitals.
    Dr. Gerberding. Just to real quickly add to that, there are 
different kinds of masks, as well, and the masks that are worn 
on health care workers, they are trained and they are fitted to 
their face so they don't leak air around them. But when people 
on the streets buy those, or buy the regular surgical masks, 
they are breathing all kinds of air in around the mask, and it 
really doesn't offer the level of protection that health 
workers need. That is why they have to be trained to use them 
properly.
    Mrs. Lesko. Well, so what I think I hear is that face masks 
do help if they are put on properly, even--they do help from 
getting it, it is just that you advise against it in community, 
because people don't know how to use it properly, they touch 
their face a lot because of the mask. Is that what you are 
saying?
    Dr. Gerberding. Just to add one additional thing is that I 
have had to wear N95 respirators for many, many, many patient 
encounters, and you can't wear them for very long. They 
increase your work of breathing. They are incredibly 
uncomfortable. So you go in the room, you do something, you 
take the mask off when you come out. To walk around with one of 
those on all day is impossible.
    Mrs. Lesko. So if you don't mind one more question on this 
mask issue, why do you think it is a lot of the Asian 
countries, everybody is wearing masks? Is it a cultural thing? 
Do they think it is going to help, or does it--do they know how 
to wear it properly?
    Dr. Gerberding. In China right now they are being required, 
so that is the main reason why you tend to see a lot of people 
on the streets of China wearing, basically, usually, surgical 
masks. But I don't think that they are there because they are 
having a significant impact on disease spread.
    Mrs. Lesko. Thank you. I yield back.
    Chairman Thompson. Thank you very much.
    A question for the committee is, Dr. Gerberding, have you 
any assessment of how long it will take before we actually will 
have a vaccine?
    Dr. Gerberding. I would probably defer to Dr. Fauci's 
statements on this topic, the head of the NIAID. I think Dr. 
Fauci has said we will get vaccines into testing in a matter of 
several weeks to a few months, but that we won't have an 
approved vaccine for at least a year, and probably longer. If I 
am not paraphrasing him correctly, I will get back to you for 
the record.
    But, you know, realistically, it is not a rapid track, even 
with all of the permissions and the energy that we are putting 
into it. Part of the reason for that is safety. We really need 
to make sure----
    Chairman Thompson. Oh, absolutely.
    Dr. Gerberding [continuing]. The vaccine is safe.
    Chairman Thompson. Absolutely.
    Dr. Inglesby, a couple of comments have come up relative to 
capacity for the virus, whether we were as robust as we needed 
to be, as a Federal Government. Have you looked at the capacity 
issue, or are we just basically caught with something that we 
just wasn't prepared to handle?
    Dr. Inglesby. I think it depends on what kind of capacity 
we are talking about. I think our public health agencies have 
been training for these kinds of things for a long time. But 
even as well-trained as they are, there are enormous resource 
challenges and personnel challenge when they are working 24/7, 
and they are having to create new quarantine sites.
    So I think, in principle, there has been a lot of 
preparedness, there has been a lot of drilling, and grants for 
States and locals around the country. But I still think this is 
a challenge that they haven't faced before. So we do have major 
capacity challenges ahead in public health and in hospitals.
    Chairman Thompson. Thank you very much.
    The gentleman from Texas, Mr. Crenshaw.
    Mr. Crenshaw. Thank you, Mr. Chairman, and thank you all 
for being here on this important topic.
    Dr. Gerberding, I will start with you. Given your lengthy 
experience in this field, director at CDC, you dealt with 
threats from anthrax, SARS, West Nile, avian flu, other 
outbreaks, I am assuming you all compile constantly and 
persistently a best practices list and lessons learned. To your 
knowledge, are those lessons carried over, administration to 
administration, even when folks like you leave the 
administration? Are those being implemented now?
    Dr. Gerberding. Thank you. When I was directing the CDC we 
implemented very formal after-action reviews, starting with 
anthrax. Dr. Jim Hughes had the National Center for Infectious 
Disease at that time, and it was one of the things that we did 
first, was just bring in anybody who we interacted with in the 
response, and learn what did we do right, what did we do wrong, 
and what do we need to do better. So that mechanism is 
consistently practiced, as far as I know, to this very day at 
CDC. Yes, those lessons are passed forward.
    But, you know, each one of these situations brings in a 
unique challenge. So it is hard to extrapolate from one after-
action review to the next one. The constant themes that go 
through them all are communication, the need for collaboration, 
and the consistency approach, whole-of-Government, but also 
Federal-State level. Those lessons come up, and I think we have 
still opportunities to improve in how we coordinate that, as a 
country.
    Mr. Crenshaw. Absolutely. This administration has taken a 
lot of heat in the media and from politicians. Do you see any 
big differences in the response that this administration has 
given, compared to, say, what a previous administration would 
have done?
    Dr. Gerberding. Well, since I left the Government I have, 
you know, of course, watched from the outside in, so I don't 
really know what is going on in the sausage factory. But I do 
see that, broadly speaking, I think the way--the 2009 influenza 
pandemic was handled quite well. I think Zika was hard, but 
people did a pretty good job with that. There were lots of 
missteps in the early days of Ebola.
    Now, here we are with this one. I think many of the people 
who are acting as leaders of the response here are the same 
people that I worked with when I was in the Government. Dr. 
Azar--or, excuse me, Secretary Azar--was part of the Department 
when we were planning for a flu pandemic. Bob Kadlec was 
involved in the Government in his role, and now he is heading 
the--as assistant secretary of preparedness and response. BARDA 
has certainly stepped up and funded many things that--BARDA 
funded the CDC--I mean, excuse me, the Merck Ebola vaccine. So 
components of the Government, I think, are doing exactly what 
they have been prepared and designed to do.
    Mr. Crenshaw. Do you think the level of outrage over the 
response is really proportional to any actual shortcomings in 
the response?
    Dr. Gerberding. Well, earlier I had a chance to talk about 
trust, and what is necessary for people to really trust what is 
going on. I think the person delivering information is critical 
at Federal, State, and local levels.
    So that is something that we need to really be mindful of, 
the consistency of the communication, and, in my view, that the 
leader, the leading edge of the communication, is about 
science, not politics. So I think that is a really important 
thing that would help a lot to calm people's criticism and get 
us on track, where people have confidence that their whole 
Government is doing the right thing.
    Mr. Crenshaw. Yes, I would just note that I think a lot of 
the criticism is not based in science or facts, or any of the 
things that you just noted, but, in fact, based on politics, 
which is the problem. I hope that the goal of that is not to 
create fear, simply for the sake of getting political points, 
although that is what I have seen, frankly, from the media and 
others.
    I want to talk--and you hit on this before--about 
innovation in creating vaccines, in creating treatments, and 
how important the subject of innovation is. But I am running 
out of time, aren't I?
    The--can you hit on--can--with respect to innovation, if--
can you hit on again--on the issue of price controls, and what 
that might do to some of these biotech firms that generally 
rely on investments from venture capitalists or the larger 
pharmaceutical companies, and some of the work they have been 
doing in the past decade?
    In fact, I have heard Johnson and Johnson, for instance, 
has been looking at a coronavirus vaccine for a decade. Would 
that research still happen if there were no incentives because 
of price controls?
    Dr. Gerberding. Well, I am not involved in a small biotech 
company, but, you know, one of the things that I have learned 
in my role in the BIO executive committee--and I interact with 
some of these amazingly creative people--is that a lot of times 
the company is based on just one idea, or one really good 
leading approach to a critical innovation. If there isn't the 
promise of reward to the investors who put their money in what 
is a really high-risk situation, they are gone.
    So if you take away the incentive for the investments to 
come forward, you have really diminished interest in pushing 
the envelope on innovation. That is true in coronavirus, the 
same as it is in antibiotics, the same as it is in any of the 
other things that we wish we had and we don't.
    Mr. Crenshaw. Thank you. Thank you, Mr. Chairman.
    Chairman Thompson. Thank you very much. I would like to 
have entered into the record articles from the Washington Post 
and National Geographic on the coronavirus subject.
    [The information follows:]
 Article from the Washington Post Submitted by Hon. Sheila Jackson Lee
   how is the coronavirus outbreak going to end? here's how similar 
                         epidemics played out.
https://www.washingtonpost.com/health/2020/03/02/how-is-coronavirus-
        outbreak-going-end-heres-how-similar-epidemics-played-out/
By William Wan, March 2, 2020.
    As stock markets plunge, travel is disrupted and new coronavirus 
infections are diagnosed across the United States, one question on 
everyone's mind is how the outbreak is going to end.
    No one knows for sure, but virologists say there are clues from 
similar outbreaks. Here are three scenarios:
Health officials control coronavirus through strict public health 
        measures
    When severe acute respiratory syndrome (SARS) hit Asia in 2002, it 
was pretty scary--with a fatality rate of about 10 percent and no drugs 
shown to be effective against it. (The current coronavirus by 
comparison has an estimated fatality rate of 2.3 percent.) But within 
months, SARS was brought under control, and for the most part stamped 
out, by international cooperation and strict, old-school public health 
measures such as isolation, quarantine, and contact tracing.
    This would be an ideal outcome. But the difference is that SARS had 
more severe symptoms than the current coronavirus, so people went to 
the hospital shortly after being infected.
    Cases of coronavirus will be harder to catch and isolate, said 
Stuart Weston, a postdoctoral virologist at University of Maryland. 
Weston is one of a small group of researchers who have received samples 
of the coronavirus and are studying it. Weston and other experts warn 
the outbreak in the United States and other countries is more 
widespread than tracked because many people with mild symptoms don't 
know they have been infected.
Coronavirus hits less developed countries, and things get worse before 
        they get better
    One of the grim lessons from the 2014-2016 Ebola outbreak in West 
Africa is how an epidemic can grow when it hits countries with weak 
health infrastructures. This is why the World Health Organization and 
others have been preparing countries in sub-Saharan Africa for the 
coronavirus, even though few cases so far have been reported there.
    Compared to the coronavirus, Ebola was less contagious and 
transmitted mainly by bodily fluids. The coronavirus can be transmitted 
in coughed and sneezed respiratory droplets that linger on surfaces. 
And yet Ebola infected more than 28,000 people and caused more than 
11,000 deaths. Ebola is more lethal, and shortages of staff and 
supplies, poverty, delays by leaders and distrust of government 
exacerbated the outbreak.
    WHO leaders have been urging countries to prepare. On Friday, the 
organization raised its assessment of coronavirus to the highest level. 
``This is a reality check for every government on the planet: Wake up. 
Get ready. This virus may be on its way, and you need to be ready,'' 
said Michael Ryan, WHO's director of health emergencies. ``To wait, to 
be complacent, to be caught unawares at this point, it's really not 
much of an excuse.''
The new coronavirus spreads so widely, it becomes a fact of life
    This is in essence what happened with the 2009 H1N1 outbreak, also 
called swine flu. It spread quickly, eventually to an estimated 11 to 
21 percent of the global population. The WHO declared it a pandemic, 
and there was widespread fear.
    H1N1 turned out to be milder than initially feared, causing little 
more than runny noses and coughs in most people. And H1N1 is now so 
commonplace, it's simply seen as a part of the seasonal flus that come 
and go every year around the globe.
    Early estimates on the fatality rate for H1N1 were much higher than 
the roughly 0.01 to 0.03 percent it turned out to be. Still, the 
Centers for Disease Control and Prevention estimates that H1N1 killed 
12,469 people in the United States during that first-year period from 
2009 to 2010, infected 60.8 million cases and caused 274,304 
hospitalizations. The true number is hard to ascertain because many who 
die of flu-related causes aren't tested to see whether it was H1N1 or 
another flu strain. As context, the seasonal flu has killed at least 
18,000 people in the United States so far this season, according to the 
CDC.
    H1N1 is a particularly good parallel, epidemiologists say, because 
while it had a lower fatality rate than SARS or MERS, it was deadlier 
because of how infectious and widespread it became.
    Not to be alarmist, but another possible parallel might be the 1918 
Spanish flu, which had a 2.5 percent fatality rate, eerily close to 
what's estimated for the coronavirus.
    CDC calls Spanish flu ``the deadliest pandemic flu virus in human 
history,'' because it infected roughly one third of the world's 
population and killed an estimated 50 million people worldwide. Spanish 
flu was deadly to young and old, while coronavirus has proven to be 
most lethal to the elderly and left young people relatively unscathed.
    Florian Krammer, a virologist specializing in influenzas, noted 
that the world was vastly different in 1918.
    ``We didn't have the tools to diagnose diseases or antibiotics to 
fight secondary infections. Hospitals back then were places where you 
went to die, not to get treatment. And in 1918, the world was at war. 
And a lot of the people infected were soldiers stuck in trenches,'' 
said Krammer, of the Icahn School of Medicine at Mount Sinai. ``That's 
hopefully not how this is going to play out.''
    Ultimately, how many people die of coronavirus depends on how 
widely it spreads, how prepared we are and what the virus's true 
fatality rate turns out to be.
A few more key things will affect the coronavirus endgame
    If the coronavirus does indeed become ubiquitous like H1N1, it will 
be crucial to develop a vaccine. After the 2009 outbreak, experts 
developed an H1N1 vaccine that was included in flu shots people 
received in subsequent years. This helped protect especially vulnerable 
populations during following waves of infection.
    In the immediate future, anti-viral drugs may help, and labs around 
the world are testing their effectiveness against the coronavirus.
    No one knows if the coronavirus will be affected by seasons like 
the flu, despite President Trump's claims that it could ``go away'' in 
April with warmer temperatures.
    ``We're still learning a lot about the virus,'' said WHO 
epidemiologist Maria Van Kerkhove. ``Right now there's no reason to 
think this virus would act differently in different climate settings. 
We'll have to see what happens as this progresses.''
    Coronaviruses are zoonotic, meaning they spread from animals to 
humans. Experts believe SARS spread from bats to civet cats to humans. 
The deadly Middle East respiratory syndrome (MERS) in 2012 was probably 
transmitted from bats to camels to humans. With the coronavirus, no one 
knows what animals caused the current outbreak. And it's a mystery 
scientists will need to solve to prevent it from repeating in the 
future.
    One prime suspect is an endangered creature called the pangolin 
that looks like a cross between an anteater and an armadillo and whose 
scales are trafficked illegally.
    ``With SARS, once they figured out the animals responsible in 
China, they were able to start culling them from the live markets,'' 
said Vineet Menachery, a virologist at University of Texas Medical 
Branch. ``It's like a burst water pipe. You have to find the source in 
order to shut it off.''
                                 ______
                                 
 Article from the Washington Post Submitted by Hon. Sheila Jackson Lee
 trump downplays risk, places pence in charge of coronavirus outbreak 
                                response
https://www.washingtonpost.com/politics/trump-downplays-risk-places-
        pence-in-charge-of-coronavirus-outbreak-response/2020/02/26/
        ab246e94-58b1-11ea-9000-f3cffee23036_story.html
By Yasmeen Abutaleb, Feb. 26, 2020.
    President Trump announced Wednesday that Vice President Pence will 
lead the administration's response to the deadly coronavirus in an 
attempt to reassure the public amid growing concerns of a global health 
crisis and criticism that the United States has been slow to respond to 
the fast-moving outbreak.
    The move came as a person in Northern California tested positive 
Wednesday for the virus, the first case in the United States that has 
no known link to foreign travel or contact with someone known to be 
infected--a sign the virus may be spreading in at least one location. 
Officials have begun tracing the contacts of the resident to find out 
how that person may have been infected and who else might have been 
exposed.
    Trump made no mention of the new case Wednesday as he struck an 
optimistic tone about the virus.
    ``We've had tremendous success, tremendous success beyond what many 
people would've thought,'' the president said during a White House news 
conference that followed days of mixed messages, tumbling stocks and 
rising death tolls abroad driven by the coronavirus. ``We're very, very 
ready for this.''
    The president declared that the risk to America was ``very low'' 
and predicted a swift end to the outbreak.
    Trump's positive message was at odds with the statements by top 
members of his administration in recent days who have warned of an 
unpredictable virus that could spread into communities and upend 
Americans' daily lives.
    The president was contradicted almost in real time by some of the 
government experts who flanked him as he stood in the White House press 
briefing room.
Do you need a face mask for the coronavirus? An expert explains.
    Medical face masks are often used during flu season or a virus 
outbreak. Demand for masks has skyrocketed amid the coronavirus 
outbreak.
    ``We could be just one or two people over the next short period of 
time,'' Trump said of the virus's impact in the United States.
    Minutes later, Health and Human Services Secretary Alex Azar and 
CDC Principal Deputy Director Anne Schuchat warned Americans to prepare 
for the number of cases to grow.
    ``We can expect to see more cases in the United States,'' Azar 
said.
    ``We do expect more cases,'' Schuchat said.
    The case confirmed Wednesday in California brought the total in the 
United States to 60.
    As several countries around the world confirmed additional cases 
and higher death tolls, Trump tried to seize the reins of his 
administration's public response to a crisis that has featured a daily 
stream of negative developments.
    But his news conference quickly devolved into campaign-style 
attacks on Democrats, predictions of a stock market rally and self-
congratulatory assessments of his handling of the crisis.
    The president said he would be willing to accept more emergency 
funding than the $2.5 billion requested by his administration after 
lawmakers pushed for a more robust Federal response. He also said he 
would consider new travel restrictions on other countries struggling to 
contain the outbreak, including South Korea and Italy.
    ``At a right time we may do that,'' he said. ``Right now it's not 
the right time.''
    He partly blamed Democrats for the drop in the stock market and 
attacked House Speaker Nancy Pelosi (D-Calif.) as ``incompetent'' after 
she had made disparaging comments about his handling of the coronavirus 
outbreak, dismissing the traditional bipartisan approach leaders take 
in the midst of natural disasters and public health emergencies while 
criticizing her for doing the same.
    The remarks were the president's most extensive public comments yet 
about a crisis that threatens a main component of his reelection 
message--the economy. Trump administration officials have said they 
expect the virus to hamper economic growth this year, something that 
could complicate the president's economy-focused campaign pitch.
    The stock market, which Trump has followed closely in recent days, 
continued its sharp slump Wednesday, with the Dow Jones industrial 
average falling an additional 124 points. After enduring its worst 2-
day slide in 4 years on Monday and Tuesday, Wednesday's decline put the 
total losses this week at more than 2,000.
    The slog has undermined Trump's attempts to downplay the risk posed 
by the virus, which he previously dismissed as a passing problem that 
had not significantly affected Americans.
    But in the wake of a stock market rout that eliminated more than $2 
trillion in wealth, the news conference was intended to be a show of 
force, with several top administration officials from a ``coronavirus 
task force'' present.
    The administration has received criticism for lacking a coherent 
message about the virus as its reach and intensity have spread.
    Azar faced tough questions from lawmakers Wednesday during hearings 
on Capitol Hill.
    ``While the immediate risks to the American public remain low, 
there is now community transmission in a number of places, including 
outside of Asia, which is deeply concerning,'' Azar said. ``We are 
working closely with State and local and private-sector partners to 
prepare for mitigating the virus's potential spread in the United 
States as we expect to see more cases here.''
    Trump has made a direct connection between the virus and his 
political fortunes, accusing Democrats and the media of trying to harm 
his reelection chances by focusing on the outbreak.
    Trump took to Twitter early Wednesday to accuse cable news channels 
of ``doing everything possible to make the Caronavirus look as bad as 
possible, including panicking markets, if possible.''
    The president's efforts to downplay the virus have focused on the 
fact that the United States has seen relatively few cases and, so far, 
no confirmed deaths. Trump has also contended that the virus was ``very 
much under control'' and has indicated it would be gone by April.
    Multiple public health officials from the administration have 
contradicted that prediction. Asked if he agreed that the coronavirus 
would be gone by April, CDC Director Robert Redfield told Congress he 
didn't.
    ``Prudent to assume this pathogen will be with us for some time to 
come,'' he said Wednesday.
    As the virus has spread to more than 30 countries, Trump's 
``America First'' doctrine has come under increasing strain. While 
Trump instituted travel restrictions to block travelers from China--the 
epicenter of the outbreak--the virus has spread rapidly in several 
additional countries.
    ``When we did the initial China ban, we were very clear: We can't 
hermetically seal the U.S. off,'' Azar told lawmakers.
    Still, the Trump administration was considering adding new travel 
restrictions for South Korea, the country with the second-largest 
number of cases after China. South Korea reported 334 additional cases 
of the coronavirus Wednesday, raising the national tally to 1,595. That 
number is expected to rise in coming days as the country begins the 
mass testing of more than 200,000 members of a messianic religious 
movement at the center of an outbreak in the city of Daegu.
    An American soldier stationed in South Korea has tested positive 
for coronavirus, the first service member to be infected, the military 
said Tuesday. The U.S. military on Wednesday restricted all 
nonessential travel to South Korea for service members, civilians and 
contractors under its authority. The CDC has advised against any 
nonessential travel to South Korea.
    Trump, who has boasted that his travel restrictions on China were 
prudent, is likely to authorize new limitations on South Korea if the 
number of coronavirus cases there continues to increase, a senior 
administration official said.
    South Korea has lobbied against such restrictions, pledging 
cooperation and heightened prevention measures to allay U.S. concerns, 
officials said.
    The ban could extend to all foreigners traveling to the United 
States from South Korea, according to an official with knowledge of the 
deliberations. The restrictions would allow U.S. citizens to return to 
the United States but would require them to be quarantined for a period 
of time, as is the case with U.S. citizens coming to the United States 
from China. Thousands of U.S. service members and students live in 
South Korea.
    Trump, who repeatedly asserted that the United States should ban 
flights from Africa during the 2014 Ebola crisis, is also considering 
travel restrictions on other countries that have seen large outbreaks 
of coronavirus, an official said.
    The president has been reluctant to call for any significant 
preventive measures within the boundaries of the country, even as other 
nations have discouraged large gatherings or closed some schools as a 
precaution.
    Trump indicated he would go ahead with a planned political rally 
Friday in South Carolina, his first since returning from India.
    ``Big Rally in the Great State of South Carolina on Friday,'' Trump 
wrote on Twitter. ``See you there!''
    Democrats have criticized the president for his handling of the 
coronavirus crisis, emphasizing what they see as a key weakness for 
Trump in the eyes of many voters.
    In a new campaign ad titled ``Pandemic,'' former New York mayor 
Mike Bloomberg's Presidential campaign described Trump's administration 
as unprepared and ill-equipped to manage the country through a public-
health emergency.
    The administration has faced bipartisan criticism for its handling 
of the crisis, as lawmakers have publicly complained about the lack of 
consistency and clarity from senior officials involved in the response. 
Congressional leaders on Wednesday began putting together a large 
emergency spending package to deal with the outbreak, seeking to spend 
far more than the $2.5 billion the White House requested earlier this 
week.
    Administration officials have sparred internally in recent days 
over the emergency budget request, with Azar and others seeking a much 
larger package and White House aides calling for a less ambitious 
approach, according to officials with knowledge of the dispute, who 
like others spoke on the condition of anonymity to discuss the 
sensitive issue.
    Trump, who praised Azar publicly Tuesday, has been skeptical of the 
secretary's ability to handle the crisis, a senior administration 
official said. The president has been reluctant to oust him in part 
because he did not want to add to the sense of disarray, the official 
said.
    Azar was blindsided by the decision to put Pence in charge of the 
coronavirus response, according to five people familiar with the 
situation, who said Azar learned of the decision only moments before 
the evening news conference.
    Pence is scheduled to run a coronavirus task force at HHS on 
Thursday, two sources familiar with the plans said. One senior 
administration official said Pence was going to HHS to lead the 
meeting, instead of the White House, ``as a show of support to Azar.''
    The officials spoke on the condition of anonymity to discuss 
internal deliberations.
    Late Wednesday, acting chief of staff Mick Mulvaney told other 
administration officials that all media requests about coronavirus 
should now be routed through Pence's office, two people with knowledge 
of his email said. The vice president asked for the email to be sent 
out, a senior administration official said.
    One of Trump's biggest gripes has been the messaging from 
administration officials, both of these people said.
    The White House considered appointing a ``czar'' to oversee the 
governmentwide response effort, a move that would essentially demote 
Azar from his role as the head of the coronavirus task force.
    ``I don't anticipate one,'' Azar told lawmakers earlier Wednesday 
when asked if a czar would be appointed. ``This is working extremely 
well.''
    Trump said his decision to put Pence in charge was not tantamount 
to appointing a czar, despite him taking a role that serves the same 
purpose.
    ``Mike is not a czar, he's vice president,'' the president said. 
``I'm having them report to Mike. Mike will report to me.''
    Still, at the end of the news conference, Azar walked back to the 
lectern to clarify that he remained the chairman of the coronavirus 
task force and had not been demoted. He said he was actually 
``delighted'' to have Pence overseeing the effort.
    As Azar was speaking, Trump walked out of the room.
                                 ______
                                 
                    Article From National Geographic
  u.s. has only a fraction of the medical supplies it needs to combat 
                              coronavirus
The country could require seven billion respirators and face masks over 
        the course of the outbreak.
By Nsikan Akpan, published March 3, 2020.
    Three hundred million respirators and face masks. That's what the 
United States needs as soon as possible to protect health workers 
against the coronavirus threat. But the nation's emergency stockpile 
has less than 15 percent of these supplies.
    Last week, U.S. Health and Human Services Secretary Alex Azar 
testified before the Senate that the Strategic National Stockpile has 
just 30 million surgical masks and 12 million respirators in reserves, 
which came as a surprise considering that the stockpile's inventory is 
generally not disclosed for national security reasons. Asked by 
National Geographic about the discrepancy, a senior official with the 
Strategic National Stockpile said the department intends to purchase as 
many as 500 million respirators and face masks over the next 18 months.
    Even such a promised surge in production may not be enough--and it 
may not come soon enough. A widely overlooked study conducted 5 years 
ago by the U.S. Centers for Disease Control and Prevention found that 
the United States might need as many as seven billion respirators in 
the long run to combat a worst-case spread of a severe respiratory 
outbreak such as COVID-19.
    The outbreak now has entered a new, more potent phase dictated by 
local or community transmission. It's no longer just being imported 
from China. Coronavirus has started spreading locally in 13 other 
countries, including South Korea, Japan, Singapore, Australia, 
Malaysia, Vietnam, Italy, Germany, France, United Kingdom, Croatia, San 
Marino, Iran, the United Arab Emirates, and the United States. On 
Wednesday, the World Health Organization announced COVID-19's global 
death rate is 3.4 percent, more than 30 times that of seasonal 
influenza, but also stated the coronavirus doesn't spread as easily as 
the flu. The global tally of confirmed cases and deaths has risen to 
93,000 and nearly 3,200, respectively.
    In the U.S., COVID-19 cases without clear ties to China began 
dotting the West Coast last week. At the same time, the Nation saw an 
uptick in fatalities--nine so far as of Tuesday--with most occurring at 
a nursing home in Kirkland, Washington. Among those deaths is one 
patient who passed away last week at Seattle's Harborview Medical 
Center. Viral tests, made well after his death, revealed a COVID-19 
diagnosis and that hospital staff may have been exposed.
    Besides confirming the threat posed to the elderly, these deaths, 
the community transmission, and genetic analysis suggest the virus has 
been spreading unnoticed in Washington since mid-January.
    ``We will have community spread,'' New York Governor Andrew Cuomo 
said Monday at a news briefing about the State's first confirmed case. 
``That is inevitable.''
    All of these events sparked a run on medical supplies over the 
weekend, a worrying prospect given the CDC has indicted there could be 
a global deficit of personal protective equipment such as surgical 
masks, goggles, full-body coveralls, and N95 respirators, the only CDC-
approved face guard, which are designed to filter 95 percent of 
airborne particles.
    ``We're concerned that countries' abilities to respond are being 
compromised by the severe and increasing disruption to the global 
supply of personal protective equipment, caused by rising demand, 
hoarding, and misuse,'' Dr. Tedros Adhanom Ghebreyesus, WHO director-
general, said at a press briefing at the agency's headquarters in 
Geneva on Tuesday. ``Prices of surgical masks have increased sixfold, 
and N95 respirators have more than tripled, and gowns cost twice as 
much.''
    What's more, even if U.S. medical centers obtain the necessary 
supplies, a second shortage of medical specialists may emerge if this 
respiratory outbreak spreads even more dramatically.
Taking stock
    The panicked demand and lack of supplies was predictable. China 
manufactures roughly 50 percent more medical and pharmaceutical 
supplies than its nearest competitor, the U.S., according to data 
supplied to National Geographic by Euromonitor International. But the 
Asian country now needs those precious supplies for its tens of 
thousands of cases, at a time when manufacturing has slowed across the 
country.
    ``The fundamental point that's exposed in situations like that is 
that autarky--the idea of self-sufficiency--is lovely in theory, but it 
almost never actually works in practice, because we tend to not 
appreciate supply chains,'' says Parag Khanna, a global strategy 
advisor and author of Connectography and Technocracy in America.
    Much of the world has become accustomed to same-day delivery 
without thinking about the bundles of transactions that support such a 
system. Some global industries can circumvent major blockages or delays 
in supply chains caused by the coronavirus outbreak. But other supply 
chains and industries--like automobiles, travel, and medical supplies--
are too tightly bound across borders in what Khanna calls a supply 
circuit.
    ``China's a manufacturer of intermediate products . . . but what 
they're really manufacturing on a wider scale is starting material for 
active pharmaceutical ingredients,'' says Scott Gottlieb, a former U.S. 
FDA commissioner and resident fellow at the American Enterprise 
Institute. ``These manufacturers have one to 3 months of supply, so 
they're going to be able to continue to manufacture for a period of 
time, but eventually they're going to run out.''
    ``The irony is that some of the other countries who could do these 
things very quickly, like Japan or South Korea, are also affected by 
the virus,'' says Khanna, who has also noted that the coronavirus 
appears to be spreading along China's ``new silk road''--echoing what 
happened with the Black Death in the 1300's. He and other experts 
expect India, Thailand, Indonesia, and Vietnam to swoop in to 
capitalize on China's deficit.
    On Friday, the FDA announced the first drug shortage due to the 
coronavirus. And for nearly a month, the CDC has warned about the 
fragility of supply circuits for personal protective equipment, as 
manufacturers struggle to meet orders for face masks and N95 
respirators. That's possibly because the CDC conducted a thought 
experiment 5 years ago that offers a clear warning for the situation 
unfolding today. Back then, the public health agency wanted to predict 
how many resources the U.S. might need over the entire course of a 
hypothetical outbreak of a severe flu virus. (Learn about how 
coronavirus compares to flu, Ebola, and other major outbreaks.)
    The result was a series of models built with parameters that bear 
an uncanny resemblance to what is currently happening with the 
coronavirus. From disease transmission rates down to the lack of 
specific antivirals or vaccines, the CDC papers offer a rough guide on 
what preparedness needs to look like to combat an emerging respiratory 
pandemic.
    ``In terms of the amount of masks, gowns, gloves, [and] respirators 
that would be needed, this influenza model is a good way to estimate 
that at this point,'' says Eric Toner, a senior scientist at the Johns 
Hopkins Center for Health Security who wasn't involved with the CDC 
papers. ``I don't see any reason to think that we would need a 
different number of those things than we do for a severe pandemic 
flu.''
    Based on the models, U.S. health care workers would need two to 
seven billion respirators for the least--to most--severe possible 
scenarios. That's up to 233 times more than what's currently in the 
Strategic National Stockpile.
    ``The demand that would be required in a severe pandemic is so 
unlike the amount that's used on a day-to-day basis,'' says Lisa 
Koonin, an epidemiologist and founder of Health Preparedness Partners. 
She worked for the CDC for more than 30 years and is a co-author on 
these reports. ``For the respirators and surgical masks, we're talking 
orders of magnitude greater need for a severe pandemic.''
    The WHO has shipped nearly half a million sets of personal 
protective equipment to 27 countries, but it says supplies are rapidly 
depleting. The global health agency estimates that each month 89 
million medical masks will be required for the COVID-19 response, along 
with 76 million examination gloves and 1.6 million goggles. The WHO 
estimates that supplies of personal protective equipment need to be 
increased by 40 percent globally.
Special staff
    ``In a severe pandemic, we certainly could run out of ventilators, 
but a hospital could just as soon run out of respiratory therapists who 
normally operate these devices.''--Eric Toner, Johns Hopkins Center for 
Health Security
    Along with the billions of respirators, the CDC predicted that U.S. 
patients and health care workers might need as many as 100 to 400 
million surgical masks, as well as 7,000 to 11,000 mechanical 
ventilators. The latter are used during life support for the most 
severe cases of respiratory disease, after a patient's lungs stop 
working on their own. A report published Friday in the New England 
Journal of Medicine states that about 2.3 percent of early coronavirus 
patients underwent mechanical ventilation.
    But ventilators, respirators, and even basic masks are only helpful 
when used by expert hands--and that presents another potential 
shortfall for the U.S.
    ``In a severe pandemic, we certainly could run out of ventilators, 
but a hospital could just as soon run out of respiratory therapists who 
normally operate these devices,'' says Toner. The Bureau of Labor 
Statistics estimates that the U.S. employs 134,000 respiratory 
specialists, or approximately 20 of these technicians for every 
hospital in America. (Will warming spring temperatures slow the 
coronavirus outbreak?)
    ``One of [the CDC's] conclusions was, it's not so much the number 
of ventilators as the number of people needed to operate the 
ventilators. That's the choke point,'' Toner adds.
    Resource demands at a single hospital could also be substantial as 
coronavirus cases increase in the U.S. Three years ago, the Mayo 
Clinic--a prestigious medical system based in Rochester, Minnesota--
asked Toner and his colleagues to assess what kind of individual 
stockpile might be required during a severe influenza pandemic.
    Unlike the CDC papers, their model ran through 10,000 scenarios, 
each with slightly different settings for epidemiologic variables such 
as hospitalization rates, hospital length of patient stays, how much 
time patients spend on mechanical ventilation, and case fatality rate.
    ``A model like this can't tell you the right thing to do. But it 
can tell you the range of possibilities,'' Toner says.
    For example, if the Mayo Clinic stockpiled 4.5 million gloves, 2.3 
million N95 respirators, 5,000 doses of a potent antiviral, and 880 
ventilators, those supplies would cover the clinic's facilities for 95 
percent of the likely outcomes--everything except the absolute worst-
case scenarios for a respiratory pandemic.
    ``We go through a lot of gloves in health care, and the numbers can 
be staggering,'' Toner says. ``Particularly with a disease like this 
where some people are advocating double gloving, you'll burn through 
gloves twice as fast.''
    But he emphasizes that every hospital's demands would be different. 
The Mayo Clinic is large, boasting more than 63,000 staff members that 
not only serve Minnesota, but accept specialty patients from around the 
world.
    ``We can't stop COVID-19 without protecting our health workers,'' 
WHO director-general Ghebreyesus says. ``Supplies can take months to 
deliver, market manipulation is widespread, and stocks are often sold 
to the highest bidder.''
Resilient circuits
    The actual demand and supply for health care equipment during this 
outbreak will depend on myriad variables, one of which is an outbreak's 
attack rate. As of this moment, that is a mystery for COVID-19.
    The attack rate is what percentage of a population catches an 
infectious disease overall. If a hundred people live in a city, and a 
virus' attack rate is 20 percent, then 20 citizens would be expected to 
get sick. Both the CDC papers and Toner's models rely on attack rates 
ranging from 20 to 30 percent, a standard estimate for severe 
pandemics. (Learn about the swift, deadly history of the Spanish Flu 
pandemic.)
    But the attack rate for COVID-19 is still unknown because it takes 
time to measure. Scientists must develop a test--known as a serology 
assay--that can detect whether a person caught the coronavirus even if 
they never reported symptoms.
    ``In terms of quantifying that specifically, it's still quite early 
days,'' Maria Van Kerkhove, an infectious disease epidemiologist and 
the technical leader for WHO's Health Emergencies Program, said at a 
press briefing at the WHO headquarters in Geneva on Monday. Van 
Kerkhove added those serologic surveys must be conducted across large 
populations, so attack rates can be determined for individual age 
groups.
    Because the attack rate reveals how much of a population is likely 
to catch a disease, it can be crucial in determining how to allocate 
resources locally, nationally, and globally. Van Kerkhove added that 
the necessary surveys are underway, and the World Health Organization 
hopes to see some preliminary results in the coming weeks.
    In the meantime, Vice President Mike Pence, the Trump 
Administration's newly appointed coronavirus czar, on Saturday 
announced a deal with the Minnesota-based corporation 3M to produce 35 
million masks a month. And the managers for the Strategic National 
Stockpile have asked companies to submit data on their inventories of 
personal protective equipment, in case the coronavirus crisis 
escalates. They also hope their recent request for 500 million 
respirators and masks will promote the growth of local manufacturers.
    ``This purchase will encourage manufacturers to ramp up production 
of personal protective equipment now with the guarantee that they will 
not be left with excess supplies once the COVID-19 response subsides,'' 
says Stephanie Bialek of the Strategic National Stockpile. ``In an 
emergency, the SNS can send these products to areas in need as 
requested by State health officials.''
    Editor's Note: This story has been updated with the latest case 
counts as of March 4 and with the new estimate for the global death 
rate. The story was originally published on March 3.

    Chairman Thompson. Let me recognize Mr. Correa for bringing 
this hearing forward. He was the first Member of the committee 
to say that we need to bring some experts before the committee 
so that we can get first-hand knowledge.
    Mr. Correa, you want to----
    Mr. Correa. I just have a couple of quick----
    Chairman Thompson. Go ahead.
    Mr. Correa [continuing]. Follow-up questions.
    Incubation period?
    Dr. Inglesby. One to 14 days, but, on average, about 5 
days.
    Mr. Correa. One to 14 days, 5.
    Symptoms similar to flu?
    Dr. Inglesby. Yes.
    Mr. Correa. You don't know if you got the flu, you don't 
know if you got corona.
    Dr. Gerberding. Just one thing about symptoms was the--I 
think the expectation is that fever is the sentinel system, but 
a lot of the people who end up in the hospital didn't start 
with fever. So about half of them came to the hospital and 
hadn't developed fever yet.
    Mr. Correa. China, is the rate going down in China? The 
infections rate.
    Dr. Inglesby. Yes, the numbers reported by China are going 
down substantially in the last couple of weeks, both numbers of 
cases and deaths.
    Mr. Correa. How certain can we be that they are accurate?
    Dr. Inglesby. I think the World Health Organization has 
said that they believe they are accurate. I think it is 
difficult to know, from where we are.
    Mr. Correa. Death rate, World Health Organization just had 
an article that said higher than the flu. You are saying, 
ma'am, that it probably is higher than flu. But yet we don't 
know the denominator, so that we really don't know what the 
death rate is at this point, we just suspect. Is that correct?
    Dr. Inglesby. That is correct. That article that said WHO 
has concluded that it is a higher case fatality rate isn't--it 
was really a misquote. WHO hasn't said just that. They have 
just basically divided the numbers of recognized cases by the 
deaths, and come up with--and said it is 3 percent, 
approximately 3 percent have died. But we do believe that there 
are many cases that are unrecognized, we just don't know how 
many there are.
    Mr. Correa. Finally, again, best practices, lesson learned. 
We have to be consistent, we have to have a system where we 
continue to invest, on an annual basis, on the system, research 
and development, coming up with vaccines and protocols so the 
next time--this will happen again--that we don't have to 
scramble and figure out where we get the test kits, the masks, 
so on and so forth.
    Dr. Gerberding. So I will say two things. One is BARDA is 
good value for Americans, and the work that BARDA has done to 
push the envelope on counter-measure development is something 
that I hope the committee is aware of and knows about, because 
that is clearly a National asset.
    The second piece is an ask that is included in the CSIS 
report, and that is that our Government needs to contribute to 
something called CEPI, which is the Coalition for Epidemic 
Preparedness Innovation. That is a global effort. It includes 
companies, countries, nonprofits, Gates, Wellcome Trust, et 
cetera, who are saying we know some of the bad things like SARS 
and MERS that may come back. Let's get those vaccines across 
the finish line, or at least into the freezer, so that if the 
problem comes back, we have got something we can pull out and 
test very quickly.
    Mr. Correa. So here in this committee----
    Dr. Gerberding. That is an investment that----
    Mr. Correa [continuing]. You are saying that we have had 
those challenges, we haven't come up with the vaccines, and yet 
we know they will be back.
    Dr. Gerberding. I think we need to expect they will be 
back. I hope they don't come back, but they may. Shame on us if 
we have another situation where we got started on something and 
we didn't bring it across the finish line.
    Mr. Correa. Thank you.
    Chairman Thompson. Well, thank you. Let me thank the 
witnesses again. There is no question about what you brought to 
the committee today. That information will be vital toward 
ultimate solutions. Some of it, obviously, is investment over 
the long haul, with respect to detection and others.
    But I do want to, just for the record, highlight the fact 
that we should be providing the public the best information we 
have. It is not a political issue, it is a health issue. We 
want to look at it in that respect. So words do matter when 
politicians get in it. So I caution everyone to govern 
themselves accordingly as we work through this.
    But in the interim, I want to again thank you for an 
absolute excellent sharing of information for the committee.
    I would like to also say that the Members of the committee 
may have additional questions for the witnesses, and we ask you 
to respond expeditiously in writing to those questions.
    Without objection, the committee shall be kept open, the 
record will be kept open for 10 days. Hearing no further 
business, the committee stands adjourned.
    [Whereupon, at 12:04 p.m., the committee was adjourned.]