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





   EBOLA IN THE HOMELAND: THE IMPORTANCE OF EFFECTIVE INTERNATIONAL, 
                 FEDERAL, STATE, AND LOCAL COORDINATION

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

                             FIELD HEARING

                               before the

                     COMMITTEE ON HOMELAND SECURITY
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                            OCTOBER 10, 2014

                               __________

                           Serial No. 113-88

                               __________

       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.gpo.gov/fdsys/
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                          Washington, DC 20402-0001

















                     COMMITTEE ON HOMELAND SECURITY

                   Michael T. McCaul, Texas, Chairman
Lamar Smith, Texas                   Bennie G. Thompson, Mississippi
Peter T. King, New York              Loretta Sanchez, California
Mike Rogers, Alabama                 Sheila Jackson Lee, Texas
Paul C. Broun, Georgia               Yvette D. Clarke, New York
Candice S. Miller, Michigan, Vice    Brian Higgins, New York
    Chair                            Cedric L. Richmond, Louisiana
Patrick Meehan, Pennsylvania         William R. Keating, Massachusetts
Jeff Duncan, South Carolina          Ron Barber, Arizona
Tom Marino, Pennsylvania             Donald M. Payne, Jr., New Jersey
Jason Chaffetz, Utah                 Beto O'Rourke, Texas
Steven M. Palazzo, Mississippi       Filemon Vela, Texas
Lou Barletta, Pennsylvania           Eric Swalwell, California
Richard Hudson, North Carolina       Vacancy
Steve Daines, Montana                Vacancy
Susan W. Brooks, Indiana
Scott Perry, Pennsylvania
Mark Sanford, South Carolina
Curtis Clawson, Florida
                   Brendan P. Shields, Staff Director
                   Joan O'Hara, Acting Chief Counsel
                    Michael S. Twinchek, Chief Clerk
                I. Lanier Avant, Minority Staff Director


















                            C O N T E N T S

                              ----------                              
                                                                   Page

                               STATEMENTS

The Honorable Michael T. McCaul, a Representative in Congress 
  From the State of Texas, and Chairman, Committee on Homeland 
  Security:
  Oral Statement.................................................     1
  Prepared Statement.............................................     4
The Honorable Bennie G. Thompson, a Representative in Congress 
  From the State of Mississippi, and Ranking Member, Committee on 
  Homeland Security:
  Oral Statement.................................................     5
  Prepared Statement.............................................     7
The Honorable Sheila Jackson Lee, a Representative in Congress 
  From the State of Texas:
  Prepared Statement.............................................     8

                               WITNESSES
                                Panel I

Dr. Toby Merlin, Director, Division of Preparedness and Emerging 
  Infection, National Center for Emerging and Zoonotic Infectious 
  Diseases, Centers for Disease Control and Prevention, U.S. 
  Department of Health and Human Services:
  Oral Statement.................................................    11
  Prepared Statement.............................................    12
Dr. Kathryn Brinsfield, Acting Assistant Secretary and Chief 
  Medical Officer, Office of Health Affairs, U.S. Department of 
  Homeland Security:
  Oral Statement.................................................    17
  Joint Prepared Statement.......................................    19
Mr. John Wagner, Acting Assistant Commisioner, Office of Field 
  Operations, U.S. Customs and Border Protection, U.S. Department 
  of Homeland Security:
  Oral Statement.................................................    21
  Joint Prepared Statement.......................................    19

                                Panel II

Dr. David Lakey, Commissioner of Health, Texas Department of 
  State Health Services:
  Oral Statement.................................................    54
  Prepared Statement.............................................    57
Dr. Brett P. Giroir, Executive Vice President and CEO, Texas A&M 
  Health Science Center, and Director, Texas Task Force on 
  Infectious Disease Preparedness and Response:
  Oral Statement.................................................    60
  Prepared Statement.............................................    61
Hon. Clay Lewis Jenkins, Judge, Dallas County, Texas:
  Oral Statement.................................................    65
  Prepared Statement.............................................    66
Ms. Catherine L. Troisi, Ph.D., Associate Professor, Division of 
  Management, Policy, and Community Health Center for Infectious 
  Diseases, The University of Texas:
  Oral Statement.................................................    67
  Prepared Statement.............................................    69

                             FOR THE RECORD

The Honorable Michael T. McCaul, a Representative in Congress 
  From the State of Texas, and Chairman, Committee on Homeland 
  Security:
  Letter From Chairman Michael T. McCaul and Senator John Cornyn.    48
The Honorable Bennie G. Thompson, a Representative in Congress 
  From the State of Mississippi, and Ranking Member, Committee on 
  Homeland Security:
  Chart..........................................................     7
The Honorable Sheila Jackson Lee, a Representative in Congress 
  From the State of Texas:
  Press Release..................................................    31
  Chart..........................................................    77
  Letter from Rep. Jackson Lee to Director Frieden...............    87
The Honorable Kenny Marchant, a Representative in Congress From 
  the State of Texas:
  Letters........................................................    46

                                APPENDIX

Questions From Honorable Lamar Smith for Toby Merlin.............    93
Questions From Honorable Beto O'Rourke for Toby Merlin...........    93
Questions From Honorable Eric Swalwell for Toby Merlin...........    93
Questions From Honorable Lamar Smith for John P. Wagner..........    94

 
   EBOLA IN THE HOMELAND: THE IMPORTANCE OF EFFECTIVE INTERNATIONAL, 
                 FEDERAL, STATE, AND LOCAL COORDINATION

                              ----------                              


                        Friday, October 10, 2014

             U.S. House of Representatives,
                    Committee on Homeland Security,
                                                        Dallas, TX.
    The committee met, pursuant to call, at 12:10 p.m., in the 
In-Transit Lounge, D-31, Dallas-Fort Worth International 
Airport, 233 South International Drive, Dallas, Texas, Hon. 
Michael McCaul [Chairman of the committee] presiding.
    Present: Representatives McCaul, Chaffetz, Sanford, 
Clawson, Thompson, Jackson Lee, Barber, O'Rourke, Vela, and 
Swalwell.
    Also present: Representatives Farenthold, Marchant, Barton, 
Burgess, Veasey, and Johnson.
    Chairman McCaul. The Committee on Homeland Security will 
come to order. The committee is meeting today to examine the 
coordinated Federal, State, and local response to the recent 
Ebola case right here in Dallas, Texas. First, I want to thank 
everybody, including the witnesses, for attending this hearing 
today, and I appreciate the efforts taken on behalf of all 
those involved to have this important field hearing.
    This is an official Congressional hearing as opposed to a 
town hall, and as such, we must abide by certain rules of the 
committee and the House of Representatives. I would like to 
kindly remind our guests that demonstrations from the audience, 
including applause and verbal outbursts, as well as the use of 
signs or placards are a violation of the rules of the House of 
Representatives, and it is important that we respect the 
decorum and the rules of this committee. I have also been 
requested to state that photography and cameras are limited to 
accredited press only.
    Before I recognize myself for an opening statement, I also 
ask unanimous consent that the gentlemen from Texas, Mr. Joe 
Barton, Mr. Michael Burgess, Mr. Kenny Marchant, Mr. Blake 
Farenthold, and Mr. Mark Veasey, and the gentlelady from Texas, 
Ms. Eddie Bernice Johnson, be permitted to sit on the dais and 
participate in today's hearing. Without objection, so ordered.
    I will now recognize myself for an opening statement.
    We are here today to discuss the threat to the United 
States homeland from the Ebola virus and what is being done to 
stop the spread of this terrible disease. This crisis is 
unfolding at an alarming pace. Thousands have died in Africa 
and thousands more have been infected, including four selfless 
Americans working in Liberia who have been flown home for 
treatment.
    Now the virus has begun to spread to other parts of the 
world, and the American people are rightfully concerned. They 
are concerned because the Ebola virus is an unseen threat, and 
it is only a plane flight away from our shores. We have 
witnessed that with the recent case here in Dallas, the first 
fatality from Ebola in the United States. But we must be sure 
to confront this crisis with the facts. Blind panic will not 
help us stop this disease from spreading, and fear-mongering 
will only make it harder to do so.
    That is why we are here today, to ask the American people's 
questions and get answers from the experts. Americans are 
seeking assurance that our Federal, State, and local officials 
are doing everything in their power to keep this virus outside 
of the United States. Already there has been a vigorous 
international, Federal, State, and local response, and we hope 
to hear more today about exactly what has been done and what 
needs to be done going forward.
    Two weeks ago, Thomas Eric Duncan traveled here from 
Liberia by way of Brussels and Dulles Airports. He fell ill and 
presented himself for treatment at Texas Health Presbyterian 
Hospital here in Dallas. Mr. Duncan's diagnosis set in motion 
an extensive public health operation involving Federal, State, 
and local officials to identify and assess any individuals with 
whom he may have had contact, a process called contact tracing. 
That contact tracing effort continues today, and our prayers 
are with everyone who is currently being monitored as part of 
this incident.
    We are thankful that today there have been no additional 
cases of Ebola stemming from this case. Contact tracing is 
time-consuming and difficult, but it is one of the few ways to 
contain the disease. Containment also requires swift, 
coordinated action. In this committee's hearings and 
investigation on the Boston Marathon bombings, we heard 
testimony about the importance of the incident command system. 
The system is a vital tool for making sure first responders at 
all levels engage quickly and decisively rather than argue 
about who is in charge. The importance of such a response 
mechanism was highlighted in the 9/11 Commission Report, and it 
has since saved countless lives.
    I was encouraged to learn officials here in Texas 
instituted the structure, and today State and Federal officials 
are co-located in the Dallas County Emergency Operations 
Center, enabling vital information sharing and coordination. To 
be clear, the situation here at home is far different than what 
is happening in West Africa. We have a strong public health 
infrastructure in place, particularly here in Texas, which 
enables us to work to contain this virus more effectively.
    But Dallas is not the only area that we must be vigilant. 
We need to ensure that State and local responders Nation-wide 
are prepared to move quickly if the virus is detected anywhere 
else within our borders. Hospitals are recognizing this and 
have made nearly 190 inquiries with the CDC about cases they 
believe could be Ebola. Thankfully, testing was only warranted 
in about 24 of these cases, and only one case was confirmed as 
Ebola.
    Public health and medical personnel must remain vigilant, 
ensure all hospital personnel are informed, follow protocols to 
identify the virus, and take appropriate quarantine measures. 
We must reinforce the importance of taking travel histories and 
sharing that information with all relevant personnel.
    Protecting the homeland from the Ebola virus also requires 
us to put measures in place at our airports. I am pleased the 
President announced earlier this week additional entry 
screening efforts that are being launched. Beginning tomorrow, 
enhanced screening measures will be activated at JFK Airport, 
and soon after at Dulles, O'Hare, Newark, and Atlanta. These 
airports receive more than 94 percent of all travelers from 
Liberia, Sierra Leone, and Guinea. I look forward to hearing 
more about these enhanced screening efforts from our witnesses.
    The Department of Homeland Security has been actively 
involved in this response, and I commend Secretary Johnson for 
his leadership. But we also must closely monitor the situation 
overseas and continue our global response efforts. I have 
spoken with the President's homeland security advisor, Lisa 
Monaco, numerous times to ensure our Government is doing all 
that is necessary. We recently discussed exit screening 
procedures that have been put in place in Liberia, Sierra 
Leone, and Guinea by CDC-trained personnel. In the past 2 
months, the screening has stopped 77 travelers with Ebola-like 
symptoms or contact history from boarding airplanes out of a 
total of 36,000 individuals screened. Fortunately, none of 
those 77 have been diagnosed with Ebola.
    While there have many positive aspects of this response, 
there have also been missteps. For instance, here in Dallas, 
Mr. Duncan's travel history was not communicated to all 
relevant medical personnel when he first sought treatment, 
which led to his release from the hospital and the potential 
that additional people were exposed to the virus. There were 
also problems removing hazardous biomedical waste from the 
apartment where Mr. Duncan's family was quarantined. The soiled 
materials remained in the home with the quarantined individuals 
for days after the Ebola diagnosis was confirmed.
    We must learn from these missteps and ensure that proper 
procedures are established and followed should another case 
arise in the United States. Going forward, we must consider all 
policy options for stopping the spread of this horrific 
disease. I have heard many ideas directly from my fellow 
Texans, everything from stopping in-bound flights from specific 
countries to additional screenings at home and abroad. We hope 
our witnesses will discuss options that are being considered in 
the trade-offs that we have to confront.
    We also have to ensure unnecessary Government red tape does 
not slow down the response. In fact, I know a reprogramming 
request was approved in the House seeking $750 million towards 
response efforts, and I would urge the Senate to follow the 
lead of the House and approve the Pentagon's request to 
transfer additional resources to this fight.
    Now is not the time for politics. Congress has been loath 
to get anything done this session, and if there's ever been a 
time to come together and put pettiness aside, it is now. We 
must get this right and make sure that Federal protocols are 
put in place and communicated to our State and local partners 
when a situation this critical occurs. My hope today is that we 
do not focus on gotcha politics, but instead hear from our 
panel and focus on solutions. We are all in the same boat, and 
we need to work hard to make sure that our Nation is protected 
from this threat.
    I want to thank the Ranking Member for being here today in 
my home State of Texas and showing his support for this shared 
goal. Before I turn it over to him, I would also like to 
commend our first responders, our medical personnel and public 
health officials, who have responded courageously to the case 
here in Dallas. Most importantly, our thoughts and prayers are 
with the victims and the families affected by this crisis. I 
look forward to hearing from the witnesses and hear from them 
what more can be done to keep Americans safe.
    [The statement of Chairman McCaul follows:]
                  Statement of Chairman Michael McCaul
                            October 10, 2014
    We are here today to discuss the threat to the U.S. homeland from 
the Ebola virus and what is being done to stop the spread of this 
terrible disease. The crisis is unfolding at an alarming pace. 
Thousands have died in Africa and thousands more have been infected, 
including 4 selfless Americans working in Liberia who have been flown 
home for treatment. Now the virus has begun to spread to other parts of 
the world, and the American people are rightfully concerned. They are 
concerned because the Ebola virus is an unseen threat, and it is only a 
plane-flight away from our shores. We've witnessed that with the recent 
case here in Dallas--the first fatality from Ebola in the United 
States.
    But we must be sure to confront this crisis with the facts. Blind 
panic won't help us stop this disease from spreading, and fear-
mongering will only make it harder to do so. That is why we are here 
today: To ask the American people's questions and get answers from our 
experts. Americans are seeking assurance that our Federal, State, and 
local officials are doing everything in their power to keep this virus 
out of the United States.
    Already, there has been a vigorous international, Federal, State, 
and local response. We hope to hear more today about exactly what has 
been done--and what needs to be done going forward. Two weeks ago, 
Thomas Eric Duncan traveled here from Liberia by way of the Brussels 
and Dulles airports, fell ill, and presented himself for treatment at 
Texas Health Presbyterian Hospital here in Dallas. Mr. Duncan's 
diagnosis set in motion an extensive public health operation involving 
Federal, State, and local officials to identify and assess any 
individuals with whom he may have had contact, a process called 
``contact-tracing.''
    That contact-tracing effort continues today, and our prayers are 
with everyone who is currently being monitored as part of this 
incident. We are thankful that, to date, there have been no additional 
cases of Ebola stemming from this case. Contact-tracing is time-
consuming and difficult, but it is one of the few ways to contain the 
disease. Containment also requires swift, coordinated action. In this 
committee's hearings and investigation on the Boston Marathon bombings, 
we heard testimony about the importance of the ``incident command 
system.''
    The system is a vital tool for making sure first responders at all 
levels engage quickly and decisively, rather than argue over who is in 
charge. The importance of such a response mechanism was highlighted in 
the 9/11 Commission report, and it has since saved countless lives. I 
was encouraged to learn officials here in Texas instituted this 
structure. Today, State and Federal officials are co-located in the 
Dallas County Emergency Operations Center, enabling vital information 
sharing and coordination.
    To be clear, the situation here at home is far different than what 
is happening in West Africa. We have a strong public health 
infrastructure in place, particularly here in Texas, which enables us 
to work to contain this virus more effectively. But Dallas is not the 
only area that must remain vigilant. We need to ensure that State and 
local responders Nation-wide are prepared to move quickly if the virus 
is detected anywhere else within our borders. Hospitals are recognizing 
this and have made nearly 190 inquiries with the CDC about cases they 
believed could be Ebola. Thankfully, testing was only warranted in 
about 24 of those cases, and only 1 case was confirmed as Ebola.
    Public health and medical personnel must remain vigilant, ensure 
all hospital personnel are informed, follow protocols to identify this 
virus, and take appropriate quarantine measures. We must reinforce the 
importance of taking travel histories and sharing that information with 
all relevant personnel. Protecting the homeland from the Ebola virus 
also requires us to put measures in place out our airports. I am 
pleased the President announced earlier this week additional entry 
screening efforts are being launched. Beginning tomorrow, enhanced 
screening measures will be activated at JFK airport and soon after at 
Dulles, O'Hare, Newark, and Atlanta. These airports receive more than 
94% of all travelers from Liberia, Sierra Leone, and Guinea. I look 
forward to hearing more about these enhanced screening efforts from our 
witnesses. The Department of Homeland Security has been actively 
involved in the response, and I commend Secretary Jeh Johnson for his 
leadership in bringing Federal resources to the fight.
    We must also closely monitor the situation overseas and continue 
our global response efforts. I have spoken with the President's 
Homeland Security Advisor Lisa Monaco numerous times to ensure our 
Government is doing all that is necessary. We recently discussed exit 
screening procedures that have been put in place in Liberia, Sierra 
Leone, and Guinea by CDC-trained personnel. In the past 2 months, this 
screening has stopped 77 travelers with Ebola-like symptoms or contact 
history from boarding planes, out of a total of 36,000 individuals 
screened. None of those 77, that we are aware of, has been diagnosed 
with Ebola. While there have been many positive aspects of this 
response, there have also been missteps.
    For instance, here in Dallas Mr. Duncan's travel history was not 
communicated to all relevant medical personnel when he first sought 
treatment, which led to his release from the hospital and the potential 
that additional people were exposed to the virus. There were also 
problems removing hazardous biomedical waste from the apartment where 
Mr. Duncan's family was quarantined. The soiled materials remained in 
the home with the quarantined individuals for days after the Ebola 
diagnosis was confirmed.
    We must learn from these missteps, and ensure the proper procedures 
are established and followed should another case arise in the United 
States. Going forward, we must consider all policy options for stopping 
the spread of this horrific disease. I have heard many ideas directly 
from my fellow Texans--everything from stopping in-bound flights from 
specific countries to additional screenings at home and abroad. We hope 
our witnesses will discuss options that are being considered and the 
trade-offs we may have to confront.
    We also have to ensure unnecessary Government red tape does not 
slow down the response. I urge the Senate to follow the lead of the 
House and approve the Pentagon's request to transfer additional 
resources to the fight. The Defense Department is seeking to move $750 
million toward response efforts, and we should move swiftly to satisfy 
that request.
    Now is not the time for politics. Congress has been loathe to get 
much done this session, and if there has ever been a time to come 
together and put pettiness aside, it is now. We must get this right and 
make sure that Federal protocols are put in place and communicated to 
our local and State leaders when a situation this critical occurs.
    My hope today is we won't focus on gotcha politics, instead hearing 
from our panels and focusing on a solutions-based hearing. We are in 
the same boat. And we need to work hard to make sure that our Nation is 
protected from this threat. I want to thank the Ranking Member for 
being here in my home State of Texas in a show of support for this 
shared goal.
    Before we begin, I also want to commend the first responders, 
medical personnel, and public health officials who have responded 
courageously to the case here in Dallas. Most importantly, our thoughts 
and prayers are with the victims and families affected by this crisis. 
I look forward to hearing from our distinguished panel of witnesses 
today on the recent response efforts and what more can be done to keep 
America safe.

    Chairman McCaul. With that, the Chairman now recognizes the 
Ranking Member, Mr. Thompson.
    Mr. Thompson. Good afternoon. I want to thank the Chairman 
for holding this timely hearing on our efforts, both domestic 
and international, to contain and prevent the spread of the 
Ebola virus. I also thank the witnesses for appearing here 
today, and I look forward to their testimony. Additionally, I 
want to thank Chair Biggins and the board of directors of the 
Dallas-Fort Worth Airport and executive staff for hosting the 
committee today.
    I also want to extend my condolences to the family of 
Thomas Eric Duncan, the first person diagnosed with Ebola on 
American soil. We are not here to dehumanize Mr. Duncan, but 
unfortunately his diagnosis and the procedures that followed 
raise critical questions about our preparedness for highly 
infectious diseases, such Ebola, and how Federal, State, and 
local authorities coordinate in their aftermath.
    As the Ranking Member of this committee, I often urge my 
colleagues not to use our positions of influence to promote 
fear in the public. Hence, I want to clarify that while it is 
proper to have serious concerns about the Ebola virus, it would 
be irresponsible for us to foster the narrative that an Ebola 
epidemic in the United States is imminent. Rather, this hearing 
provides us an opportunity to review our State, local, Federal, 
and global public health infrastructure, learn where there are 
inconsistencies and gaps, and lay the foundation for 
eliminating these disparities.
    While the Ebola virus has caused the United States to 
institute new screening procedures at airports, it is incumbent 
upon us to work with our international partners to eradicate 
the virus at its origin in West Africa. The current Ebola 
outbreak is the deadliest outbreak on record. According to the 
Assistant Secretary General of the United Nations, it is also 
impairing National economies, wiping out livelihoods and basic 
services, and could undo years of efforts to stabilize West 
Africa. Eliminating this virus at its source is a sure-fire way 
to prevent more Ebola cases in the United States.
    As citizens of the global community, it is our moral 
obligation to not only eradicate this virus that is devastating 
West Africa, but also ensure that these countries can continue 
to function and recover. The United States' response to the 
current Ebola outbreak will affect the ways it works to 
coordinate international responses to future disease outbreaks.
    In this case, it seems as if the United States and the 
international community did not act aggressively soon enough. 
In March, the World Health Organization issued a notice of an 
Ebola outbreak in Guinea after the virus spread to Sierra Leone 
and Liberia. There was a lull in new cases in the spring, and 
as a result efforts waned. In June, Doctors Without Borders, a 
nongovernmental organization, declared the outbreak out of 
control. However, the World Health Organization and the 
international community did not improve on its efforts until 
August.
    According to a chart that I have here, we had a lull until 
the spike started in August of this year. Mr. Chairman, I will 
submit for the record this chart.
    Chairman McCaul. Without objection, so ordered.
    [The information follows:]
    
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
   
    
    Mr. Thompson. Thank you. Earlier I stated that an Ebola 
outbreak in the United States is not imminent. But what should 
be discussed post haste is the value of our public health 
infrastructure and the cost of maintaining it. Many times 
public health is used as a pawn for partisan bickering. 
However, Mr. Chairman, viruses such as Ebola, the flu, and EV-
D68, which has affected over 500 children in the United States, 
do not know political parties.
    Cuts to public health preparedness grants from the 
Department of Homeland Security, and Health and Human Services, 
the Centers for Disease Control, and the Office of the Surgeon 
General hit already struggling State and local health 
departments hard. As Members of Congress, we can use our 
platforms to restore grant funding and support the Federal cost 
of maintaining a public health infrastructure.
    I hope that our discussion today can yield a step in this 
direction, and I also support the Chairman's comment that this 
disease does not see party or anything. It is an American 
problem that the world needs our best minds to address. I look 
forward, Mr. Chairman, to the testimony and witnesses and yield 
back the balance of my time.
    [The statement of Ranking Member Thompson follows:]
             Statement of Ranking Member Bennie G. Thompson
                            October 10, 2014
    I want to thank the Chairman for holding this timely hearing on our 
efforts--both domestic and international--to contain and prevent the 
spread of the Ebola virus. I also thank the witnesses for appearing 
today, and I look forward to their testimony. Additionally, I want to 
thank Chair Biggins and the board of directors of the Dallas Fort Worth 
Airport and the executive staff for hosting the committee today.
    I also want to extend my condolences to the family of Thomas Eric 
Duncan, the first person diagnosed with Ebola on American soil. We are 
not here to dehumanize Mr. Duncan, but unfortunately his diagnosis and 
the procedures that followed raise critical questions about our 
preparedness for highly-infectious diseases such as Ebola and how 
Federal, State, and local authorities coordinate in their aftermath.
    As Ranking Member of this committee, I often urge my colleagues not 
to use our positions of influence to promote fear in the public. Hence, 
I want to clarify that while it is proper to have serious concerns 
about the Ebola virus, it would be irresponsible for us to foster the 
narrative that an Ebola epidemic in the United States is imminent.
    Rather, this hearing provides us the opportunity to review our 
State, local, Federal, and global public health infrastructure, learn 
where there are inconsistencies and gaps, and lay the foundation for 
eliminating these disparities. While the Ebola virus has caused the 
United States to institute new screening procedures at airports, it is 
incumbent upon us to work with our international partners to eradicate 
the virus at its origin in West Africa.
    The current Ebola outbreak is the deadliest outbreak of record. 
According to the assistant secretary general of the United Nations, it 
is also impairing national economies, wiping out livelihoods and basic 
services, and could undo years of efforts to stabilize West Africa. 
Eliminating this virus at its source is a surefire way to prevent more 
Ebola cases in the United States.
    As citizens of the global community, it is our moral obligation to 
not only eradicate this virus that is devastating West Africa, but also 
ensure that these countries can continue to function and recover. The 
United States' response to the current Ebola outbreak will affect the 
way it works to coordinate international responses to future disease 
outbreaks. In this case, it seems as if the United States and the 
international community did not act aggressively soon enough.
    In March, the World Health Organization issued a notice of an Ebola 
outbreak in Guinea after the virus spread to Sierra Leone and Liberia. 
There was a lull in new cases in the spring, and as a result, efforts 
waned. In June, Doctors Without Borders, a non-Government organization, 
declared the outbreak out of control. However, the World Health 
Organization and the international community did not improve on its 
efforts until August. According to this chart from the Washington Post, 
the rate of new cases and fatalities appears to have grown 
exponentially during this time. We must do better, and I want to learn 
how the international community will be more engaged in the future.
    Earlier, I stated that an Ebola outbreak in the United States is 
not imminent, but what should be discussed post haste is the value of 
our public health infrastructure and the cost of maintaining it. Many 
times, public health is used as a pawn for partisan bickering. However, 
viruses such as Ebola, the flu, and EV-D68 which has affected over 500 
children in the United States do not know political parties.
    Cuts to public health preparedness grants from the Departments of 
Homeland Security and Health and Human Services, the Centers for 
Disease Control, and the Office of the Surgeon General hit already 
struggling State and local health departments hard. As Members of 
Congress, we can use our platforms to restore grant funding and support 
the Federal costs of maintaining a public health infrastructure. I hope 
that our discussions today can yield a step in this direction.

    Chairman McCaul. I thank the Ranking Member for his 
thoughtful comments and spirit of bipartisanship. Other Members 
are reminded that statements may be submitted for the record.
    [The statement of Hon. Jackson Lee follows:]
               Statement of Honorable Sheila Jackson Lee
                            October 10, 2014
    Good morning. I would like to begin by thanking Chairman McCaul and 
Ranking Member Thompson, for convening this hearing on ``Ebola in the 
Homeland: The Importance of Effective International, Federal, State, 
and Local Coordination.''
    I would also like to thank all the witnesses testifying before us 
today:
   Dr. Toby Merlin, director of the Division of Preparedness 
        and Emerging Infection Office for the National Center for 
        Emerging and Zoonotic Infectious Diseases with the Center for 
        Disease Control;
   Dr. Kathryin Brisfield, acting assistant secretary for 
        health affairs and chief medical officer with the Department of 
        Homeland Security;
   John P. Wagner, acting assistant commissioner, with the 
        Office of Field Operations (OFO) with U.S. Customs and Border 
        Protection;
   Dr. David L. Lakey, commissioner, Texas Department of State 
        Health Services;
   Dr. Brett Giroir, executive vice president & CEO Texas A&M 
        Health Science Center, who is also a professor in the College 
        of Medicine at Texas A&M Health Science Center;
   Dr. Catherine L. Troisi, Ph.D., associate professor in the 
        divisions of management, policy, and community health and 
        epidimiology.
   The Hon. Clay Jenkins, judge, for Dallas County, TX.
    Thank you all for being here and sharing your expertise and 
valuable experience with us as the Nation addresses the global Ebola 
crisis and the first U.S. patient, Mr. Thomas Eric Duncan, who became 
ill with Ebola after returning from West Africa and succumbed to the 
disease.
    The topic of today's hearing clearly highlights the scope and 
responsibility of the House Committee on Homeland Security and the 
important role that the Homeland Security Department fulfills in 
protecting our Nation's people and securing our borders.
    The World Health Organization reports that the numbers of deaths 
from Ebola is approaching 4,000. Medical experts are certain that this 
number is much higher than the deaths that have been reported.
    Today, the goal of this committee, the Obama administration, and 
the governments around the world, both inside and outside of America, 
is to prevent Ebola from becoming the next AIDS.
    As a senior Member of the House Committee on Homeland Security and 
the Ranking Member of the Subcommittee on Border Security, I am pleased 
that the Centers for Disease Control, the Department of Homeland 
Security's U.S. Customs and Border Protection Agency, and the United 
States Coast Guard are coordinating to establish a new level of 
screening for international air travelers during the global Ebola 
health crisis that is impacting the United States.
    I understand this coordinated effort will add new screening 
protocols beginning Saturday, October 11, 2014 for passengers with 
flight itineraries originating in the countries of Guinea, Liberia, or 
Sierra Leone. I have requested that the George Bush Intercontinental 
Airport serving the Houston area be included among the airports where 
these protocols will be applied.
    The Ebola virus cannot be ignored, it cannot be locked away and 
kept at bay, and it must be aggressively treated at its source--in 
Africa.
    This is no time for hand-wringing or finger-pointing regarding this 
Ebola outbreak--this is the time for action. I commend this committee's 
leadership, President Obama; and the doctors and medical professionals 
who are bringing attention and resources to the forefront to stop this 
terrible disease.
    I would offer that Members of this committee must renew our efforts 
to end sequestration. We cannot wage the fight that lies ahead without 
the full measure of resources that must be brought to contain and 
ultimately end this Ebola outbreak.
    Ebola is not airborne.
    It is only transmitted through body fluids when a person is 
symptomatic,--(i.e. has a fever from the disease and experiencing other 
symptoms.)
    Incubation of the Ebola virus in victims can range from 2 to 21 
days before signs of the illness emerge.
    The Ebola virus is a single strain of RNA that is comprised of 7 
genes that can attach to healthy red blood cells, invade the blood 
cell, and use the blood cell's environment to rapidly reproduce.
    Typically a little over a week after exposure a patient may begin 
to exhibit symptoms, which include fever, chills, muscle pain, sore 
throat, weakness, and general discomfort.
    The Ebola virus attacks immune cells in the bloodstream, which take 
the infection to the liver, spleen, and lymph nodes. Ebola then blocks 
the release of interferon, a protein made by immune cells to fight 
viruses.
    At this stage of the infection, other tissues and organs can become 
compromised along with other cellular functions that disrupt vital 
organ function and autonomic processes that are carried out by cells.
    Surviving Ebola requires the body to have time for the immune 
system to figure out how to fight the Ebola virus. Patients get time 
from receiving aggressive supportive care as early as possible in the 
Ebola infection process.
    Supportive care begins with proper identification of symptoms and 
signs of the disease causing stress or distress to organs or body 
functions and using the appropriate symptom management treatments.
    Active treatment to stave off the effects of the disease can 
include:
    1. ibuprofen to address fevers;
    2. transfusion of blood to deal with bleeding, moderate to severe 
        pallor or signs of emergency circulatory shock;
    3. pain reduction; and
    4. difficulty in respiration and dehydration.
    Providing supportive care as early as possible to stabilize the 
Ebola victim and allow the patient's immune system time to learn how to 
fight the disease is the most important factor for successful recovery.
    There are several experimental treatments that have been used in 
patients, but it is too early to say whether these medicines have made 
a difference in their recoveries.
    The disease is not just a threat to the patient; it also poses a 
significant threat to first-line responders that provide critical 
health care to Ebola patients.
    Doctors Without Borders have developed a very detailed and care 
process that health care workers around the world must follow without 
deviation to make sure that they are protected, while providing care to 
Ebola patients.
    The posture of the United States must be one of vigilance, and for 
this reason, I recently wrote to President Obama to thank him for his 
leadership, both globally and Nationally, in addressing the threats 
posed by the largest Ebola outbreak in history.
    I mentioned earlier, I also requested that George Bush 
Intercontinental Airport be included on the list of airports to receive 
the enhanced Ebola screening protocols for those passengers whose 
flight itineraries indicate that the air travel originated in the 
countries of Guinea, Liberia, or Sierra Leone.
    The George Bush Intercontinental Airport serves the Houston area 
and is a major originating and connecting hub for international air 
travelers. From January to August 2014, there were 99,452 West African 
passengers traveling into and out of the George Bush Intercontinental 
Airport with a total of 1,856,421 international travelers.
    In 2013 nearly 40 million passengers traveled through the George 
Bush Intercontinental Airport of which 8.9 million were international 
travelers.
    George Bush Intercontinental Airport ranks as the 9th largest 
airport in the United States for flight operations and ranks as one of 
our Nation's busiest airports.
    I requested that George Bush Intercontinental Airport be added to 
the list of airports receiving new layers of entry screening.
    I look forward to the testimony of today's witnesses and what they 
believe we are doing to be helpful to them in their work and where we 
can do better in supporting their efforts to stop the spread of Ebola.
    Once again, I would like to thank you Chairman McCaul and Ranking 
Member Thompson for convening this hearing. I yield back the balance of 
my time.
    Thank you.

    Chairman McCaul. We have a very distinguished panel of 
experts here today. First, Dr. Toby Merlin is the director of 
the Division of Preparedness and Emerging Infections at the 
National Center for Emerging and Zoonotic Infectious Disease at 
the U.S. Centers for Disease Control and Prevention, CDC. In 
this role, he is responsible for the CDC's Laboratory Response 
Network, infectious disease emergency response coordination, 
and emerging infections epidemiology, and laboratory capacity 
programs. Thank you for being here, sir.
    Next, Dr. Kathryn Brinsfield serves as the acting assistant 
secretary of health affairs and chief medical officer for the 
Department of Homeland Security's Office of Health Affairs. She 
began her service with DHS in July 2008. She previously served 
as associate chief medical officer and director of the Division 
of Workforce, Health, and Medical Support within OHA. Prior to 
serving as acting assistant secretary, she served on a detail 
to the National security staff as the director of medical 
preparedness policy. Thank you so much for being here.
    Last, Mr. John Wagner. I want to thank you for the tour you 
gave me earlier of this facility and how you would deal with 
potential Ebola victims coming through this airport. Mr. Wagner 
became acting assistant commissioner, Office of Field 
Operations, for Customs and Border Protection in April 2014. In 
his current position, he oversees nearly 28,000 employees with 
more than 22,000 CBP Officers and CBP Ag Specialists that 
protect our borders. An annual operating budget of $3.2 billion 
provides for operations at over 329 ports of entry and programs 
that support National security, immigration, customs, and 
commercial trade related to the missions.
    The full written statements will appear in the record. The 
Chairman now recognizes Dr. Merlin for 5 minutes.

     STATEMENT OF TOBY MERLIN, M.D., DIRECTOR, DIVISION OF 
   PREPAREDNESS AND EMERGING INFECTION, NATIONAL CENTER FOR 
EMERGING AND ZOONOTIC INFECTIOUS DISEASES, CENTERS FOR DISEASE 
  CONTROL AND PREVENTION, U.S. DEPARTMENT OF HEALTH AND HUMAN 
                            SERVICES

    Dr. Merlin. Thank you, and good afternoon, Chairman McCaul, 
Members of the committee, and members of the Texas delegation. 
I appreciate the opportunity to be here today to discuss the 
current epidemic of Ebola in West Africa, as well as the work 
CDC is doing to manage the global consequences of this 
epidemic. I have been particularly involved with colleagues 
here in Dallas addressing the first U.S.-diagnosed Ebola case, 
and like you, our hearts go out to the family and friends of 
Mr. Duncan. As CDC Director Dr. Frieden noted, ``Mr. Duncan 
puts a real face on the epidemic for all Americans.''
    The Ebola epidemic in Guinea, Liberia, and Sierra Leone is 
ferocious and continues to spread exponentially. The current 
outbreak is the first that has been recognized in West Africa, 
and the biggest and most complex Ebola epidemic ever 
documented. As of last week, the epidemic surge passed 7,900 
cumulative reported cases and nearly 3,800 documented deaths, 
though we believe the numbers could be 2 or 3 times higher.
    Fortunately, the United States and others in the global 
community are intensifying our response in order to bring this 
critical situation under control. From the time the situation 
in West Africa escalated from an outbreak to an epidemic, we 
have anticipated that a traveler might arrive in the United 
States with the disease. The imported case of Ebola in Dallas 
required the CDC and the Nation's public health system to 
implement rapid response protocols that have been developed in 
anticipation of such an event.
    Within hours of confirming that the patient had Ebola, CDC 
had a team of 10 people on the ground in Dallas to assist the 
capable teams from the Texas State Health Department and local 
authorities. We have worked side-by-side with State and local 
health officials to prevent infections of others. Together, we 
assessed all 114 individuals who might have possibly had 
contact with the patient. We narrowed down the contacts to 10 
who may have been around the patient when he was infectious, 
and 30 others with whom possible infection could not be ruled 
out. These individuals are being tracked and will be tracked 
for 21 days for any signs of symptoms, and they will quickly be 
isolated if symptoms develop.
    We are also working to identify and learn lessons from the 
initial patient encounter and other events that complicated our 
response, and to apply them in any other responses. We are 
confident that our public health and health care systems can 
prevent an Ebola outbreak here, and that the authorities and 
investments provided by Congress have put us in a strong 
position to protect Americans.
    To make sure the United States is prepared as the epidemic 
in West Africa has intensified, CDC has done the following. No. 
1, it has instituted layers of protection starting in affected 
countries where our staff work intensively on airport exit 
screening. No. 2, we have provided guidance for airline 
personnel and for agents from DHS on how to identify sick 
passengers and how to manage them.
    No. 3, along with partners in DHS and State and local 
health agencies, we have continually assessed and improved 
approaches to in-bound passenger screening and management. As 
the President announced on October 6, CDC is working with DHS 
to intensify the screening at United States' airports. This is 
something my colleagues from DHS will be discussing this 
morning.
    We have worked with American hospitals to reinforce and 
strengthen infection controls. Fifth, with State health 
departments, we have intensified training and outreach to build 
awareness. Six, we have expanded lab capacity across the United 
States to test for Ebola. Seven, we have developed response 
protocols for the evaluation, isolation, and investigation of 
symptomatic individuals. We have extensively consulted to 
support evaluation, and when indicated, testing of suspected 
cases.
    We remain confident that Ebola is not a significant public 
health threat to the United States. It is not transmitted 
easily, and it does not spread from people who are not ill. It 
is possible that another infected traveler might arrive in the 
United States. Should this occur, we are confident that our 
public health and health care systems can prevent the kind of 
significant transmission of Ebola that would lead to an 
outbreak here in the United States.
    It is important to remember that the only way to protect 
Americans, though, is to end this Ebola epidemic and to 
continue our intensive focus on West Africa, and there 
implement proven public health interventions. Working with our 
partners, we have been able to stop every previous Ebola 
outbreak, and we are determined to stop this one. It will take 
meticulous work, and we cannot take shortcuts.
    Thank you again for the opportunity to appear before you 
today and for making CDC's work on this epidemic and other 
health threats possible. Thank you, Mr. Chairman.
    [The prepared statement of Dr. Merlin follows:]
                   Prepared Statement of Toby Merlin
                            October 10, 2014
    Good afternoon Chairman McCaul, Members of the committee, and 
members of the Texas Delegation. Thank you for the opportunity to 
testify before you today and for your on-going support for the Centers 
for Disease Control and Prevention's (CDC) work in global health. I am 
Dr. Toby Merlin, director of CDC's Division of Preparedness and 
Emerging Infections. I appreciate the opportunity to be here today to 
discuss the epidemic of Ebola in West Africa, as well as the work the 
CDC is doing to manage the global consequences of this epidemic in the 
wake of the first diagnosed case here in the United States 2 weeks ago, 
which ultimately and tragically, has become the first death from Ebola 
in the United States.
    From the time the situation in West Africa escalated from an 
outbreak to an epidemic, we have anticipated that a traveler could 
arrive in the United States with the disease. We have been preparing 
for this possibility by working closely with our State and local 
partners and with clinicians and health care facilities so that any 
imported case could be quickly contained. This occurrence underscores 
the need to carefully follow the protocols that have been developed, to 
work closely across levels of government, and to continue our urgent 
effort to address the epidemic in West Africa, which remains the 
biggest risk to the United States.
    As we work to learn from the recent case in Dallas and continue the 
public health response there, we remain confident that Ebola is not a 
significant public health threat to the United States. It is not 
transmitted easily, and it does not spread from people who are not ill, 
and cultural norms that contribute to the spread of the disease in 
Africa--such as burial customs--are not a factor in the United States. 
We know how to stop Ebola with strict infection control practices which 
are already in wide-spread use in American hospitals, and the United 
States is leading the international effort to stop it at the source in 
Africa. CDC is committing significant resources both on the ground in 
West Africa and through our Emergency Operations Center here at home.
    We have been constantly monitoring our response in the United 
States, and will continue to do so. The CDC and the U.S. Customs & 
Border Protection (CBP) in the Department of Homeland Security (DHS) 
announced this week that we will begin new layers of entry screening at 
five U.S. airports that receive over 94 percent of travelers from the 
Ebola-affected nations of Guinea, Liberia, and Sierra Leone. New York's 
JFK International Airport will begin the new screening October 11. In 
the 12 months ending July 2014, JFK received nearly half of all 
travelers from those three West African nations. The enhanced entry 
screening will also be implemented at Washington-Dulles, Newark, 
Chicago-O'Hare, and Atlanta international airports.
    This is a whole-of-Government response, with agencies across the 
United States Government committing human and financial resources. 
Across HHS, CDC is actively partnering with the Office of Global 
Affairs, the Office of the Assistant Secretary for Preparedness and 
Response, the National Institutes of Health, and the Food and Drug 
Administration to coordinate and respond to this epidemic. Also, CDC 
has embedded technical staff in the USAID-led DART team in West Africa. 
Additionally, staff, logistical support, and resources from the 
Department of Defense (DoD) are already being deployed to rapidly scale 
up our efforts to include constructing Ebola treatment units and 
training health care workers. We are working closely with our 
international partners to scale up the response to the levels needed to 
stop this epidemic.
    Ebola is a severe, often fatal, viral hemorrhagic fever. The first 
Ebola virus was detected in 1976 in what is now the Democratic Republic 
of Congo. Since then, outbreaks have appeared sporadically. The current 
epidemic in Guinea, Liberia, and Sierra Leone is the first time an 
outbreak has been recognized in West Africa, the first-ever Ebola 
epidemic, and the biggest and most complex Ebola challenge the world 
has ever faced. We have seen cases imported into Nigeria and Senegal 
from the initially-affected areas and we have also seen in Nigeria and 
Senegal that proven practices such as contact tracing can contribute to 
managing Ebola and preventing a small number of cases from growing into 
a larger outbreak.
    Ebola has symptoms similar to many other illnesses, including 
fever, chills, weakness and body aches. Gastrointestinal symptoms such 
as vomiting and diarrhea are common and profound, with fluid losses on 
average of 5-7 liters in 24 hours over a 5-day period. These fluid 
losses can result in life-threatening electrolyte losses. In 
approximately half of cases there is hemorrhage--serious internal and 
external bleeding. There are two things that are very important to 
understand about how Ebola spreads. First, the current evidence 
suggests human-to-human transmission of Ebola only happens from people 
who are symptomatic--not from people who have been exposed to, but are 
not ill with the disease. Second, everything we have seen in our 
decades of experience with Ebola indicates that Ebola is not spread by 
casual contact; Ebola is spread through direct contact with bodily 
fluids of someone who is sick with, or has died from Ebola, or exposure 
to objects such as needles that have been contaminated. While the 
illness has an average 8-10 day incubation period (though it may be as 
short as 2 days and as long as 21 days), we recommend monitoring for 
fever and signs of symptoms for the full 21 days. Again, we do not 
believe people are contagious during that incubation period, when they 
have no symptoms. Evidence does not suggest Ebola is spread through the 
air. Catching Ebola is the result of exposure to bodily fluids, which 
we are seeing occur in West Africa, for example, in hospitals in weaker 
health care systems and in some African burial practices. Getting Ebola 
requires exposure to bodily fluids of someone who is ill from--or has 
died from--Ebola.
    The earliest recorded cases in the current epidemic were reported 
in March of this year. Following an initial response that seemed to 
slow the early outbreak for a time, cases flared again due to weak 
systems of health care and public health and because of challenges 
health workers faced in dealing with communities where critical 
disease-control measures were in conflict with cultural norms. As of 
last week, the epidemic surpassed 7,900 cumulative reported cases, 
including nearly 3,800 documented deaths, though we believe these 
numbers may be substantially under-reported. The effort to control the 
epidemic in some places is complicated by fear of the disease and 
distrust of outsiders. Security is tenuous and unstable, especially in 
remote isolated rural areas. There have been instances where public 
health teams could not do their jobs because of security concerns.
    Many of the health systems in the affected countries in West Africa 
are weak or have collapsed entirely, and do not reach into rural areas. 
Health care workers may be too few in number or may not reliably be 
present at facilities, and those facilities may have limited capacity. 
Health care workers are at greater risk of Ebola due to conditions they 
are working in and we must work to reduce that risk. Poor infection 
control in routine health care, along with local traditions such as 
public funerals and cultural mourning customs including preparing 
bodies of the deceased for burial, make efforts to contain the illness 
more difficult. Furthermore, the porous land borders among countries 
and remoteness of many villages have greatly complicated control 
efforts. The secondary effects now include the collapse of the 
underlying health care systems resulting for example, in an inability 
to treat malaria, diarrheal disease, or to safely deliver a child, as 
well as non-health impacts such as economic and political instability 
and increased isolation in these areas of Africa. These impacts are 
intensifying, and not only signal a growing humanitarian crisis, but 
also have direct impacts on our ability to respond to the Ebola 
epidemic itself.
    Fortunately, we know what we must do. In order to stop an Ebola 
outbreak, we must focus on three core activities: Find active cases, 
respond appropriately, and prevent future cases. The use of real-time 
diagnostics is extremely important to identify new cases. We must 
support the strengthening of health systems and assist in training 
health care providers. Once active cases have been identified, we must 
support quality patient care in treatment centers, prevent further 
transmission through proper infection control practices, and protect 
health care workers. Epidemiologists must identify contacts of infected 
patients and follow up with them every day for 21 days, initiating 
testing and isolation if symptoms emerge. And, we must intensify our 
use of health communication tools to disseminate messages about 
effective prevention and risk reduction. These messages include 
recommendations to report suspected cases, to avoid close contact with 
sick people or the deceased, and to promote safe burial practices. In 
Africa, another message is to avoid bush meat and contact with bats, 
since ``spillover events,'' or transmission from animals to people, in 
Africa have been documented through these sources.
    Many challenges remain. While we do know how to stop Ebola through 
meticulous case finding, isolation, and contact tracing, there is 
currently no cure or vaccine shown to be safe or effective for Ebola. 
We are working to strengthen the global response, which requires close 
collaboration with the World Health Organization (WHO) and additional 
assistance from our international partners. At CDC, we activated our 
Emergency Operations Center to respond to the initial outbreak, and are 
surging our response. As of last week, CDC has over 139 staff in West 
Africa, and over 1,000 staff in total have provided logistics, 
staffing, communication, analytics, management, and other support 
functions. CDC will continue to work with our partners across the 
United States Government and elsewhere to focus on key strategies of 
response:
   Effective incident management.--CDC is supporting countries 
        to establish National and sub-National Emergency Operations 
        Centers (EOCs) by providing technical assistance and standard 
        operating procedures and embedding staff with expertise in 
        emergency operations. All three West African countries at the 
        center of the epidemic have now named and empowered an Incident 
        Manager to lead efforts.
   Isolation and treatment facilities.--It is imperative that 
        we ramp up our efforts to provide adequate space to treat the 
        number of people afflicted with this virus.
   Safe burial practices.--Addressing local cultural norms on 
        burial practices is one of the keys to stopping this epidemic. 
        CDC is providing technical assistance for safe burials.
   Infection control throughout the health care system.--Good 
        infection control will greatly reduce the spread of Ebola and 
        help control future outbreaks. CDC has a lead role in infection 
        control training for health care workers and safe patient 
        triage throughout the health care system, communities, and 
        households.
   Communications.--CDC will continue to work on building the 
        public's trust in health and Government institutions by 
        effectively communicating facts about the disease and how to 
        contain it, particularly targeting communities that have 
        presented challenges to date.
    The public health response to Ebola rests on the same proven public 
health approaches that we employ for other outbreaks, and many of our 
experts are working in the affected countries to rapidly apply these 
approaches and build local capacity. These include strong surveillance 
and epidemiology, using real-time data to improve rapid response; case-
finding and tracing of the contacts of Ebola patients to identify those 
with symptoms and monitor their status; and strong laboratory networks 
that allow rapid diagnosis.
    The resources provided for the period of the Continuing Resolution 
will support our response and allow us to ramp up efforts to contain 
the spread of this virus. More than half of the funds are expected to 
directly support staff, travel, security and related expenses. A 
portion of the funds will be provided to the affected area to assist 
with basic public health infrastructure, such as laboratory and 
surveillance capacity, and improvements in outbreak management and 
infection control. Should other outbreaks occur in this region, 
authorities will have the experience and capacity to respond without a 
massive external influx of aid, due to this investment. The remaining 
funds will be used for other aspects of strengthening the public health 
response such as laboratory supplies/equipment, and other urgent needs 
to enable a rapid and flexible response to an unprecedented global 
epidemic. CDC is working to identify our potential resource needs for 
the rest of the fiscal year, and possibly further, as we deal with this 
evolving situation. CDC will continue to coordinate activities directly 
with critical Federal partners, including the United States Agency for 
International Development (USAID), DoD, DHS, and non-Governmental 
organizations. Over the past few weeks, we have seen progress, as the 
DoD has begun deploying assets to the area and laying the ground work 
to construct 17 Ebola treatment facilities, train local workers to 
staff the facilities, and move supplies into the area. In addition, 
USAID is working closely with non-Governmental organizations to scale 
up efforts in all areas of the response. Currently, there are over 50 
burial teams in all 15 counties of Liberia for the management of safe 
human remains. More than 70 organizations are providing Ebola education 
and awareness in Liberia, Guinea, and Sierra Leone. Organizations are 
also working to increase infection control practices in all health 
facilities to ensure functionality of the health care system. We 
continue to work with national governments, WHO, and USAID to provide 
for interim measures such as isolation in community settings with 
proper protections, and improvements to ensure the safe burial of those 
who have died from the virus.
    Though the most effective step we can take to protect the United 
States is to stop the epidemic where it is occurring, we are also 
taking strong steps to protect Americans here at home. The imported 
case of Ebola in Dallas, diagnosed on September 30 in a traveler from 
Liberia, required CDC and the Nation's public health system to 
implement rapid response protocols that have been developed in 
anticipation of such an event. Within hours of confirming that the 
patient had Ebola, CDC had a team of 10 people on the ground in Dallas 
to assist the capable teams from the Texas State health department and 
local authorities. We have worked side-by-side with State and local 
officials to prevent infection of others. Together, we assessed all 114 
individuals who might possibly have had contact with the patient. We 
narrowed down the contacts to 10 who may have been around the patient 
when he was infectious and 38 others with whom infection cannot be 
ruled out. These individuals will be tracked for 21 days for any signs 
of symptoms, and they will quickly be isolated if symptoms develop. We 
are also working to identify and learn lessons from the initial patient 
encounter and other events that complicated our response, and to apply 
them in any other responses. We are confident that our public health 
and health care systems can prevent an Ebola outbreak here, and that 
the authorities and investments provided by the Congress have put us in 
a strong position to protect Americans. To make sure the United States 
is prepared, as the epidemic in West Africa has intensified, CDC has 
done the following:
   Instituted layers of protection, starting in affected 
        countries where our staff work intensively on airport exit 
        screening, such as temperature scanning for outbound 
        passengers.
   Provided guidance for airline personnel and for DHS Customs 
        and Border Protection Officers on how to identify sick 
        passengers and how to manage them. Though it was one of many 
        false alarms, the recent incident with an in-bound passenger to 
        Newark, New Jersey shows how CDC's quarantine station at the 
        airport worked with airline, DHS, airport, EMS, and hospital 
        personnel to assess and manage a sick passenger, and to protect 
        other passengers and the public.
   Developed guidance for monitoring and movement of people 
        with possible exposures.
   Along with partners in DHS and State and local health 
        agencies, continually assessed and improved approaches to in-
        bound passenger screening and management, and as the President 
        announced on October 6, CDC is working with DHS to enhance 
        screening measures at United States airports.
   Worked with American hospitals to reinforce and strengthen 
        infection controls, and CDC has provided checklists and 
        instructions to all health care facilities to assess patients 
        for travel history. We have also worked with State and local 
        health departments to ensure that these practices are being 
        followed.
   With State health departments, intensified training and 
        outreach to build awareness since the Dallas case.
   Through the Laboratory Response Network (LRN), expanded lab 
        capacity across the United States--in addition to CDC's own 
        world-class laboratories, 14 LRN labs now have capacity for 
        testing, ensuring that we have access to labs for timely 
        assessment--and surge capacity in case it is needed.
   Developed response protocols for the evaluation, isolation, 
        and investigation of any incoming individuals with relevant 
        symptoms.
   Extensively consulted to support evaluation and, when 
        indicated, tested suspect cases. With heightened alert, we are 
        receiving hundreds of inquiries for help in ruling out Ebola in 
        travelers--a sign of how seriously airlines, border agents, and 
        health care system workers are taking this situation. So far 
        just over a dozen of these hundreds of suspect cases have 
        required testing, and only one (the Dallas patient) has been 
        positive.
    Our top priority at CDC is to protect Americans from threats. We 
work 24/7 to do that. In the case of Ebola, we are doing that in many 
different ways here at home, but we also need to retain our focus on 
stopping the outbreak at its source, in Africa.
    Working with our partners, we have been able to stop every prior 
Ebola outbreak, and we will stop this one. It will take meticulous work 
and we cannot take short cuts. It's like fighting a forest fire: Leave 
behind one burning ember, one case undetected, and the epidemic could 
re-ignite. For example, in response to the case in Nigeria, 10 CDC 
staff and 40 top Nigerian epidemiologists rapidly deployed, identified, 
and followed 1,000 contacts for 21 days. Even with these resources, one 
case was missed, which resulted in a new cluster of cases in Port 
Harcourt. However, due to the meticulous work done in Nigeria, no new 
cases have been identified, and the outbreak appears to have been 
extinguished there.
    Ending this epidemic will take time and continued, intensive 
effort. Before this outbreak began, we had proposed, in the fiscal year 
2015 President's budget, an increase of $45 million to strengthen lab 
networks that can rapidly diagnose Ebola and other threats, emergency 
operations centers that can swing into action at a moment's notice, and 
trained disease detectives who can find an emerging threat and stop it 
quickly. Building these capabilities around the globe is key to 
preventing this type of event elsewhere and ensuring countries are 
prepared to deal with the consequences of outbreaks in other countries. 
We must do more, and do it quickly, to strengthen global health 
security around the world, because we are all connected. Diseases can 
be unpredictable--such as H1N1 coming from Mexico, MERS emerging from 
the Middle East, or Ebola in West Africa, where it had never been 
recognized before--which is why we have to be prepared globally for 
anything nature can create that could threaten our global health 
security.
    Investments in strengthening health systems in West Africa have 
been very challenging due to the low capacity of the systems. However, 
all of the donor partners agree that adequately strengthening the 
public health infrastructure in West Africa could allow such outbreaks 
to be detected earlier and contained. This Ebola epidemic shows that 
any vulnerability could have wide-spread impact if not stopped at the 
source.
    In February, the United States Government joined with partner 
governments, WHO and other multilateral organizations, and non-
Governmental actors to launch the Global Health Security Agenda (GHSA). 
Over the next 5 years, the United States has committed to working with 
over 40 partner countries (with a combined population of at least 4 
billion people) to improve their ability to prevent, detect, and 
effectively respond to infectious disease threats--whether naturally-
occurring or caused by accidental or intentional release of pathogens. 
As part of this Agenda, the President's fiscal year 2015 budget 
includes $45 million for CDC to accelerate progress in detection, 
prevention, and response, and we appreciate your support for this 
investment. We are working to evaluate the needs to strengthen the 
Ebola-affected nations and neighboring ones most at risk, and are 
asking that GHSA partners make specific commitments to establish 
capacity in West African countries in 2 or 3 years to prevent, detect, 
and rapidly respond to infectious disease threats. The economic cost of 
large public health emergencies can be tremendous--the 2003 Severe 
Acute Respiratory Syndrome epidemic, known as SARS, disrupted travel, 
trade, and the workplace and cost to the Asia-Pacific region alone $40 
billion. Resources provided for the Global Health Security Agenda can 
improve detection, prevention, and response and can potentially reduce 
some of the direct and indirect costs of infectious diseases.
    Improving these capabilities for each nation improves health 
security for all nations. Stopping outbreaks where they occur is the 
most effective and least expensive way to protect people's health. 
While this tragic epidemic reminds us that there is still much to be 
done, we know that sustained commitment and the application of the best 
evidence and practices will lead us to a safer, healthier world. With a 
focused effort, and increased vigilance at home, we can stop this 
epidemic, protect Americans, and leave behind a strong system in West 
Africa and elsewhere to prevent Ebola and other health threats in the 
future.
    Thank you again for the opportunity to appear before you today. I 
appreciate your attention to this terrible epidemic and I look forward 
to answering your questions.

    Chairman McCaul. Thank you, Dr. Merlin.
    The Chairman recognizes Dr. Brinsfield for her testimony.

   STATEMENT OF KATHRYN BRINSFIELD, M.D., M.P.H., F.A.C.E.P, 
ACTING ASSISTANT SECRETARY AND CHIEF MEDICAL OFFICER, OFFICE OF 
      HEALTH AFFAIRS, U.S. DEPARTMENT OF HOMELAND SECURITY

    Dr. Brinsfield. Chairman McCaul, Ranking Member Thompson, 
distinguished Members, thank you for inviting me to speak with 
you today. I appreciate the opportunity to testify on the 
Department of Homeland Security's role in the Federal 
Government's Ebola response. I am also honored to testify 
alongside my colleagues from the Centers for Disease Control 
and Prevention and U.S. Customs and Border Protection. I also 
want to thank the Texas State and local officials who will be 
testifying later. DHS works closely with the State of Texas on 
a number of important issues, and we appreciate their hard 
work, coordination, and collaboration.
    As you know, DHS is responsible for securing our Nation's 
borders and safeguarding the American public from communicable 
disease that threaten to traverse our borders, including Ebola. 
The DHS Office of Health Affairs is at the intersection of 
homeland security and public health with a mission to advise, 
promote, integrate, and enable a safe and secure workforce in 
the Nation in pursuit of National health security. OHA achieves 
this by enhancing the health and wellness of the DHS workforce, 
and by protecting the Nation from the health impacts of events, 
including diseases of public health significance.
    In my role as acting chief medical officer for the 
Department, I provide medical and health expertise to DHS 
components and senior leadership. In this capacity, I am 
helping to coordinate with components and provide them with 
medical advice regarding the Department's efforts in preparing 
for and responding to Ebola.
    As my CDC colleague has noted, the 2014 Ebola epidemic is 
the largest Ebola in history, and it has had devastating 
impacts in multiple West African countries, the hardest-hit 
being Liberia, Sierra Leone, and Guinea. On September 30, 2014, 
CDC confirmed the first travel-associated case of Ebola in the 
United States. The patient had traveled from Liberia to Dallas, 
Texas, connecting through the Brussels airport in Belgium and 
Dulles in Virginia. Sadly, he has since passed away.
    The patient did not have symptoms when he left Liberia, nor 
when he entered the United States, but developed them 
approximately 5 days after his arrival. The public concern 
surrounding this event and possible future public exposure to 
Ebola from international travelers is understandable, although 
it is important to remember that the CDC has stated that the 
risk of an Ebola outbreak in the United States is very low.
    The President has been focused every day on the 
Government's response, and has stated to his senior health, 
homeland security, and National security advisors that the 
epidemic in West Africa is a top National security priority. 
DHS takes this issue very seriously and has been closely 
monitoring the Ebola virus since its outbreak in April.
    We are actively engaged in the Ebola response working with 
our Federal and international partners to develop multiple 
mechanisms to allow screening at different stages of transit to 
minimize the potential spread of Ebola outside of West Africa. 
We are closely monitoring this situation, actively engaged with 
our State and local partners and adjusting our processes as 
needed.
    DHS has executed a number of measures to minimize the risk 
of individuals with Ebola from entering the United States, and 
we take a layered approach to ensure there are varying points 
at which an ill individual could be identified so that there is 
no single point of failure. To this end, DHS is also focused on 
protecting those traveling by air and taking steps to ensure 
that passengers with communicable diseases like Ebola are 
screened, identified, isolated, and quickly and safely referred 
to medical personnel. We have been working with the CDC to 
implement an additional layer of screening for travelers 
entering the United States, which is scheduled to begin this 
weekend.
    These additional screening protocols are just some of the 
many actions the Federal Government has taken in our layered 
approach to help ensure the risk of Ebola in the United States 
remains minimal. Assistant Commissioner Wagner will go into 
more detail regarding the specific measures CBP is taking, but 
I would like to highlight some other key actions we at DHS have 
taken to date and will continue to take.
    CBP and the Transportation Security Administration have 
posted messages from the CDC at select airport locations that 
provide awareness on how to prevent the spread of infectious 
disease, typical symptoms of Ebola, and instructions to call a 
doctor if the traveler becomes ill. TSA is engaging with 
industry partners and domestic and foreign air carriers to 
provide awareness on the current outbreak, and has issued an 
information circular to air carriers reinforcing the CDC's 
message on Ebola and providing guidance on identifying 
potential passengers with Ebola.
    OHA through our National Biosurveillance Integration Center 
is continuing to monitor the outbreak and is producing tailored 
Ebola products. These reports are disseminated to more than 
15,000 Federal, State, and local public health and law 
enforcement officials. The U.S. Coast Guard is monitoring 
vessels known to be inbound from Ebola-affected countries, and 
is providing information to the captain of the port, district, 
and CDC representatives.
    DHS is also committed to ensuring that our own employees 
have up-to-date information. We have provided our personnel 
with health advisories on the current outbreak, including 
impacted regions, symptoms of the virus, and mode of 
transmission, and operational procedures and precautions.
    The Department of Homeland Security has worked closely with 
its interagency partners to develop a layered approach to Ebola 
response. DHS is always assessing the measures we have in place 
and will consider additional actions moving forward if 
appropriate to protect the American people. I look forward to 
working with you to address any concerns or questions.
    [The joint prepared statement of Dr. Brinsfield and Mr. 
Wagner follows:]
     Joint Prepared Statement of Kathryn Brinsfield and John Wagner
                            October 10, 2014
    Chairman McCaul, Ranking Member Thompson, distinguished Members of 
the committee, and the Texas Delegation, we appreciate the opportunity 
to submit this statement on the U.S. Customs and Border Protection's 
(CBP) and the Office of Health Affairs' (OHA) roles in the Federal 
Government's Ebola response.
    The 2014 Ebola epidemic is the largest in history with devastating 
impacts in multiple West African countries--the hardest-hit being 
Liberia, Sierra Leone, and Guinea. In the midst of this public health 
event, it is important to remember that the Centers for Disease Control 
and Prevention (CDC) has stated that the risk of a widespread Ebola 
outbreak in the United States is very low. OHA and CBP, as part of the 
Department of Homeland Security's (DHS) overall strategy, are engaged 
on a daily basis with DHS interagency partners to prepare for and 
respond to Ebola and other potential threats to public health.
    As you know, DHS is responsible for securing our Nation's borders 
and assisting the Department of Health and Human Services (HHS) in 
safeguarding the American public from communicable diseases that 
threaten to traverse our borders. In doing so, DHS is committed to 
ensuring that our responses to the Ebola epidemic are conducted 
consistent with established civil rights and civil liberties 
protections. OHA is at the intersection of homeland security and public 
health, better known as health security. OHA provides medical and 
health expertise to DHS components and senior leadership, and is 
helping to coordinate with components and provide them with medical 
advice regarding the Department's efforts in preparing for and 
responding to Ebola. In today's remarks, we will provide an overview of 
the Department's efforts to protect the American people from Ebola, and 
CBP's specific efforts within ports of entry to identify and respond to 
travelers who may pose a threat to public health.
    As the Nation's unified border security agency, CBP is responsible 
for securing our Nation's borders while facilitating the flow of 
legitimate international travel and trade that is so vital to our 
Nation's economy. Within this broad responsibility, CBP's priority 
mission remains to prevent terrorists and terrorist weapons from 
entering the United States. CBP also plays an important role in 
limiting the introduction, transmission, and spread of serious 
communicable diseases from foreign countries.
    The President has been focused every day on this response and has 
stated to his senior health, homeland security, and National security 
advisors that the epidemic in West Africa is a top National security 
priority, and that we will continue to do everything necessary to 
address it. Because of the steps we have taken, the President 
reiterated that he is confident that the chances of an outbreak in the 
United States are extraordinarily low.
                  screening and observation protocols
    CBP and the CDC have closely coordinated to develop policies, 
procedures, and protocols to identify travelers to the United States 
who may have a communicable disease, responding in a manner that 
minimizes risk to the public. These pre-existing procedures--applied in 
the land, sea, and air environments--have been utilized collaboratively 
by both agencies on a number of occasions with positive results.
    As a standard part of every inspection, CBP Officers observe all 
passengers as they arrive in the United States for overt signs of 
illness, and question travelers, as appropriate, at all U.S. ports of 
entry. CBP Officers are trained in illness recognition by the CDC. 
Officers look for overt signs of illness and can obtain additional 
information from the travelers during the inspection interview. If a 
traveler is identified with overt signs of a communicable disease of 
public health significance, the traveler is isolated from the traveling 
public and referred to CDC's Regional Quarantine Officers or local 
public health for medical evaluation.
    It is important to note that the CDC has worked closely with 
affected countries, and CBP has provided support and assistance, to 
ensure that all out-bound travelers from the areas affected by the West 
Africa Ebola outbreak are screened for Ebola symptoms before departure. 
CDC provides ``Do Not Board'' recommendations to CBP and the 
Transportation Security Administration (TSA) regarding individuals who 
may be infected with a highly contagious disease, present a threat to 
public health, and should be prevented from traveling via commercial 
aircraft. TSA is performing vetting of all airline passengers coming 
to, departing from or flying within the United States to identify 
matches to the ``Do Not Board'' list and flag matched individuals' 
records in the Secure Flight system to prevent the issuance of a 
boarding pass. TSA is also supporting CDC requirements to identify all 
passenger reservations on flights where it has been determined that one 
or more passengers present an Ebola risk, such as when passengers have 
traveled from the affected African areas and have exhibited Ebola 
symptoms.
                  additional ebola screening measures
    Although we have recently seen the first cases of Ebola virus in 
the United States, the CDC believes that the U.S. clinical and public 
health systems will work effectively to prevent the spread of the Ebola 
virus. DHS has executed a number of measures to minimize the risk of 
those sick with Ebola entering the United States, and we take a layered 
approach to ensure there are varying points at which an ill individual 
could be identified. To this end, DHS is also focused on protecting the 
air traveling public and taking steps to ensure that travelers with 
communicable diseases like Ebola are identified, isolated, and quickly 
and safely referred to medical personnel.
    On October 21, DHS announced travel restrictions in the form of 
additional screening and protective measures at our ports of entry for 
travelers from the three Ebola-affected countries in West Africa. As of 
October 22, all passengers arriving in the United States whose travel 
originated in Liberia, Sierra Leone, or Guinea are required to fly into 
one of five airports including New York John F. Kennedy; Washington 
Dulles; Newark; Chicago O'Hare; and Atlanta International Airport. DHS 
is working closely with the airlines to implement these restrictions 
with minimal travel disruption.
    At these five airports, all travelers from the affected countries 
undergo enhanced screening measures consisting of targeted questions 
and a temperature check, through the use of non-contact thermal 
thermometers, seeking to determine whether the passengers are 
experiencing symptoms or may have been exposed to Ebola. Detailed 
contact information is also collected in the event the CDC needs to 
contact them in the future. If there is reason to believe a passenger 
has been exposed to Ebola, either through the questionnaire, 
temperature check, or overt symptoms, CBP refers the passenger to CDC 
for further evaluation. The CDC has surged staff to these airports to 
support this mission requirement.
    In addition to these measures, CBP Officers are asking all 
passengers traveling on a passport from Liberia, Sierra Leone, and 
Guinea, regardless of where they traveled from, whether they have been 
in one of the three countries in the prior 21 days. If the traveler has 
been in one of the three countries in the prior 21 days, he or she will 
be referred for additional screening and, if necessary, CDC or other 
medical personnel in the area will be contacted pursuant to existing 
protocols.
    The U.S. Coast Guard is also monitoring vessels known to be in-
bound from Ebola-affected countries, and is providing information to 
the Captain of the Port, District, and CDC representatives.
    The CDC maintains Federal jurisdiction to determine whether to 
isolate or quarantine potentially-infected arrivals. DHS personnel may 
be called upon to support the enforcement of the CDC's determinations, 
and we stand ready to help.
                    information sharing and training
    DHS has prioritized sharing information and raising awareness as 
important elements in combating the spread of Ebola, and CBP has a 
unique opportunity to deliver critical information to targeted 
travelers from the affected countries in ports of entry. Secretary 
Johnson recently directed CBP to distribute health advisories to all 
travelers arriving in the United States from the Ebola-affected 
countries of Liberia, Sierra Leone, and Guinea. These advisories 
provide the traveler with information on Ebola, health signs to look 
for, and information for their doctor should they need to seek medical 
attention in the future.
    CBP and TSA have posted messages from the CDC at select airport 
locations that provide awareness on how to prevent the spread of 
infectious disease, typical symptoms of Ebola, and instructions to call 
a doctor if the traveler becomes ill in the future.
    We also share information with our non-Governmental and State and 
local partners. TSA is engaging with industry partners and domestic and 
foreign air carriers to provide awareness on the current outbreak, and 
has issued an Information Circular to air carriers reinforcing the 
CDC's message on Ebola and providing guidance on identifying potential 
travelers with Ebola.
    OHA, through the National Biosurveillance Integration Center, is 
continuing to monitor the outbreak to coordinate information in 
response to the event. These reports on biological events are 
disseminated to more than 15,000 Federal, State, and local users, many 
of whom work in the public health sector or support 78 fusion centers 
across the Nation, helping to ensure that the most up-to-date 
information is available.
    DHS is committed to ensuring that our own employees have up-to-date 
and accurate information. We have provided our own personnel with 
background information on the current outbreak, information on the 
regions of importance; symptoms of the virus and mode of transmission; 
and operational procedures and precautions for processing travelers 
showing signs of illness. CBP field personnel will be kept up to date 
on National, regional, and location-specific information on Ebola 
preparedness and response measures through regular field musters. CBP 
has provided guidance to the field on baggage inspection for 
international travelers from impacted countries, proper procedures for 
inspection and handling of prohibited meat products, and proper 
safeguarding and disposal of garbage from all in-bound international 
flights.
    CBP Officers receive the CDC's public health training, which 
teaches officers to identify symptoms and characteristics of ill 
travelers. CBP also provides operational training and guidance to 
front-line personnel on how to respond to travelers with potential 
illness, including referring individuals who display signs of illness 
to CDC quarantine officers for secondary screening, the use of personal 
protective equipment (which is available for employees at these 
airports along with instructions for use), as well as training on 
assisting CDC with implementation of its isolation and quarantine 
protocols. CBP Officers are trained to employ universal precautions, an 
infection control approach developed by the CDC, when they encounter 
individuals with overt symptoms of illness or contaminated items in 
examinations of baggage and cargo. Universal precautions assume that 
every direct contact with body fluids is infectious and requires 
exposed employees to respond accordingly. TSA also ensures that its 
employees are adequately trained and, where appropriate, are provided 
personal protective equipment. The health and safety of DHS employees 
is also our priority as we carry out this critical mission.
                               conclusion
    The Department of Homeland Security has worked closely with its 
interagency partners to develop a layered approach to identifying ill 
travelers and protecting the air traveling public. DHS is always 
assessing the measures we have in place and continues to look at any 
additional actions that can be taken to ensure the safety of the 
American people. We look forward to working with you to address this 
problem collaboratively. We will continue to closely monitor the Ebola 
outbreak, and will evaluate additional measures as needed.
    We thank you for your time and interest in this important issue. We 
look forward to answering your questions.

    Chairman McCaul. Thank you, Dr. Brinsfield.
    Mr. Wagner, you are recognized for 5 minutes.

STATEMENT OF JOHN WAGNER, ACTING ASSISTANT COMMISIONER, OFFICE 
 OF FIELD OPERATIONS, U.S. CUSTOMS AND BORDER PROTECTION, U.S. 
                DEPARTMENT OF HOMELAND SECURITY

    Mr. Wagner. Thank you, Chairman McCaul, Ranking Member 
Thompson, and distinguished Members of the committee for the 
opportunity to discuss the efforts of U.S. Customs and Border 
Protection in deterring the spread of Ebola by means of 
international travel.
    Each day CBP processes over 1 million people into the 
United States. About 280,000 of them enter at our international 
airports each day. CBP is responsible for securing our Nation's 
borders while facilitating the flow of legitimate trade and 
travel that is so vital to our Nation's economy.
    Within this broad responsibility, our priority mission 
remains to prevent terrorists and terrorist weapons from 
entering the United States. However, we also play an important 
role in limiting the introduction, transmission, and spread of 
serious communicable diseases from foreign countries. We have 
had this role for over 100 years, and as travel and threats 
change, CBP has changed as well.
    In coordination with CDC, we have modern protocols in place 
for well over a decade that have guided response to a variety 
of a significant health threats over recent years. CBP Officers 
at all ports of entry assess each traveler for overt signs of 
illness. In response to the recent Ebola virus outbreak in West 
Africa, CBP in close collaboration with the DHS Office of 
Health Affairs and the Centers for Disease Control and 
Prevention is working to ensure that front-line officers are 
provided the information, training, and equipment needed to 
identify and respond to international travelers who may pose a 
threat to public health.
    All CBP Officers are provided guidance and training on 
identifying and addressing travelers with any potential 
illness, including communicable diseases, such as the Ebola 
virus. CBP Officer training includes CDC public health 
training, which teach officers to identify through visual 
observation and questioning the overt symptoms and 
characteristics of ill travelers.
    CBP also provides operational training and guidance on how 
to respond to travelers with potential illness, including 
referring individuals who display signs of illness to CDC 
quarantine officers for secondary screening, as well as 
training on assisting CDC with implementation of its isolation 
and quarantine protocols. Additionally, CBP provides web-based 
training for its front-line personnel, covering key elements of 
CBP's blood-borne pathogens, exposure control plan, protections 
from exposure, use of personal protective equipment, and other 
preventive measures and procedures to follow in a potential 
exposure incident.
    We are committed to ensuring our field personnel have the 
most accurate, updated information regarding the Ebola virus. 
Since this outbreak began, CBP field personnel have been 
provided a steady stream of guidance starting with initial 
information on the current outbreak at the beginning of April 
this year with numerous and regular updates since then. We have 
provided field personnel information on the regions of 
importance, the symptoms of the virus, and modes of 
transmission, and operational procedures and precautions for 
processing passengers showing signs of illness.
    We will continue to provide our officers National, 
regional, and location-specific----
    Voice. Is your mic on, sir?
    Mr. Wagner. Yes.
    Voice. Can you lift your mic up?
    Mr. Wagner. Absolutely. Sorry.
    Voice. Thank you.
    Mr. Wagner. We will continue to provide our officers 
National, regional, and location-specific information on Ebola 
preparedness and response measures through field musters. We 
have also provided guidance to the field on baggage inspection 
for travelers from impacted countries, proper procedures for 
inspection and handling of prohibited meat products, and proper 
safeguard against disposal of garbage from all in-bound 
international flights.
    Information sharing is critical, and CBP continues to 
engage with health and medical authorities at the National, 
State, and local level. Since January 2011, CDC's Division of 
Global Migration and Quarantine has stationed a liaison officer 
at the CBP National Targeting Center to provide subject-matter 
expertise and facilitate requests for information between the 
two organizations. CBP has also been actively engaged with the 
air carrier industry and other Federal partners regarding Ebola 
preparedness and potential response operations.
    Now, in response to the current outbreak, CBP identifies 
travelers whose travel originated in or transited through 
Guinea, Liberia, and Sierra Leone. Starting October 1, CBP 
began providing a CDC Ebola travel health alert notice to 
travelers entering the United States from these affected 
countries. This information notice provides the traveler 
information and instructions should he or she have a concern of 
possible infection.
    In addition to visually screening all passengers for overt 
signs of illness, starting October 11, CBP and CDC will begin 
enhanced screening of travelers from the three affected 
countries entering JFK Airport given that a significant number 
of travelers from the affected countries enter at JFK. In 
coordination with CDC, these targeted travelers will be asked 
to complete a CDC questionnaire, provide contact information, 
and have their temperature checked. Based on these enhanced 
screening efforts, CDC Quarantine Officers will make a public 
health assessment.
    These enhanced efforts will roll out next week at Dulles, 
O'Hare, Atlanta, and Newark. Combined approximately 94 percent 
of all travelers from the affected countries entering the 
United States come through these five airports. CBP will 
continue to screen for overt signs of illness on all 
passengers, and will also provide Ebola tear sheets to 
travelers at all other locations who come in from these 
affected countries.
    While CBP Officers receive training in illness recognition 
and response, if they identify an individual believed to be 
ill, we will separate the traveler from the public and contact 
the local CDC Quarantine Officer along with local public health 
authorities to help with a further medical assessment.
    CBP will continue to monitor the Ebola outbreak, provide 
timely information and guidance to our field personnel, and 
work closely with DHS and our interagency partners to develop 
or adopt measures as needed to deter the spread of Ebola in the 
United States. So thank you for the opportunity to testify 
today, and thank you for the attention you are giving to this 
very important issue. I am happy to questions.
    Chairman McCaul. Thank you. The Chairman recognizes himself 
for questions. You know, like any threat overseas, we would 
rather eliminate that threat before it can get into the United 
States, and this threat is no exception.
    I commend the efforts overseas in Africa to contain and 
control this. Part of that effort are flights into western 
Africa with health care officials to help stop the spread of 
this viral disease. But many of my constituents and many 
Americans are asking the question, why are we not banning all 
flights from West Africa into the United States. So, Dr. 
Merlin, I want to give you an opportunity to answer that 
question. Why should we not ban all flights from West Africa 
into the United States?
    Dr. Merlin. Mr. Chairman, I appreciate the opportunity to 
speak to that because I know it is a concern of many people. 
The disease outbreak in Liberia, Guinea, and Sierra Leone is 
now at a point where we may be able to stop it if we focus our 
efforts and our resources on stopping it. In order to stop it, 
we need uninhibited transit into and out of the country so that 
we can bring the resources there to bear that are needed to 
stop it, as well as to keep the countries from collapsing.
    If we do not do that, the disease will grow exponentially. 
Our projections are there could be from 400,000 to 1.4 million 
cases by the end of the year if we do not do anything. There is 
no way in that circumstance to prevent disease from spilling 
from those countries into neighboring countries and then out 
into the rest of the world. So our opportunity now is to get 
the disease at its source. What we want is to not do things 
that may give the appearance currently of protecting us, but 
actually put us at greater risk later on by allowing the 
disease to grow there.
    Chairman McCaul. I appreciate that. Dr. Brinsfield.
    Dr. Brinsfield. So, sir, we work closely with our partners 
in CDC. We work through an interagency process with this. DHS 
is prepared to take any steps necessary, but want to make sure 
that we defer the public health expertise in this issue to CDC.
    Chairman McCaul. Dr. Merlin, you said that this is not a 
significant health threat to the United States, I believe, in 
your testimony. Dr. Brinsfield, you said the risk is very low. 
I wanted to see if you could elaborate on that and explain how 
this deadly, wicked virus is actually transmitted.
    Dr. Merlin. Thank you, Mr. Chairman. As you say, the virus 
is a horrible virus because it causes horrible disease. In 
people who are infected, it has a high mortality rate. But we 
know a lot about this virus, and we know from 40 years' 
experience how to stop outbreaks of this virus. The virus is 
acquired by people by direct contact from infected individuals 
who are symptomatic. They do not get the disease from contact 
with people who are asymptomatic. It is often contacted by 
people caring for an individual who is infectious and sick.
    After acquisition, there is an incubation period where the 
person who has acquired the virus is not him or herself 
symptomatic. That incubation period ranges usually about 8 to 
11 days. It can be shorter. It can be longer. But then when the 
person develops symptoms, and only when the person develops 
symptoms, is the person capable of spreading the disease to 
other individuals.
    Chairman McCaul. Dr. Brinsfield.
    Dr. Brinsfield. I would agree, sir. I would also point out 
as the USAID director has stated, this is a disease that preys 
on poor public health and poor public infrastructure. We have 
excellent public health and public infrastructure in this 
country.
    Chairman McCaul. As I understand, it is bodily fluid 
contact rather than influenza, which would be airborne.
    Dr. Brinsfield. That is correct, sir. That is our current 
knowledge.
    Chairman McCaul. I think a lot of people want to know at 
what point are we going to have a treatment, or a cure, or 
vaccine for this disease. Where are we? What is the latest on 
that?
    Dr. Merlin. Mr. Chairman, I will provide a brief overview. 
There are a number of investigational countermeasures that are 
being explored for either vaccinating to prevent Ebola or drugs 
or biologics that can be used to treat Ebola. The time course 
when those would be available on a size and scale to treat 
large populations is fairly prolonged. The clinical trials with 
a vaccine will not take place until early next year.
    Chairman McCaul. I would hope that the clinical trials 
would be expedited in this case.
    Dr. Merlin. They are being expedited as quickly as 
possible. I should, you know, also say that this work is not 
work that CDC itself does, but it is work that is done by NIH 
and BARDA. They can provide more details on it. The point I 
wanted to make is that these countermeasures, although they may 
be available on an investigational new drug basis to treat 
occasional cases in the United States and occasional cases in 
Africa now, they are not a method that we can use now to attack 
the outbreak, the epidemic in Africa. What we need to use now 
is the standard public health methods of isolating infectious 
people so they do not spread the disease to other individuals, 
and safe burials of people because their bodies are infectious 
and they need to be handled appropriately.
    Chairman McCaul. Lastly, Dr. Brinsfield, in the Clinton and 
Bush administrations, they had a senior biodefense advisor in 
the White House to coordinate Federal, State, and local 
efforts. That position was eliminated in the current 
administration. Do you know why that was eliminated, and who is 
responsible now for coordinating at the Federal, State, and 
local level?
    Dr. Brinsfield. I think, sir, that we have a very robust 
interagency process. We have meeting regularly on this issue 
and this particular disease for months. We believe very 
strongly that the different and varied expertises available are 
all necessary to come to the table and make educated decisions.
    Chairman McCaul. I thank you. The Chairman now recognizes 
the Ranking Member.
    Mr. Thompson. Thank you very much, Mr. Chairman. When I 
left the Jackson, Mississippi airport this morning, the news 
talked about this hearing. A number of people saw me, and they 
wanted to know: Is it safe, what do I have to have? So needless 
to say, it is on the minds of a lot of people in this country.
    To that extent, Dr. Merlin, I think it is important that to 
the extent that we can sing off the same page of music as we 
push information out, the better off we are. Can you provide 
this committee with how that process works from a public health 
standpoint and notification to State and local partners around 
the country?
    Dr. Merlin. Mr. Thompson, I will tell you how the process 
works for identification of cases. Is that what you would like 
me----
    Mr. Thompson. That is fine.
    Dr. Merlin. Okay. We have worked with our Federal partners 
and our State and local partners to distribute information to 
health departments, to health department personnel, as well as 
to hospitals and physicians on the signs and symptoms of Ebola, 
the travel history that is there for Ebola, and how to detect 
Ebola infections.
    We on our website have provided a checklist for facilities. 
We have provided guidance for facilities on how to do this. We 
have provided guidance on how facilities and physicians should 
handle an individual who they think is suspected of Ebola and 
how they can place them in isolation immediately so that they 
do not infect others, and we have provided testing for Ebola 
diagnostics around the country. We offer 24/7 consultative 
services through the CDC for people who have questions about 
how to handle a suspected case. Am I addressing your----
    Mr. Thompson. That is it, but I want to go to a simpler 
reference. Some people are saying, well, we had two people to 
come and get treated from West Africa who lived, and Mr. Duncan 
came and died. The public is trying to say, what happened? I 
think we have to somehow provide a level of confidence to the 
public that the difference is still part of the system. Can you 
help me, if not other Members of the committee, with a response 
for that?
    Dr. Merlin. Yes, I will. Ebola is a horrible disease, as 
many people have said. The virus infects many parts of the body 
and interferes with the functions of many parts of the body. It 
is in the gastrointestinal tract. It is in the heart. It is in 
the liver. It is in the skin. People develop profound diarrhea 
and profound nausea and vomiting. The outcome of untreated 
Ebola cases is a mortality of from 50 to 90 percent, depending 
on a number of factors, including the age of the person.
    We have limited experience with treating Ebola with our 
developed medical system, and the outcomes are dependent on a 
number of factors. A lot have to do with preexisting illness in 
the patient, how quickly after onset of symptoms the patient 
receives therapy. So I wish we had the assumption that every 
person who comes down with Ebola who gets Western-style 
medicine would survive, but I do not think that is the case.
    Mr. Thompson. Thank you. Mr. Wagner, you talked a little 
bit about this enhanced screening that we will start 
implementing. I want to give you a scenario, and I want you to 
help me with an answer. If someone buys a ticket in West Africa 
to Brussels and then buys another ticket from Brussels to the 
United States, will that enhanced targeting pick that person 
up, or is that still a vulnerability we need to address?
    Mr. Wagner. It could be a vulnerability depending on how 
the airline has provided us with the information. If it is a 
continuous ticket, we will absolutely see it. If it is multiple 
tickets, we may not. In that case, we would use our officer 
that interviews the person when they arrive in the United 
States, and they flip through the passport booklet to look for 
stamps to see where they have been.
    Everyone goes through a series of questions just about 
purpose and intent of travel, so we may ask the person, you 
know, how long were they were in Brussels and what were they 
doing there. When the answer is, well, I was transiting there, 
we could ask from where. So from our questioning we should be 
able to determine where that travel originated. Also on the 
customs declaration, we ask people what countries they are 
traveling from and where they have been to. So there are a few 
different ways we would find that out.
    Mr. Thompson. Thank you. Yield back, Mr. Chairman.
    Chairman McCaul. The Chairman now recognizes Mr. Chaffetz.
    Mr. Chaffetz. Thank you. I thank the Chairman and the 
Ranking Member for holding this hearing on such an important 
topic. Mr. Wagner, I would like to start with you by first 
recognizing the people in Customs and Border Protection, the 
men and women who do a very difficult job, very demanding job 
day in and day out. We appreciate, love them, and care for 
them. They have our thoughts and prayers as they have a very 
tough duty, and then to add this on top of it is obviously----
    I want to talk about the legal authority and what you are 
able to do. Being sick is not illegal, but if they are coming 
here and they are from a suspected region, a suspected country, 
and they do appear to be sick, and they do not want to be 
detained, if they do want to, what can you do and not do?
    Mr. Wagner. So if they are not a U.S. citizen or permanent 
resident, some of our immigration authorities allow us to 
declare someone inadmissible to the United States if they have 
certain communicable diseases. Other than that, you know, we do 
screening of all the people just for overt signs of illness in 
general, and then we can work with CDC on some of their 
authorities to detain and quarantine or isolate sick travelers 
that would have it.
    Mr. Chaffetz. So if somebody is appearing to be sick and 
they are a United States citizen, but they have been in, say, 
Liberia, what can you do or not do at that point?
    Mr. Wagner. We would closely with CDC then and use some of 
their authorities to get----
    Mr. Chaffetz. But what is that authority? I am just 
wondering how far you can take this, what you can do or not do.
    Dr. Merlin. I am not a person at CDC who is familiar with 
all of CDC's quarantine authorities. But CDC has statutory 
authority to quarantine people who are suspected of having 
infectious diseases that are a risk to the public health. We 
can do that through any of our quarantine stations, and we can 
work with CBP so that----
    Mr. Chaffetz. So can you help me understand what the 
standard is? Is it going to be if you have traveled to those 
countries, if you have the sniffles? What is the standard?
    Dr. Merlin. No. I will have to get back to you on the exact 
details of that. It certainly is more than you say. It would 
have to be, you know, a reasonable suspicion that the person 
could cause harm and infect other individuals by entering the 
country, and the person needs to be placed in isolation.
    Mr. Chaffetz. So if they are a United States citizen, not a 
United States citizen, does that come into play?
    Dr. Merlin. Not from our perspective. If they are a threat 
to the public health and they need to be in isolation, we will 
exercise our legal authority.
    Mr. Chaffetz. So what determines the threat to public 
health?
    Dr. Merlin. That is an area that I am afraid I do not know, 
and I----
    Mr. Chaffetz. But if you do not know, how are the men and 
women are supposed to, you know, be screening somebody in 2 
minutes and they have got a line of 12 people behind them, they 
are pressured. If you, Dr. Merlin, do not know that, how are 
Mr. Wagner's people supposed to figure it out?
    Dr. Merlin. I wish I knew all of these things in detail, 
but we actually a division of people who focus on quarantine 
and migration.
    Mr. Chaffetz. I guess my concern is we are starting this 
new process. You have articulated the need, and if you do not 
know it, how is Mr. Wagner's--by the thousands we have to train 
and teach people how to identify this and then pull the right 
people out of a line. So when will you have that?
    Dr. Merlin. Well, fortunately Mr. Wagner works with people 
at CDC who do know this.
    Mr. Chaffetz. Okay. So, Mr. Wagner, what is the answer to 
this question?
    Mr. Wagner. So, we will identify the travelers with the 
overt symptoms. We then contact CDC for the medical 
professionals to make that determination as to what meets that 
standard and what the follow-up care is going to be.
    Mr. Chaffetz. Is that only going to happen at the five 
ports? What if it happens in Salt Lake City, and they are 
coming out?
    Mr. Wagner. We do that at all our locations now.
    Mr. Chaffetz. There is a CDC representative at every port 
of entry.
    Mr. Wagner. No, we have 20 locations where they are located 
at. But we have contact information for them at all of our 
ports of entry, and if we encounter a traveler that has overt 
signs of illness, we will contact CDC and coordinate with them.
    Mr. Chaffetz. So you are going to hold those people until 
CDC shows up?
    Mr. Wagner. We potentially could depending on the nature of 
what it is. That----
    Mr. Chaffetz. So if they have got a high fever, they are 
from Liberia, and they are showing up, they are trying to walk 
through the port at Nogales, what are you going to do?
    Mr. Wagner. I would think we would stop them and call CDC 
and contact them until we could get some medical guidance about 
what they wanted to do with that person. But at the end of the 
day, that is going to be the medical professionals that make 
those determinations, not CBP.
    Mr. Chaffetz. Mr. Chairman, I guess the encouragement here 
is somehow we need to CDC to come up with some really, good 
teachable standards so that the people in Mr. Wagner's Customs 
and Border Protection actually know what to look for and then 
what to actually do. If we do not have that information, we are 
going to make this job impossible. So, again, I thank you for 
holding this hearing, and I yield back.
    Chairman McCaul. Yes, and for clarification, though, Dr. 
Merlin, you said there is a division devoted to this legally.
    Dr. Merlin. Yes. There is an entire division at CDC that is 
devoted to quarantine and migration.
    Chairman McCaul. Do they coordinate with CBP?
    Dr. Merlin. They coordinate with CBP. What I would do if 
the question were asked of me by someone in the CBP section, I 
would immediately get in touch with someone who knows the 
answer to this question.
    Chairman McCaul. The Chairman now recognizes the gentlelady 
from Texas, Ms. Jackson Lee.
    Ms. Jackson Lee. Mr. Chairman and Ranking Member, let me 
thank you very much for this vital hearing and the expression 
of the concern of the Members of the United States Congress. I 
thank my colleagues for their presence. I particularly, again, 
as I note thank my Chairman and Ranking Member, and I thank 
several Members that are from this region. I thank them so very 
much for their engagement and participation in this on-going 
challenge.
    I know that we will see some of our local officials on the 
second panel, but I want to acknowledge them now and appreciate 
all the work that the county and all of the first responders 
have done in this community. We need to express our 
appreciation to them. Certainly I thank all of you for your 
presence here today and the very valiant work that you have 
done.
    Ten days ago I was at Bush Intercontinental Airport, and I 
raised the red flag, not the historical flag, as I was able to 
be escorted by Customs and Border Protection to look at the 
very fine men and women who work there. I visited the 
containment unit by CDC. We were told on the day that I visited 
that my CDC team was here in Dallas. I saw the equipment that 
was there. I went down to the sub-basement to look at the 
amount of equipment. When I say ``equipment,'' I think it is 
the Tyvek suits that are there to ensure that both CDC and 
others have it. So I think that it is important for the 
American public to know that stocked in many of the airports is 
this kind of equipment, but I raised the red flag to ensure 
that there was this kind of screening.
    Publicly today I am going to make a request and think there 
was an error made by not designating Bush Intercontinental 
Airport as one of the sites to have this enhanced screening. I 
have made a request to the President, and to the Secretary, and 
to the Centers for Disease Control, and I hope that this will 
be responded to. Again, this is a red flag. This is not 
hysteria. It is based upon the travel that comes into Bush 
Intercontinental Airport.
    Let me also say that it is not West Africa, and all of us 
must be restrained in how we define it. It is particular 
countries such as Guinea, Liberia at this time, and Sierra 
Leone. In fact, I offer this headline that says ``Sierra Leone 
Leader Pleads for Ebola Aid,'' which means that we are 
interrelated.
    The President has done a remarkable job, and I want to 
thank him for the 130 civilians, the ETU units. These are the 
containment units that have been set up. The 50 site burial 
teams, and of course, $350 million and another $700 million, I 
believe, that I hope that the Congress and all of us will 
convince the Congress to support. I especially want to thank 
the men and women of the United States military, particularly 
from Fort Bliss and Fort Hood that are now on their way or soon 
to be on their way.
    But let me raise this question. I took the time to talk to 
some of our medical professionals at Baylor and the Harris 
Health System, which is our county health system. They 
indicated that--let me stop for a moment and join my colleague 
by expressing my sympathy to Mr. Duncan's family, and, again, 
pray for them as they mourn his passing, and take a moment to 
do that.
    But I want to just relate to you where I think 
infrastructure and practical implementation may be two distinct 
things. We have the greatest health system in the world, but 
are we practically prepared? I do not think that we are 
practically prepared, and that is why we are having this 
oversight hearing.
    If you have any indication of an Ebola patient, I would 
think with not any condemnation, you clear out any hospital. 
Patients are not going to come. So the question is: Do we need 
to--Dr. Merlin, I just need a yes or no--do we need to put 
contagion units together?
    I hear from my health professionals in this flu season that 
hospitals are saying when persons have those similar symptoms 
and they are just an average citizen, that they are getting 
pushback on the ambulances to bring people with those kinds of 
symptoms. You have already indicated it is vomiting. It is 
quite different, but they are alike, similar. Do you think it 
would be appropriate to have those kinds of units? I know you 
are seeing them in the hospitals. Do you think they need to be 
separately placed?
    Dr. Merlin. I understand the question, and, no, I think 
that all facilities need to be able to care for people who 
present to those facilities for care. We cannot rely on 
individuals to present to selected facilities. All facilities 
need----
    Ms. Jackson Lee. Let me go on----
    Dr. Merlin. Sure.
    Ms. Jackson Lee [continuing]. To the next question, and I 
want to ask one to Mr. Wagner before my runs out. This question 
goes to the two medical persons. I am told that in a survey by 
nurses that they are telling me across the country, 80 percent 
are saying that the hospitals have not communicated to them any 
policy regarding potential admission of patients infected by 
Ebola. Eighty-five percent say their hospital has not provided 
education on Ebola with the ability for the nurses to interact. 
I am going to ask to put this into record. One-third say their 
hospital has insufficient supplies of eye protection, face 
shields, et cetera.
    Chairman McCaul. Without objection.
    [The information follows:]
    Press Release Submitted For the Record by Honorable Jackson Lee
  even after dallas, hospitals still lagging in preparation for u.s. 
                             ebola patients
National Nurses United Press Release, 10/6/14
            85% say their hospital has not provided proper training, 
                    education in response to possible Ebola infection
    News of the first confirmed patient in the U.S. infected with the 
Ebola virus still has not led to effective communication with 
registered nurses who would be among the first to respond and interact 
with patients possibly infected, according to survey responses from at 
least 1,400 registered nurses across the U.S.
    National Nurses United is stepping up the call on U.S. hospitals to 
immediately upgrade emergency preparations for Ebola in this country.
    ``Nurses know that what is critical now in the face of this deadly 
disease is to spread readiness, not fear. It is Ebola today, but other 
infectious diseases are not far away. All hospitals need to take steps 
now to protect patients, frontline caregivers, and public safety,'' 
said Bonnie Castillo, RN, who directs NNU's disaster relief program, 
Registered Nurse Response Network.
    Several weeks ago, National Nurses United began surveying 
registered nurses across the U.S. about emergency preparedness. Most of 
the nurses are telling NNU that they remain unaware of proper 
preparation for the Ebola virus.
    As of Monday morning, about 1,400 RNs at more than 250 hospitals in 
31 states have responded to the NNU national survey. Notably, the 
number of RNs responding has more than tripled since the news of the 
Dallas case--and yet the overwhelming number of RNs voicing concern 
over lack of preparedness at their hospitals has showed virtually no 
improvement.
    Current findings show:
   Nearly 80 percent say their hospital has not communicated to 
        them any policy regarding potential admission of patients 
        infected by Ebola.
   85 percent say their hospital has not provided education on 
        Ebola with the ability for the nurses to interact and ask 
        questions.
   One-third say their hospital has insufficient supplies of 
        eye protection (face shields or side shields with goggles) and 
        fluid resistant/impermeable gowns.
   Nearly 40 percent say their hospital does not have plans to 
        equip isolation rooms with plastic covered mattresses and 
        pillows and discard all linens after use, fewer than 10 percent 
        said they were aware their hospital does have such a plan in 
        place.
    NNU is calling for all U.S. hospitals to immediately implement a 
full emergency preparedness plan for Ebola, or other disease outbreaks. 
That includes:
   Full training of hospital personnel, along with proper 
        protocols and training materials for responding to outbreaks, 
        with the ability for nurses to interact and ask questions.
   Adequate supplies of Hazmat suits and other personal 
        protective equipment.
   Properly equipped isolation rooms to assure patient, 
        visitor, and staff safety.
   Proper procedures for disposal of medical waste and linens 
        after use.
    ``Handing out a piece of paper with a link to the Centers for 
Disease Control, or telling nurses just to look at the CDC website--as 
we have heard some hospitals are doing--is not preparedness. Hospitals 
can and must do better, and we should have uniform national standards 
and readiness,'' Castillo said.
    The Dallas case, where the infected patient was sent home after 
arriving at the hospital, hardly provides any reassurance, said NNU.
    Media reports have indicated that the Dallas patient's exposure was 
not properly communicated to hospital staff. But, Castillo added, it's 
not just a failure to communicate, but also a reminder that hospitals 
should not just rely on automated protocols with computerized scripts 
for interacting with patients.
    ``It's time to move from the electronic computer plan to a national 
healthcare action plan,'' said Castillo. ``We have the expert nurses 
and physicians, we have to train and drill with the whole team, from 
triage to treatment to waste disposal.''
    ``As we have been saying for many months, electronic health records 
systems can, and do, fail. That's why we must continue to rely on the 
professional, clinical judgment and expertise of registered nurses and 
physicians to interact with patients, as well as uniform systems 
throughout the U.S. that are essential for responding to pandemics, or 
potential pandemics, like Ebola,'' Castillo said.
    Finally, Castillo said criminalizing the patient in Dallas or 
elsewhere is ``exactly the wrong approach and will do nothing to stop 
Ebola or any other pandemic.''
    NNU is also calling for significant increases in provision of aid, 
financial, personnel, and protective equipment, from the U.S., other 
governments, and private corporate interests to the nations in West 
Africa directly affected to contain and stop the spread of Ebola.

    Ms. Jackson Lee. Your answer to how you are going to get 
all hospitals prepared, and, Mr. Wagner, your answer on 
airports that are not in this scheme of several airports, what 
are your men and women doing, and where do they take these 
patients if they find they are infected? Dr. Merlin, you can 
answer about this survey by nurses who say that they are 
actually not prepared.
    Dr. Merlin. That is concerning, and we will reach out to 
our State and local health departments and medical and hospital 
associations to see that those things are addressed. Nurses 
need to feel that they practice in a safe environment and that 
they can deal with patients who are potentially infectious, 
whether it is something like Ebola or something as simple as 
influenza. They need to have the needed personal protective 
equipment, and we will follow up on that.
    Ms. Jackson Lee. Mr. Wagner, if he is able to answer the 
question. What are you doing in airports that are not in this 
five-member----
    Chairman McCaul. If the gentleman would answer the 
question. We do need to keep to the 5-minute rule. We have 16 
Members of Congress. Go ahead and answer.
    Mr. Wagner. Okay. So any location outside of the five, what 
we will do is we will identify their travel as originating from 
one of those areas, and we will provide them with an 
information notice about the symptoms of Ebola and where to go 
for help and assistance if they start to develop these symptoms 
and where they can go get additional information.
    Chairman McCaul. Thank you. The Chairman now recognizes Mr. 
Sanford.
    Mr. Sanford. Thank you, Mr. Chairman, and, again, thank you 
for holding this hearing. Thank the Ranking Member as well.
    What I am hearing back home is that people are really 
concerned about the disconnect between what they see and what 
they hear. So, what they are hearing is it is not communicable. 
People are relatively safe. But meanwhile they are seeing 
pictures of people coming out of buildings wearing space suits, 
and what people are telling me back home is, I do not have a 
space suit, how am I safe? So there is a real disconnect 
between what they are seeing in terms of the imagery and what 
they are hearing.
    I would also, though, follow up on the Chairman's point. It 
was your words, Mr. Merlin, just a few moments ago that this 
disease was ``ferocious.'' Your words were that it was 
spreading exponentially, and it was the largest outbreak ever 
of Ebola. I asked our staff to look at, you know, how we 
treated some of these things in the past. One of the big 
benchmarks they used was the Spanish flu of 1918 which killed 
millions around the world, and the different protocols between 
New York City and at that time Pittsburgh, which were two of 
the bigger cities on the East Coast. New York immediately 
implemented quarantine. Pittsburgh waited a month, and as a 
result, very, very different results in terms of death in those 
respective cities, New York faring quite well relative to 
Pittsburgh.
    So, what people have been saying to me back home is that, 
well, wait a minute, if this thing is as virulent as some folks 
suggest, why in the world of quarantine are we going to let 
people fly from that part of the world--and this is following 
up on the Chairman's question that he is getting from his 
constituents as well--to this part of the world? What you said 
just a moment ago was we need uninhibited travel, but last time 
I checked, the 101st Airborne, they do not fly on Delta. I 
mean, military air can get resources, people, health 
professionals in without having civilians going in and out.
    Then the second thing you said was we want to prevent these 
countries from collapsing economically. I think that that 
overstates the case. I mean, from a U.S. standpoint, certainly 
what happens economically in Guinea or Sierra Leone is not 
going to drive the American economy and vice versa. From the 
opposite end, we have had a travel embargo with Cuba for about 
50 years now. It has not crippled the country.
    So, it seems to me, again, what a lot of people back home 
are saying to the Chairman's point and question is, why would 
you not just, you know, if you are over there, we are not going 
to issue a travel issue coming over here until we get this 
thing sorted out? Because going back to my colleague from 
Utah's question just a moment ago, it seems to me that there is 
a real mismatch between, well, CDC is saying, well, you know, 
Border Patrol folks have got it, and they are pointing to 
health care professionals. Until we get all that sorted out, 
why would you not just say let us just wait on travel right 
now?
    Dr. Merlin. Congressman, those are very good questions, and 
they are understandable questions. I have to admit that I wince 
every time I see the TV images with people in space suits 
because it gives an impression about the infectivity of the 
virus that is not realistic. It is an overreaction, and I think 
it flames people's fears about Ebola and how Ebola is spread. 
Doctors Without Borders has taken care of Ebola patients for 
years by using established personal protective equipment that 
does not include those sort of space suits that you see on 
television without acquiring infection in their workers. So, 
some of this is unfortunately media-driven.
    As to the difference between the influenza epidemic of 1918 
and Ebola, there are really major differences----
    Mr. Sanford. Understood, but I see we have gone to a yellow 
light, and we have a couple of seconds left. But why not, 
again, prohibition on civilian travel from this part of the 
world, that part of the world? If you are over there, do not 
come here. Why not?
    Mr. Wagner. We feel that that would cause the disease to 
grow in that area and to spill over into other countries, and 
then spill over more into the United States, and the real 
opportunity now is to put out that disease there. Every travel 
restriction that has been placed on travel into that area has 
interfered with people who are trying to help not being able to 
get there, either travel restrictions or reduction in air 
travel.
    It is not just the U.S. military, you know. It is people 
from Europe. It is people from China. It is people from Cuba 
who are trying to get there to help. It would make doing what 
we need to do harder, and that is why we ask the American 
people's understanding of that.
    Mr. Sanford. I hear you. I have questions on that, but my 
time has expired. Thank you, Mr. Chairman.
    Chairman McCaul. I thank the gentleman, and Mr. Barber is 
recognized.
    Mr. Barber. Thank you, Mr. Chairman, and thank you, Ranking 
Member Thompson, for convening this very important hearing 
today. People back home are concerned, and I came here to ask 
questions on their behalf as well as to get answers.
    But before I do that, I just want to extend my condolences 
to Mr. Duncan's family and to all of the people in the 
countries that are affected. I think the video we have seen on 
television of the suffering in Africa just touches our hearts, 
and I know the United States is mobilizing to help. So, I 
commend our men and women in uniform for taking this mission 
on. I know they will do an incredible job building facilities 
to help care for those who are sick. I also, Commissioner 
Wagner, want to commend your men and women because you are 
really on the front line when it comes to how do we make sure 
that we control people coming in who might be bringing this 
disease to our country.
    I appreciate what the Chairman said earlier about this not 
being a political issue, and we have to make sure we avoid 
making it one. This is an American issue for the safety of the 
people we represent, and it is an American issue for what we 
always do so well, and that is help other countries who are not 
able to do what they need to do for themselves.
    I do hope, Mr. Chairman, as we look at what is needed here 
today that we as Members of Congress will return after the 
election fully committed to providing the funding that is 
necessary, to provide the resources that are necessary, for CDC 
and for our men and women who are trying to protect the Nation 
and address this disease.
    I want to go to the question that has come up now a couple 
of times, Commissioner Wagner, about how it is that we control 
or manage travelers coming from the countries that are most 
affected today. I understand the concerns about stopping 
flights, but let me suggest another possible measure to you and 
get your reaction. Would it be helpful to require individuals 
who are not U.S. citizens or permanent residents traveling from 
the countries that are affected, to require them to go to the 
local American consulate or embassy in their respective 
countries to get a visa, and perhaps we could implement some 
screening at that location before people actually embark for 
the United States. Could you comment?
    Mr. Wagner. Well, they have to have a visa already to come 
here, part of that process. It does make a person inadmissible 
to the United States if you have any number of communicable 
diseases. Once they get that visa, if they develop that disease 
or that illness, upon entry into the United States, as part of 
our immigration authorities and admissibility questioning and 
inspection process, we will be alert for overt signs of illness 
of a person.
    Mr. Barber. Well, can I just interject, though? I 
appreciate that people have to have a visa. I guess what I was 
going at, and maybe this is a question for the State 
Department. Could we not implement at our consulates or 
embassies the same kind of screening procedures that you are 
implementing and perhaps even beyond what you are implementing 
at people coming into our country? It seems to me if we could 
catch the disease before it actually embarks, we would be in a 
much better place to protect the United States and the citizens 
of the United States.
    Mr. Wagner. Yes. I would have to defer to the Department of 
State on that one if everyone had to, say, reapply for a new 
visa subject to that level of condition.
    Mr. Barber. Well, let me turn next to Dr. Merlin. I just 
want to commend the CDC for taking on this incredible 
challenge. I have a lot of confidence in what the CDC does for 
our country. But I am also cognizant that unfortunately the CDC 
has been impacted heavily by budget cuts over the last several 
years, and I hope when we return, as I said earlier, we will 
take a look at what you need to make sure that this job is done 
with the resources that are needed.
    You mentioned earlier, Dr. Merlin, that we have known about 
this disease for 30 years. I have one question as my time is 
running out. Is it not possible, and perhaps it is already 
underway, for us to develop a test that would understand the 
nature of the illness in an individual before we have to wait 
21 days? Can we not examine that person in another way rather 
than waiting for the disease to be apparent?
    Dr. Merlin. Congressman Barber, that is an excellent 
question, and it comes up repeatedly. We have currently no 
diagnostic test that will detect Ebola before an individual 
develops symptoms. In fact, our current testing may not detect 
Ebola in the first 3 days of illness. If there is a patient who 
is suspected of having Ebola and the first test is negative, we 
often recommend a second test at 72 hours.
    I think that is a good challenge, and it would be very 
helpful to have a test like that. Developing tests to perform 
on asymptomatic individuals is very difficult because you need 
to find a target. You need to find something that is 
distinctive and present enough in the infected individual and 
the non-infected individual. That is very hard to do.
    Mr. Barber. I appreciate it. Mr. Chairman, my time is up. 
Let me just close by saying I think we ought to redouble our 
efforts to do just such testing. I think it would be very 
useful to our efforts to control this disease. Thank you, Dr. 
Merlin.
    Dr. Merlin. I will take that back. Thank you.
    Mr. Barber. Thank you, Mr. Chairman.
    Chairman McCaul. The Chairman now recognizes the gentleman 
from Florida, Mr. Clawson.
    Mr. Clawson. Thank you for coming here today. Appreciate 
your service to our country, and I know how hard you all are 
working now to keep us safe. Thank you to the Ranking Member 
and Chairman for doing this committee meeting, particularly 
here in Dallas. Good job. We have great first responders in our 
country. Having lived large parts of my life overseas, I just 
think it is not comparable to anywhere else that I have seen. I 
want to congratulate you all on that, those of you involved in 
that, first of all, and really say it is a good job.
    I am worried now about our first responders that are going 
to Africa, so my first question is to Dr. Merlin. You know, we 
are going to have 3,200 troops that are not medical experts in 
these mobile labs, as I understand it, doing testing and so 
forth. So my first question is to you all regarding that. Are 
our Good Samaritans going to be okay here? Are our Good 
Samaritans going to be safe? That is the first thing that 
popped in my mind. I have so many veterans in my district. Are 
our first responders going to be okay to go to Africa?
    The second thing I wanted to ask is how long until we do 
have a vaccine? What will it take to get there? If I understood 
this morning you all saying this a highly infectious disease, 
Dr. Merlin, is that right? Fatal up to 90 percent? If I heard 
you right, not necessarily contagious like influenza. Okay. It 
sounds still pretty deadly. So, how far out is a vaccine?
    Then my question to Mr. Wagner, you talked about the 
enhanced efforts, and you are going to get us more information 
on exactly procedurally what that means. How long until you are 
there? I remember after 9/11, it took us a while for TSA really 
to get up to speed, and they are a lot better at what they now 
than right after the disaster, and a similar analogy. How long 
until you think that you are confident that there are no holes 
in the security wall that is your force? If you all would 
answer these questions for me, I would really appreciate it.
    Dr. Merlin. Thank you, Congressman Clawson. The safety of 
anyone who we deploy in an epidemic like this is of utmost 
concern. We are putting people in harm's way by having them go 
to someplace where they might get infected. We, working with 
our partner organizations and DoD, do training and provide 
personal protective equipment or coordinate the use of personal 
protective equipment to keep people from getting infected. Our 
military forces are going to be not on a treatment mission. 
They are not going to be providing direct care, but they are 
going to be doing logistical work, but still it is a concern. 
We will do everything possible to prevent people who are trying 
to help from getting infected.
    Mr. Clawson. I think the goal here is zero.
    Dr. Merlin. I agree. I agree completely. Now I am 
forgetting your second question.
    Mr. Clawson. Vaccine.
    Dr. Merlin. Vaccine. You know, I would prefer that the 
National Institutes of Health, which is responsible for 
overseeing the vaccine development, and BARDA speak to the 
actual time tables for development. Fortunately, there are 
candidate vaccines available that have shown efficacy in non-
human primates, but before administering those vaccines to 
people, you need to be absolutely sure that they do no harm to 
people when you administer them to people. Those trials are 
going on now. Then you have to know the right dose to 
administer, and you have to have the manufacturing capability.
    I know that the agencies are working simultaneously to do 
those trials and ramp up the manufacturing capability. But both 
BARDA and NIH are better to testify on that than I am.
    Mr. Clawson. Do those trials in these sorts of days of 
crisis, do those trials go to the top of the heap?
    Dr. Merlin. Yes.
    Mr. Clawson. Because there is quite a backlog, as you know.
    Dr. Merlin. They have gone to the top of the heap. I can 
assure you of that.
    Mr. Clawson. Thank you. Mr. Wagner.
    Mr. Wagner. Today we screen all travelers for any over 
signs of illness for a host of communicable diseases, from 
measles, to tuberculosis, to H1N1, to MERS, to SARS, you know, 
including, you know, symptoms of Ebola. What we are kicking off 
Saturday at JFK is some extended procedures about taking 
people's temperatures and asking them very specific questions 
about contact with people who have Ebola and then working 
closely with the CDC to get those people that answer 
affirmative or have a temperature in getting them into some 
professional medical care to address that.
    All the other locations will continue to--I think we have 
four other locations--I am sorry--that will kick off following 
Saturday at some point next week. That will cover about 94 
percent of all of the travelers to the United States coming 
from those three regions. All our other locations will continue 
to identify any travelers that go to those locations.
    Mr. Clawson. Can I butt in real quick?
    Mr. Wagner. Yes.
    Mr. Clawson. That means you are doing face-to-face training 
right now in those airports with those officers so that we will 
have an upgraded procedure starting almost immediately.
    Mr. Wagner. We have on-going training. We have an annual 
certification for all officers about blood-borne pathogens and 
diseases. Our Basic Training Academy covers a lot of the work 
with CDC and recognizing signs of illness and the protocols for 
handing that person off to CDC for the medical care. That is 
on-going and continuous. We have done that for a number of 
years going back to a lot of our pandemic planning with SARS, 
and MERS, and a lot of the other contagious illnesses out 
there.
    Mr. Clawson. Thank you all three.
    Chairman McCaul. The Chairman recognizes Mr. O'Rourke.
    Mr. O'Rourke. Thank you, Mr. Chairman. For Dr. Merlin, my 
understanding is that there are experimental treatments for 
Ebola, and that Mr. Duncan was diagnosed on the 30th of 
September, but did not receive treatment until the 4th of 
October. Give me your thoughts on that and whether or not that 
might have contributed to his death; in other words, the delay 
in his receiving that treatment.
    Dr. Merlin. Yes. The people who understand best the 
decision-making process around whether and when to administer 
experimental therapies to the patient are really the care team 
providing care for the patient, and the patient, and the 
patient's family. We at CDC, our job is to make the public 
health officials and the team aware of what experimental 
therapies are available and how to go about acquiring them. 
Sometimes we facilitate that, but we do not actually----
    Mr. O'Rourke. You do not have authority to order a specific 
treatment, so that would be a question better asked to the care 
team.
    Dr. Merlin. Exactly.
    Mr. O'Rourke. Let me then move on to my next question. We 
have talked a lot about airports and what we are doing to 
screen their capacity, training, protocols. What--from a public 
health perspective, and then I am going to ask Mr. Wagner from 
an operational perspective. What are the threats at our other 
ports of entry, sea ports and land ports, from a public health 
perspective?
    Dr. Merlin. We have had already a number of cargo ships 
that come in all the time with people who are sick on the 
ships. Often, you know, the Coast Guard is the sort-of first 
line of defense on that. They engage with the Coast Guard, and 
then usually with, I believe, with CBP and with us to determine 
what the best course of action is with the person on a ship.
    This is more complicated because often there is a question 
of how long the person has been on the ship, and where the ship 
has been, and what the person's nature of exposure was. So 
these are harder cases to deal with, and they are also harder 
because often the person who is sick on the ship is gravely 
ill. It is a more difficult situation to deal with.
    Mr. O'Rourke. Mr. Wagner, what capacity do we have at these 
other ports to handle potentially infected travelers?
    Mr. Wagner. The land border is a lot more challenging 
because we do not have the advanced notice of the travelers' 
itinerary or their arrival. So, again, we would be alert for 
any overt signs of illness, and through our routine 
questioning----
    Mr. O'Rourke. CBP Officers at land ports are receiving that 
training to know now to look that?
    Mr. Wagner. Yes. Absolutely, yes, all our officers get 
that. So during their normal processing of a traveler, if they 
see these signs of illness, they have the contacts with CDC to 
get the medical professional advice on what to do and for 
follow-up for the traveler. But tuberculosis, measles, other 
communicable-type diseases, you know, we do see coming across 
the border.
    Mr. O'Rourke. My last question, again, for Dr. Merlin, CDC 
administers public health emergency preparedness grants, $640 
million that go to all States. What concerns or questions do 
you have or answers for us about accountability for how that 
money is spent and used, especially given some of the mistakes 
made in Dallas with the handling of Mr. Duncan's case? What 
recommendations, if any, do you have going forward in terms of 
additional accountability and potentially additional resources 
if you feel that those are needed?
    Dr. Merlin. That is a very good question, Congressman. I 
think we need to assure that, and steps have already been taken 
in this, that the PHEP grant and the hospital preparedness 
grant programs are well-coordinated. That both grants assure 
that not only health departments, but facilities are well-
prepared for potential and infectious disease emergencies, and 
that we sort-of have a seamless system.
    You know, prior to about 2 years ago, the grants were 
administered independently, and now they are better-
coordinated. But we need to be sure that the guidance is 
reaching the people in the facilities who will encounter the 
patient for the first time and they know how to respond, and 
that they are exercised. They are not simply protocols that are 
put away, that they are things that people know how to do.
    Mr. O'Rourke. We will submit for the record some questions 
that try to get to the root of this, whether that money is 
being well-spent right now or whether we have the appropriate 
accountability to ensure that we have the training in place, 
especially given some of the mistakes that were made. I would 
love to get your answers to those in a little more specificity. 
Thank you. With that, I yield back to the Chairman.
    Chairman McCaul. The Chairman recognizes the former 
Chairman of the Energy and Commerce Committee, Mr. Barton.
    Mr. Barton. I am glad to be recognized, Mr. Chairman, and I 
am glad to be a junior member ad hoc of your committee today.
    [Laughter.]
    Chairman McCaul. We are glad to have you.
    Mr. Barton. You and Mr. Thompson are holding a good 
hearing, and I am glad to be a small part of it.
    Mr. Chairman, I want to feed off of the very first question 
that you asked in your question period. I think this is a 
serious issue. It is obvious that people are affected by it. It 
is very obvious that people are concerned by it. Here in the 
North Texas region, it is real. We have had an Ebola case. An 
individual not from the area who was traveling to the area has 
contracted the disease and has died, so it is not academic.
    But first and foremost, this should be treated, I think, as 
a public health issue. It is not an international diplomacy 
issue. It is not a foreign policy. It is not a civil rights 
issue. It is a public health issue. In the community that I 
actually live in, Ennis, Texas, about 3 years ago a teacher 
contracted tuberculosis, was teaching his class. One of his 
students contracted the disease.
    When that became known, the Texas Department of Public 
Health, which is going to testify on the next panel, came into 
the school district, interviewed all of the students 
immediately in the class, quarantined some, monitored some, 
came down, held a public hearing that I helped facilitate. But 
that was treated immediately as a public health issue and dealt 
with in such a way that there were no other cases contracted of 
TB.
    It really does not appear to me right now that we are 
treating this primarily as a public health issue. Dr. Merlin, 
in a direct response to Chairman McCaul about why we do not 
stop flights from these countries in Africa, your response was 
because we need to send people and supplies over there to 
combat the disease. Well, obviously that is something that 
needs to be done. But as Governor Sanford pointed out, you do 
not have to have commercial flights to send flights into a 
country.
    If we were really treating this as a public health issue, 
why would we not immediately stop these flights, and then on a 
case-by-case basis send equipment and people as necessary, and 
on a case-by-case basis allow people to come out? Why do we 
have to have commercial flights that under the best of 
screening procedures that you have talked about, you are almost 
guaranteed mathematically to miss some people?
    So with due respect, I do not accept that answer that we 
cannot stop flights simply because we need to get people in. Do 
you have a response to that--or maybe Dr. Brinsfield might want 
to respond, too.
    Dr. Merlin. Well, Mr. Barton, I understand, and our 
experience has been that when there are interruptions in air 
travel, it impedes the public health response. Although there 
might be work-arounds, like military transport, that is 
difficult, and right now, time is of the essence in what we do.
    Mr. Barton. Well, who makes that decision? Is that a 
Presidential decision? Is that a Secretary of State decision? 
Is that a Secretary of Homeland Security decision? Who makes 
that decision about banning flights?
    Dr. Brinsfield. So, sir, I would just like to point out, 
and I will defer to Chief Wagner here, that there are no direct 
flights from those areas, so that it is more an issue of what 
people are on flights coming from the intermediate airports.
    Mr. Wagner. Correct. So there are no direct flights from 
those three affected regions. These travelers are going to 
Brussels, Ghana, London, Paris, and Morocco to come here, and 
it may just be a couple of people on a single flight of 300 or 
350 people. You may have----
    Mr. Barton. Well, you could still ban it. I mean, you could 
still. The gentleman who came from Liberia through, I believe, 
Brussels, he could have been stopped in Brussels or not even 
allowed a visa to leave to go to Brussels.
    Dr. Brinsfield. I think that is the most important point, 
sir. At that point we defer to our colleagues at State, and 
there is a good coordination process around those questions.
    Mr. Barton. But my question on the table is: Who makes the 
decision? Is it the President, or the Secretary of State, or 
the Homeland Security, or who makes that decision?
    Dr. Brinsfield. Sir, I would defer to the interagency 
process that is on-going under the President on this one.
    Mr. Barton. So it is the President?
    Dr. Brinsfield. I would say that there are many different 
actions that you have discussed here, one related to visas, one 
related to flights landing. Those are different authorities. If 
the Department of State or Department----
    Mr. Barton. I know my time is expired, Mr. Chairman. Could 
a Governor of a State or could an airport authority ban flights 
from a particular region, or that has to be done at the Federal 
level?
    Mr. Wagner. Sir, most of the airports are landing rights 
airports, and they request permission from Customs and Border 
Protection to land. So I think it is a question more for the 
airlines and the airport authorities on what business they 
choose to do or not do.
    Mr. Barton. So theoretically DFW Airport could ban a flight 
from a passenger coming----
    Mr. Wagner. I would have to defer to them on what business 
decisions they make and where to fly to and which airlines they 
go to.
    Mr. Barton. Thank you, Mr. Chairman, for your courtesy.
    Chairman McCaul. Thank you. The Chairman recognizes Mr. 
Vela from Texas.
    Mr. Vela. Thank you, Mr. Chairman. Dr. Merlin, I am trying 
to understand, what is the scientific explanation for the 
response that a travel ban would actually make things worse?
    Dr. Merlin. Mr. Vela, thank you for asking that question. 
We have a disease now that we understand the range of how many 
people are infected. We know how many people would be infected 
next month if nothing is done, and how many people will be 
infected by the end of the year if nothing is done. We know the 
size and the scale of the international effort. It is a 
remarkable international effort that is required to stop it.
    We have good projections on how many deaths will be caused 
by delay, and we are very afraid that things that are done that 
impede travel will delay the interventions that prevent the 
progression of the disease. If the disease progresses to the 
point that it cannot be stopped, it is going to spill over into 
other countries and create a greater threat for the United 
States.
    So we feel that understandably the notion of stopping 
travelers now might prevent a traveler from arriving in the 
United States, though we know we can prevent an outbreak from 
that. But the greater risk is that by delaying stopping the 
epidemic in Guinea, Sierra Leone, and Liberia, you create a 
much larger epidemic that is impossible to control. That 
disease becomes endemic in Africa, and that we are dealing with 
this for the foreseeable future, that we cannot stop it. What 
we want to do is stop it right now. We know how to do it. We 
just need to get the resources there to do it. We do not want 
to do things that would impede that.
    Mr. Vela. It also seems to me that there are two great 
risks, and that is the spread of the disease outside those 
three countries, and then following up a point Mr. Wagner was 
making from the flight standpoint, from people who are 
traveling from those three countries anywhere else.
    What kind of international coordination are we seeing, and 
I was wondering if you could maybe give us an idea. I mean, who 
is helping us? What is the international community doing to 
stop the spread of the virus into the other adjacent countries, 
and from going to airports, like Brussels and any other point 
in between?
    Dr. Merlin. I can tell you from a public health 
perspective, CDC regards this as a very high priority. We have 
over 140 individuals deployed to not only Sierra Leone, Guinea, 
and Liberia, but neighboring countries where they are involved 
in working with the ministries of health and training 
individuals so that they know how to detect disease early and 
engage in contact tracing and break the transmission of 
disease.
    So what we want to happen in those countries is when an 
ember of the disease lands in their country and starts a fire, 
for them to be able to quench the disease as quickly as 
possible, and that is the sort of public health approach. I do 
not know about the air travel issue, and I would defer to my 
colleagues. They may know about the coordination of air travel.
    Dr. Brinsfield. I would just say that the response is well-
coordinated under the United Nations and has been for several 
weeks. I would defer questions on follow-up on the 
international response to them and their Department of State 
partners.
    Mr. Vela. Let me ask you this question. Aside from the 
hemorrhaging, the symptoms of the virus appear very similar to 
any severe flu. Are there any other distinctions?
    Dr. Merlin. In clinical presentation, early clinical 
presentation, no. It is unfortunate that it has the name of 
viral hemorrhagic fever because only a minority of patients 
develop bleeding symptoms, and that is late in the course of 
the disease. So early in the course of the disease, the first 3 
days, it is a flu-like illness. It is fever, malaise. There is 
nothing about the clinical presentation that would make you 
know it was Ebola. After about 3 days, there is usually 
profound nausea, vomiting, and diarrhea, and that is what my 
colleagues and I, when we hear stories about people presenting, 
that what really raises the flag that this might be Ebola.
    So the travel history and exposure history are very 
important to include with the early symptoms to understand 
where someone might actually have Ebola. You cannot tell just 
on the symptoms alone. You need more information.
    Mr. Vela. Is my time up? Thank you.
    Chairman McCaul. The Chairman recognizes Dr. Burgess, who 
actually practiced at Dallas Presbyterian Hospital.
    Mr. Burgess. Thank you, Mr. Chairman, and I thank our panel 
for being here. Dr. Brinsfield, Mr. Wagner, appreciate you all 
spending time with me on the telephone earlier this week. It 
was very helpful, and I am sure we will continue to have 
discussions as this story evolves.
    We are appropriately respectful of the passing of Mr. 
Duncan. I think we also ought to acknowledge the passing of 
Patrick Sawyer at the end of July. Mr. Sawyer was an individual 
who worked in Liberia, commuted to there from his home in 
Minneapolis. After attending his ill sister in Liberia, flew on 
to Lagos. Before he could board the plane back to Minneapolis 
died of Ebola, and could have been Patient Zero 2 months before 
we had the experience here.
    So, Dr. Merlin, I guess my question is, I am sure there 
will be after-action reports on the case that occurred here in 
Dallas. Did you do any study of what might have happened had 
Patient Zero arrived in Minneapolis on July 30?
    Dr. Merlin. Congressman Burgess, I am not aware of that, 
and I will have to get back to you on that. I do not know.
    Mr. Burgess. Well, the reason I asked the question, and Ms. 
Jackson Lee, I think, put it pretty clearly, you have a 
situation at Presbyterian. A nurse does an intake evaluation, 
and apparently some travel history is given that perhaps 
provided a really important clue that was subsequently lost in 
all of the activities involved with treating the individual. 
From the CDC standpoint, are you concerned at all with the 
directives and missives and action alerts that you have putting 
out for months that somehow they were not getting through to 
the front line, to the people at the triage desk? Because 
really there was only one response: I am here for a fever and a 
stomach ache. I have traveled from Africa. Put down the iPad. 
Go through that door with the two men in moon suits. We will 
meet you and walk you into an isolation unit. Really that is 
the only response; is that not correct?
    Dr. Merlin. Congressman Burgess, I agree with you. As 
someone who has worked in a hospital and in an emergency room, 
I am sure you know that things in retrospect are often a lot 
clearer than they are when present.
    Mr. Burgess. But from a CDC perspective, you have put out 
these directives to the hospitals, to the people on the front 
lines. You know, this is not the flu as usual. You have got to 
be thinking about this. If I am at CDC, I have to be concerned 
that that message did not get down to the front line. Not to be 
critical of anyone. Not to be accusatory of anyone. But the 
message did not get to the front line. What are you going to do 
now differently to make sure that message does get to the 
people on the front line, because that is really the critical 
part that was missed?
    Dr. Merlin. I think what we need to do is to work with the 
regulatory organizations, like the Joint Commission, to be sure 
that compliance with preparedness is a higher priority, and 
that when facilities are accredited, that it is something that 
is looked at critically, and they look at whether the front 
line is trained on these things.
    Mr. Burgess. I would just offer that business as usual may 
not get it because this is not an ordinary time with what we 
are dealing with.
    Now, two airlines, Air France and British Airways, stopped 
going to Monrovia in the summer, I think in August. So they 
just simply on their own decided they were going to stop 
service there. I know people have asked me. The President 
actually suspended air operations through the FAA into the 
airport in Israel for a while this summer while there was some 
bombing going on, so we know that authority exists.
    Okay. Mr. Thompson provided this nice graph, and Dr. 
Brinsfield, you will recognize this graph. This is a classic 
growth curve. You have got a lag phase. You have got a log 
phase, the log phase, the phase of logarithmic growth, the 
exponential phase. In two countries at least it appears--Sierra 
Leone and Liberia--they are in the logarithmic phase. Dr. 
Fouts, he said in another hearing that I was at in Washington a 
few weeks ago that when you get to logarithmic, when you get to 
exponential growth, exponential always wins.
    So my question is: Where on this line is the threat matrix 
such that you would recommend to the President we have got to 
do something different, and we have got to stop this disease, 
and not allow it to be imported to our country, but this does 
not come in through a migratory flyway? It is not like pandemic 
flu. You can only get Ebola if you go get it and then bring it 
home. So where is the point on this graph where that would 
occur?
    Dr. Merlin. We are already at the point where we believe 
that all stops needs to be pulled out in preventing the growth 
of the disease in Africa, and that is what we need to focus on 
because the risk in this country will not be eliminated until 
we eliminate the spread of disease in Africa.
    I think that comes down to the crucial point is that we 
will not be safe until we stop the growth of that disease 
because it has now infected so many people, and it is 
reproducing so quickly that unless we stop it, it will 
inevitably become endemic, and it will inevitably be a greater 
threat. So I think the President has already taken the message 
out to the American people and to the United Nations that this 
is the time. The opportunity space is right now.
    Mr. Burgess. Dr. Merlin, I know my time is up. With all due 
respect, I disagree with you. I do not think the President has 
put a significant amount of importance on this. I have not 
heard the President say this is the time of zero defects. We 
have got to do everything perfectly. Doctors Without Borders, 
that has been their experience over in those countries. They 
have a low infection rate even though health care workers have 
a high infection rate because they do everything by the book 
every time, and we need to adopt that same attitude here.
    Thank you, Mr. Chairman. You are very kind.
    Chairman McCaul. The gentleman's time has expired. The 
Chairman recognizes Mr. Swalwell form California.
    Mr. Swalwell. Thank you, Mr. Chairman, and thank you to our 
panelists. What I have taken away from this hearing and what we 
have learned over the past month is we have to fight this 
aggressively, and, most importantly, over in the countries 
involved in West Africa. To that, we have to be prepared here 
locally, whether it is the airport screens that take place or 
the hospitals that are ready. Also, No. 3, that we have to bust 
some of the myths out there that are creating, I think, 
unnecessary hysteria.
    So I want to first start with what we can do here locally 
with the airport screens. Mr. Wagner, we know that every day 
about 1.75 million people are in the air in the United States. 
We have about 100,000 pilots, 95,000 flight attendants who are 
on the front lines who could be exposed to this. I think some 
good questions are rightfully being asked.
    So, one of my concerns, although we have five airports that 
are now going to have intensified screenings, what would happen 
if somebody were to fly from, say, Brussels to Dallas-Fort 
Worth Airport, and then, like many foreign travelers, stuck 
around in the United States for 2 to 3 weeks and went from 
Dallas-Fort Worth to, say, San Francisco International Airport? 
That is not one of the five designated airports. Would that 
person who perhaps did not present symptoms at DFW, but started 
to present symptoms as they went into San Francisco, is there 
anything there that would allow us to screen that individual?
    Mr. Wagner. Well, Customs and Border Protection is only 
going to screen them on their initial entry into the United 
States. So when we see them coming into DFW, we would identify 
that travel as having originated in one of those three areas. 
We would have provided them the information notice about 
symptoms to watch out for and where to go and seek help. The 
information notice also has a message to the doctor that they 
can provide. But then we are relying on that person wherever 
they travel within the United States, if they start to develop 
those symptoms, they need to go get the proper medical care and 
get the medical authorities to make that determination that is 
it Ebola or is the flu or is it something else.
    Mr. Swalwell. Sure. Dr. Merlin, as far as our local 
hospitals, I am having a conference call with all of our 
hospital officials on Tuesday. What are we doing to reach out 
to them to make sure that they know what to look for if a 
patient comes in and has been traveling to some of these West 
Africa countries and is presenting symptoms?
    Dr. Merlin. We have been communicating with hospitals 
through a variety of mechanisms. We have an established email 
electronic communication, a health alert network, that goes to 
thousands of facilities and providers in the country. We have 
been working with our State and local partners to reach out to 
facilities and physicians. We have a regular conference call 
called the COCA call, which is a clinical outreach call, where 
I believe one of the ones recently on Ebola had about 6,000 
participants on it.
    We have been working through the medical societies. There 
were a lot of presentations. This is Infectious Disease Week, 
and the Infectious Disease Society of America just had its 
meetings, and there were a lot of presentations on Ebola. We 
have a large group in our Emergency Operations Center that 
regularly now is having outreach calls to either individual 
hospitals that want questions answered or professional groups 
that want to have questions answered. We have had conference 
calls from, you know, single facilities to large groups of 
facilities trying to help them with their preparations.
    Mr. Swalwell. Dr. Merlin, my colleague, Mr. Barber from 
Arizona, alluded to the CDC budget, and budgets reflect 
priorities and values. I think the numbers around the CDC 
budget over the past few years reflect that prioritizing public 
health and addressing world-wide health emergencies have not 
been our top priority when it comes to the numbers.
    From 2010 to 2014, the CDC budget has steadily gone down. 
From 2012 to 2013, the program level for the CDC was cut by 
$293 million, which included $13 million in cuts to our efforts 
to prevent and respond to outbreaks of emerging infectious 
diseases. Is today's funding level for the CDC adequate to 
address the world-wide threat and what could happen here in the 
United States? Would you like more, and if you had more, what 
would you do with it?
    Dr. Merlin. The response to that I would defer to the CDC 
director and HHS. I am not in the position at CDC where I 
really understand and participate in the full budget 
formulation.
    Mr. Swalwell. Has your budget been cut, though, since 
sequestration?
    Dr. Merlin. I will have to get back to you on that. My 
budget comes from multiple different sources, and I would have 
to get back to you on that.
    Mr. Swalwell. Sure. Thank you, Mr. Chairman, and I yield 
back.
    Chairman McCaul. The Chairman now recognizes the gentleman 
from Texas, Mr. Marchant.
    Mr. Marchant. I would like to thank the Chairman today for 
holding this hearing and welcome all the Congressmen to my 
district. This is the heart of my Congressional district. It is 
the economic hub. Thousands of my constituents come to work 
every day in this district, and as you know, 5 million 
international travelers come through this airport every year.
    So in response to that, I would like to submit for the 
record a letter to the Honorable Jeh Johnson that I made this 
morning asking for Dallas-Fort Worth International Airport to 
be included or added to the list of five airports that are 
going to have the increased screening and a letter from the 
Dallas-Fort Worth International Airport.
    Chairman McCaul. Without objection, so ordered.
    [The information follows:]
      Letter Submitted for the Record by Honorable Kenny Marchant
                                   October 9, 2014.
The Honorable Jeh Johnson,
Secretary, Department of Homeland Security, Washington, DC 20528.
    Dear Secretary Johnson: I am writing to strongly call for the 
immediate inclusion of Dallas/Fort Worth (DFW) International Airport--
which I represent in Congress--in the list of other major U.S. airports 
at which the administration has announced it will implement heightened 
Ebola-related security screening protocols. DFW Airport is the third 
busiest airport in the world, hosting over 1,800 flights per day and 
serving more than 62 million passengers each year. As you are aware, it 
was also the final U.S. arrival destination of Thomas Eric Duncan, the 
first individual diagnosed with Ebola inside the United States. Action 
must be taken to ensure that the people of North Texas do not suffer 
greater exposure to this deadly virus.
    The White House has said that five U.S. airports receive roughly 
94% of the roughly 150 passengers from the three affected countries 
that arrive in the U.S. each day. What risk do the remaining 6% of 
passengers have on major airports, such as DFW, that have not been 
selected for additional screening? How difficult would be it for 
Customs to review the additional 6% of passengers, which amounts to 
approximately 9 people per day? The administration should execute every 
defense against persons and materials entering the U.S. to guard 
against any new Ebola cases arriving in the United States.
    Thank you for your review of this correspondence. Should you have 
any questions regarding this letter, please feel free to contact me or 
my Legislative Director.
            Sincerely,
                                            Kenny Marchant,
                                                Member of Congress.
                                 ______
                                 
 Letter From the Dallas/Fort Worth International Airport Submitted for 
                 the Record by Honorable Kenny Marchant
                                   October 7, 2014.
The Honorable Kenny Marchant,
Member of Congress, 24th District, Texas, 1110 Longworth House Office 
        Building, Washington, DC 20515.
    Dear Congressman Marchant: Dallas/Fort Worth International Airport 
(DFW) appreciates your concern and your leadership on behalf of our 
country and your constituents. In response to your recent letter, I 
want to assure you that the Airport takes our responsibility for the 
safety and security of customers, passengers and employees very 
seriously. DFW's role in response to infectious disease is that of 
first responder to any report of anyone at the Airport who exhibits 
signs or symptoms consistent with any communicable disease. DFW has in 
place a robust and exercised pandemic response plan that has been 
reviewed by all relevant agencies.
    With regard to infectious disease control and our country's 
pandemic response, DFW is part of an integrated response system under 
the direction of the Centers for Disease Control and Prevention (CDC) 
and local public health authorities.
    We rigorously adhere to the guidelines of the CDC which has 
jurisdiction in the matter of infectious disease control. As such, 
procedures and protocols are in place to ensure that DFW effectively 
responds to reports of infectious disease by U.S. Customs and Border 
Protection (CBP) as individuals are entering the country, by airlines 
for passengers or employees who show symptoms of infectious diseases of 
many types, as well as reports from other segments of the travel 
industry and public health community.
    In addition to the CDC, in the case of our terminals, we follow the 
direction of the Tarrant County Department of Public Health, which is 
also responsible for public communication.
    DFW will continue to take direction and guidance from the CDC and 
our federal government with regard to any additional safety and 
security measures deemed necessary to protect the safety and security 
of our country and the traveling public.
            Sincerely,
                                              Sean Donohue,
                Chief Executive Officer, DFW International Airport.

    Mr. Marchant. Thank you. Mr. Wagner, there are 
approximately 13,500 people from the affected areas that have 
travel visas that are active at this point. What Federal agency 
is responsible for knowing who those 13,500 people are and the 
status of their travel?
    Mr. Wagner. Well, the Department of State issues that visa, 
so they would be responsible for who has them and under what 
conditions. Customs and Border Protection would encounter that 
individual when they arrive to the United States. Part of what 
we determine in that inspection process is does that person 
intend to comply with the terms of that visa, and then are 
there any grounds for inadmissibility, such as a communicable 
illness, that would prevent them from coming in?
    Mr. Marchant. So if we indeed are at a critical point in 
containing this disease, do you not think it is important or 
would you not think that it is important that there be some 
identifiable base of people that have come through Customs and 
Border Protection that are in the United States or have 
traveled in the United States that have presented their 
passport, have been questioned, have been screened, and so that 
we have some idea of what the number is? I mean, how many 
people could this possibly have affected?
    Mr. Wagner. Well, we would know how many people came into 
the United States from those affected regions over the course 
of, you know, any period of time. You know, where they are in 
the United States, or who they have had contact with, or what 
has, you know, transpired since then is a much more complex 
issue.
    Mr. Marchant. So DFW Airport is not usually the primary 
point of entry for these countries, but as most people across 
the country know, if you go anywhere in the United States, you 
are probably going to have to go through DFW Airport. I think 
it is very critical at this point that we understand that 
people are coming into JFK and they are coming into Newark and 
these other five entry points and staying 1 or 2 or 3 weeks or 
4 weeks, and then they are coming through DFW Airport, and they 
are going all over the country.
    So I think this is a key place where we need to have an 
active program of screening going on. Do we have a CDC facility 
that is close? Are we are one of the 20 areas where the CDC has 
a center?
    Dr. Merlin. No, we do not have a staffed facility at DFW. 
We may have a physical space, but it is not currently staffed.
    Mr. Marchant. Mr. Chairman, I would like to request that 
the CDC strongly consider DFW Airport, as well as George Bush 
International in Texas, and fully staffing those. Our Governor 
has just recently asked questions about whether our CDC 
facilities--where they were located and how well they are 
staffed.
    Chairman McCaul. Without objection. Just for the record, I 
submitted a letter along with Senator Cornyn to the Secretary 
asking the same request. I'll include it also. So ordered.
    [The information follows:]
     Letter From Chairman Michael T. McCaul and Senator John Cornyn
                                  October 10, 2014.
R. Gill Kerlikowske,
Commissioner, U.S. Customs and Border Protection, Washington, D.C.
Dear Commissioner Kerlikowske: We are writing about the decision by the 
Department of Homeland Security to provide enhanced screening to 
passengers from the Ebola-affected nations of Guinea, Liberia, and 
Sierra Leone.
    As you may know, Texas is home to both Houston George Bush 
Intercontinental Airport (IAH) and Dallas-Fort Worth International 
Airport (DFW) where a combined 15.6 million international passengers 
visited in 2013. Neither airport has been designated for enhanced 
screening. Because those traveling from Guinea, Sierra Leone, and 
Liberia can transit to the United States from many other countries, we 
have concerns that the current decision to screen only at five airports 
may not adequately protect Americans and others traveling to America 
from the Ebola virus.
    Therefore, we request that you provide answers to the following 
questions:
    (1) According the Administration, the enhanced screening will take 
        place at five airports that receive 94 percent of the 
        passengers from the three affected countries. Where do the 
        other 6 percent arrive? Will other major international airports 
        be designated for enhanced screening procedures and additional 
        resources if this limited initiative does not effectively 
        mitigate against entry of potentially infected passengers?
    (2) How many from those Ebola-affected countries enter the United 
        States through other ports of entry, such as sea ports and land 
        border stations?
    (3) What other Ebola-related measures are being taken at other 
        vulnerable port environments, particularly at high traffic land 
        border ports of entry along the Texas-Mexico border? If none, 
        why? Will U.S. Border Patrol apply enhanced screening 
        procedures to those apprehended between land border ports of 
        entry?
    (4) Please explain the tracking system in place for those traveling 
        from Liberia, Guinea, and Sierra Leone to the U.S. How are you 
        working with other countries that have connecting flights from 
        West Africa to the U.S. to ensure an adequate screening 
        process?
    (5) What passenger travel documentation do Customs and Border 
        Protection Officers inspect when a passenger arrives in the 
        U.S.? Is documentation other than the origin and connection of 
        the passenger available for inspection?
    We ask that you consider adding IAH and DFW to the list of airports 
performing enhanced screening.
    Thank you for your attention to this matter. We look forward to a 
prompt reply.
            Sincerely,
                                               John Cornyn,
                                     United States Senator.
                                         Michael T. McCaul,
                                      United States Representative.

    Mr. Marchant. Thank you, sir.
    Ms. Jackson Lee. Mr. Chairman, does that include Bush 
Intercontinental?
    Chairman McCaul. I would have to look at the letter again, 
but I would concur with that as well.
    Ms. Jackson Lee. Thank you, Mr. Chairman.
    Mr. Marchant. Mr. Chairman, I yield back my time.
    Chairman McCaul. The Chairman now recognizes Mr. Veasey 
from Texas. I am sorry, Ms. Johnson, Eddie Bernice Johnson.
    Ms. Johnson. Thank you very much, Mr. Chairman. My usual 
appreciation for all of the people that are here, and all of 
the respondees to this particular crisis.
    Being a nurse, my concern really will center on the details 
of why we are in this position. It would seem to me, and I know 
that CDC had put protocols in every major hospital in this 
country for a number of weeks prior to this happening. So, no 
matter what else we do, we have got to depend on people that we 
question and whether or not they give the correct information.
    I know we are talking about taking temperatures, and I do 
not know what other type of interrogation that they will have. 
But it would seem to me that we could not sit here and plan for 
the expenditure of a whole lot money that we are not going to 
do when we get back to Washington, but look very closely at 
what we have in place already, and to make sure that is given 
the kind of attention it demands to make it work.
    Now, I do not know what questions were asked when this man 
went to the hospital the first time, nor do I know what 
temperature he had. But it would seem to me that much of what 
we are worried about right now could have been eliminated 
because the protocols were in place. Now, I do not know what 
happened with the protocols. But no matter how much we do to 
look at every person coming in this country, we have also got 
to carry out our own written protocols when they get here.
    So, I am concerned about us sitting here and thinking about 
all the elaborate things we can do to make things better when 
we know we are not going to pay for it when we go back to 
Washington. We have not yet. We do not have the money. We do 
not have any more now than we did before we did it. So, I am 
concerned that we not get too much pie-in-the-sky in planning, 
but rather utilize what we have in place. Was there any 
faltering in the protocols that were in place?
    Dr. Merlin. Ms. Johnson, in terms of the adherence to 
protocols and what would have happened at Presbyterian 
Hospital, I really defer to the hospital itself and the local 
health department, the local and State Health Department. They 
are the ones who are responsible for reviewing that. I would 
not want to say things because I do not know the details.
    Ms. Johnson. Yes.
    Dr. Merlin. But I do want to say to your point I think it 
is important to move from things like protocols to things like 
checklists where every patient in order to process through the 
facility, there has to be a checklist and they have to check 
off and sign whether they have done this, because that takes 
the protocol and makes it a firm responsibility. For things 
important like this, we really need to do it. That is one 
approach that I do not think adds much in the way of burden and 
assures better compliance with recommendations.
    Ms. Johnson. Thank you very much. Mr. Wagner, what are we 
going to be doing differently than what we did when the patient 
entered this country? Was he not asked questions?
    Mr. Wagner. So if he were to enter through Dulles next week 
at some point, we will set up some enhanced level of screening. 
So we will have identified him as traveling from one of the 
affected regions. We would have given him a questionnaire to 
fill out that we work with CDC that talks about their contact 
information, their health status, do they have any symptoms in 
place, and, most importantly probably in this case, have they 
had any contact with anyone that has had Ebola. We would then 
also refer them to a medical professional on site to have their 
temperature taken.
    If there any indications through that information that they 
need additional medical professional review, we would then 
coordinate with CDC on site to be able to have that.
    Ms. Johnson. Can it not be assumed that someone comes in 
from Liberia that they have been in contact?
    Dr. Merlin. No. Our questions about contact really have to 
do not with being around or in an area that is infected, but 
really particularly whether someone has had contact exposure to 
body fluids. Have they had a splash of body fluids, with their 
unprotected hands touched body fluids? Have they have known a 
person who was known to have Ebola? Have they been for an 
extended period of time around someone who was known to have 
Ebola?
    One of the things that we know about the disease in places 
like Liberia is it is actually patchy. There are places where 
there is a lot of disease, and there are places where there is 
very little disease. Our strategy out there, you know, is to 
actually prevent it from beginning to spread all over the 
place. We would not say in our public health line people from 
those countries have had contact with the disease.
    Ms. Johnson. Well then, how would you determine an origin? 
If you cannot assume or at least act as if it is a possibility 
coming from those areas where it is very prominent, how would 
you draw the line from wherever they are coming from?
    Dr. Merlin. You know, your question is excellent and I 
think it ties into the question earlier about the test for a 
symptomatic disease. There is no objective test. We rely on 
examination, a visual, looking at the person, trying to tell 
whether the person might be ill, and a person's answering a 
series of questions to see whether the answers to the questions 
make sense. But that is the nature of the examination. Mr. 
Wagner, do you----
    Ms. Johnson. Thank you--excuse me. Did I miss something?
    Chairman McCaul. If we can make it brief, yes.
    Mr. Wagner. No, that is correct. It depends on how the 
people answer the questions and what they say to any follow-up 
questions we would ask.
    Ms. Johnson. Thank you, Mr. Chairman. My time has expired.
    Chairman McCaul. Of course, Mr. Duncan did not reveal that 
he had been in contact with the Ebola virus in Liberia, is that 
correct?
    Mr. Wagner. I believe so. I am not sure if he was aware----
    Chairman McCaul. Dr. Merlin.
    Dr. Merlin. He did not truthfully answer the questions on 
the exit screening where he was asked whether he had an 
exposure. It turned out subsequently that he had a known 
exposure.
    Chairman McCaul. The Chairman now recognizes Mr. 
Farenthold.
    Mr. Farenthold. Thank you very much. I am going to clean up 
here. I am going to have a bunch of quick questions, and if you 
could keep your answers relatively short. A lot of this is 
follow-ups on other questions.
    I do want to say we have got to be real careful here. I do 
not think we are doing enough. If this disease gets a foothold 
in the United States, we take away the diagnostic question of 
have you been in these affected countries, so I think it is 
absolutely critical. I do not think we are doing enough.
    Let me start with you, Mr. Wagner. We picked five airports 
to do. We learned that Mr. Duncan was less than truthful on his 
screening. We have just announced to the world what airports 
not to go through if you want to come to the United States 
because we have got better treatment. Could we maybe do 
something like funneling everybody who has a visa from one of 
these countries or who has traveled from one of these countries 
through one of the airports? Is that a step at least in the 
right direction? I think maybe banning all the flights is a 
right step, but is an intermediate step funneling everybody 
through the airport and screening?
    Mr. Wagner. I do not know that we can do that. I think it, 
again, relies on who the airlines choose to bring to us from 
different parts of the world.
    Mr. Farenthold. So we do not have the authority to say if 
you are coming from this country you can only enter through 
this port?
    Mr. Wagner. I do not believe so. I will have to look at 
that.
    Mr. Farenthold. If not, that is something we might be able 
to fix. Let me ask you another question, Mr. Wagner. You talked 
about how you all have the authority to stop people for health 
reasons. How often does that happen? Do you stop one person a 
day? I mean, it seems to me I do not ever hear about it on the 
news. Is it a frequent occurrence that you stop people?
    Mr. Wagner. We have a million people coming into the United 
States every day, so I would say it is not frequent, but it 
happens several times a week. You know, we have----
    Mr. Farenthold. All right. So you have less than a 1 in a 
million chance of getting----
    Mr. Wagner. No, I think it is who we have been advised that 
have a communicable disease, and we do get information about 
that and put it in our computer systems and are able to 
recognize that, I mean, and stop them from coming in.
    Mr. Farenthold. Right. But even now somebody that is not 
showing any symptoms is going to get through.
    Mr. Wagner. Well, if they are not showing any overt 
symptoms, it is tough for us to be able to recognize that they 
would be sick or have a disease that is, you know, to emerge in 
them. So I am not sure how----
    Mr. Farenthold. I understand. Listen, I do not want to shed 
all my rights to international travel any more than anyone else 
does, but we have got the obvious countries that we really need 
to be suspect of. Short of an absolute travel ban on these 
countries or canceling commercial flights, you know, an interim 
step is substantially enhanced screening and maybe follow-up 
screening every few days after they arrive.
    I see, Mr. Merlin, you are nodding your head, but I have a 
couple of questions for you. I am sorry if I am skeptical of 
you and some of the things that you are saying. The American 
people and my constituents have lost trust in the Government 
for a variety of reasons, and I do not want to bring politics 
into public health. But we have the lowest level of trust in 
the Government, I think, in my memory. Add to that, every 
outbreak novel or zombie movie you see starts with somebody 
from the Government sitting in front of a panel like this 
saying there is nothing to worry about.
    So you have got to remember the first two Ebola patients 
that came back to the United States were American doctors who 
became infected, who had all the training in the world and were 
Ebola experts. So my constituents, and to some degree I am, a 
little skeptical of the statement, oh, actually if you take the 
precautions it is very difficult to get. How did these two 
doctors get it, American-trained doctors? How did they come up 
with it in the first place if it is that difficult to get it, 
if our health care workers and the American public is safe?
    Dr. Merlin. Let me clarify for you what I said. For people 
who are health care workers who are putting themselves in 
environments where there are patients known to be infected with 
Ebola who have copious body fluids in the environment that 
carry the virus, the people have to practice scrupulously-known 
procedures for preventing acquisition of the virus. It is a 
dangerous environment in which to work, and it can only be done 
by scrupulous adherence to those precautions and caretaking 
measures.
    Outside of those environments, when you are talking about a 
situation like the United States where we have a very 
sophisticated health care system and a sophisticated public 
health system, when we identify a case, we are capable of 
doing, what we have done with Mr. Duncan and we do with any 
future case, is assuring in collaboration with local and State 
health officials and the hospital community that the case is 
isolated and treated, that all contacts are quickly identified, 
and aggressively identified. If contacts are not reliable, that 
steps are taken to be sure that the contacts can be followed, 
that their temperatures are monitored. If they should become 
symptomatic, they are immediately hospitalized.
    We know this works. It works in the United States, and it 
worked in Nigeria, and it worked in Senegal, so we can stop 
cases like that. Hopefully the difference between the zombie 
films and this testimony is this is real.
    Mr. Farenthold. I hope so. I see my time has expired, and I 
wish you the best of success in your efforts to contain this 
both in Africa and here in America.
    Chairman McCaul. The Chairman now recognizes Mr. Veasey.
    Mr. Veasey. Thank you, Mr. Chairman. I want to ask Dr. 
Merlin a question. A second ago you said that it appeared that 
Mr. Duncan may have, you know, deceived the screeners at the 
airport. But I am looking at this memo that was prepared for 
the committee, and let me read you this and maybe see, is there 
something that needs to be clarified. ``Although it is now 
believed that Mr. Duncan contracted the virus while helping a 
pregnant woman to the hospital, reports indicate that the 
woman's family told neighbors she was suffering from malaria, a 
disease with similar symptoms, not Ebola. Accordingly, there is 
no proof that Mr. Duncan intended to deceive airport screener 
on his questionnaire.''
    Dr. Merlin. That is a fair question, and maybe we need to 
re-look at the questionnaire to see what the language is. I am 
skeptical myself, and there is no way to know. There is no way 
to ask Mr. Duncan. I am skeptical that with Ebola well-
established in Monrovia. I believe this woman he assisted was 
being taken to an Ebola hospital for treatment of Ebola, and 
she was turned away, and this is my understanding, and we can 
probably try to find out the facts on this. I am skeptical that 
he actually thought she had malaria.
    But, you know, to your point, if we are asking whether you 
have been exposed to Ebola, it may have to be have you been 
exposed to anyone who has died of an infectious disease in the 
last period of time, because we need to be sure that we are not 
overly permissive in the questions.
    Mr. Veasey. Also let me get your opinion, again, on how the 
disease is spread. Is it your opinion that it would be highly 
unlikely that the disease would be spread through spit or 
sputum, or if someone sneezed or coughed, or, you know, for 
instance, in airline travel, bodily fluids inside of a 
lavatory?
    Dr. Merlin. In advanced Ebola disease, all bodily fluids 
are highly infectious. For someone with advanced disease, I 
think all of those materials would be highly infectious.
    Mr. Veasey. Including coughing and sneezing?
    Dr. Merlin. Well, you know, coughing, I mean, you would 
basically have to get the splatter into your face or into your 
eyes for it to be infectious. But I want to emphasize that 
people who are traveling, on exit screening, they have had 
their temperatures taken, so they are asymptomatic when they 
board the airlines. They are not going to do develop advanced 
disease on the 8- to 12-hour or 18-hour flight, so there is no 
risk that there is going to be an exposure on aircraft to 
someone with highly-infectious bodily fluids like that. That is 
just not going to happen.
    Mr. Veasey. But if someone could transmit Ebola through a 
conversation, and you do not have on a hazmat suit, if there is 
spit or sputum that is put in someone's eye through a 
conversation, which happens in normal conversations. So are you 
telling us that that would be a way to----
    Dr. Merlin. Yes, but, you know, people who are in close 
contact with someone with advanced disease are at risk. I want 
to emphasize that people who have no symptoms pose no risk to 
anyone. So the asymptomatic individual who coughs and speaks 
poses no risk. Someone who develops symptoms early in disease, 
which is the fever and fluid, they are not highly infectious. 
It is only late in disease. Now, if you are caring for someone 
who has advanced disease, and they cough on you, and they get 
the fluid in your face, yes, that is a risk.
    Mr. Veasey. Okay. One more question before my time expires 
here. Should we be concerned about other strands of the Ebola 
virus? I know you talked earlier about different strands. 
Should we be concerned about other strands of Ebola?
    Dr. Merlin. There are several species of Ebola virus. We 
are now dealing with Ebola Zaire. Yes, we do need to be 
concerned in Africa about all of the other species where they 
are and other outbreaks of Ebola Zaire to be sure that they are 
contained because most of them can cause very severe disease. 
So, yes, we do need to be concerned about the other strains.
    Mr. Veasey. Thank you, Mr. Chairman.
    Chairman McCaul. I thank the witnesses for their testimony. 
This has been very valuable to the American people, and we 
support you and wish you all the best in your efforts to 
control and contain this horrific virus.
    This panel is now dismissed. The clerk will prepare the 
witness table for our second panel.
    [Recess.]
    Chairman McCaul. We are ready to begin our second panel. 
First, we have Dr. David Lakey. He served as the commissioner 
of the Texas Department of State Health Services, leading one 
of the State's largest agencies with a staff of 11,500. He 
oversees programs such as disease prevention and bioterrorism 
preparedness, family and community health services, and many 
others.
    Next, we have Dr. Brett Giroir. He assumed leadership of 
the Texas A&M Science Center in October 2013. I was just there 
a couple of days ago. The center is a premiere assembly of 
colleges devoted to educating health professionals and 
investigators through innovative teaching and research in 
dentistry, medicine, nursing, and biomedical sciences, and the 
list goes on and on. You served as vice chancellor for the 
Center of Innovation and Advanced Development. Your resume is 
very lengthy and very illustrative. Thank you for being here.
    Next, we have the Honorable Clay Lewis Jenkins, county 
judge for Dallas County. He is responsible for the truancy 
court system. In addition, as the chief elected official of the 
county, Judge Jenkins is responsible for the county's disaster 
and emergency preparedness. He appointed a director of homeland 
security and emergency preparedness person to manage the 
county's 24-hour operation. Thank you for being here, sir.
    Last, we have Dr. Troisi, who is an associate professor, 
Division of Management Policy and Community Health with the 
Center for Infectious Diseases at the University of Texas. She 
has expertise in infectious diseases, including influenza, 
hepatitis, sexually transmitted diseases, as well as outbreaks, 
including Ebola as well. Thank you so much for being here.
    The Chairman now recognizes Dr. Lakey for his testimony.

 STATEMENT OF DAVID LAKEY, M.D., COMMISSIONER OF HEALTH, TEXAS 
              DEPARTMENT OF STATE HEALTH SERVICES

    Dr. Lakey. Good afternoon, and thank you, Chairman McCaul, 
and thank you, Ranking Member Sheila Jackson Lee, and thank you 
to all the Members that are here today. I thank you for this 
opportunity to discuss our efforts here in Dallas to prevent 
the spread of Ebola.
    I want to start by saying that I know the people in Dallas 
and the rest of the State, and I know also in the rest of the 
Nation, are scared. Ebola is a frightening disease with grave 
health consequences. It is an unknown, something that we have 
never diagnosed here within the borders before, and the specter 
of the heartbreaking outbreak in West Africa reminds of how 
serious this situation could be.
    But fortunately, Ebola is also a disease that we can fight 
through simple preventative public health measures, measures 
that we have in the United States and have long experience 
with, measures that have had success in that we can depend on 
their effectiveness.
    Regretfully, as you know, Mr. Duncan lost his fight with 
Ebola on Wednesday, and my condolences really go out to the 
family right now. It is hard to image what he and his family 
have endured in the last 2 weeks, and the struggle for Mr. 
Duncan's family is not over yet. Our goal, however, is to 
minimize the possibility that other Texans will be exposed to 
Ebola and, thus, reduce the possibility of another case, 
another death, and another grieving family.
    I know that for all of us our minds weigh heavy on the 
thought of Mr. Duncan's family right now and the 48 individuals 
and their loved ones who must wait another 2 weeks to feel 
confident in their health, uncertain of their future. As Texas 
State's health official, responsibility weighs heavy on me, 
that we identify every possible contact, that we take every 
precaution to prevent the spread of the disease, that we 
monitor individuals closely, and that we are earning the 
Texans' trust in public health prevention and control.
    For decades, public health has taken the role of responding 
to infectious disease events. Public health response includes 
identification of individuals who have been exposed to a 
disease, monitoring people identified as having risk for 
exposure, and immediate care and public health follow-up should 
symptoms become apparent.
    Every infectious disease event is different based on the 
nature of the disease and the scope of the event. Despite these 
differences, the response structure remains the same. In Texas, 
local authorities who best know their affected community lead 
response efforts. That is not to say, however, that local 
officials are alone in this response. Effective disease 
investigation also involves support by the State and by the 
Federal Government.
    We at the Department of State Health Services are always 
prepared to offer local governments our knowledge and our 
experience as they respond to infectious disease events. When 
an event oustrips local capabilities, the State is ready as 
appropriate to take a leadership role. Similarly, the Centers 
for Disease Control and Prevention offers Federal expertise and 
advice, and can provide additional help for large-scale events 
and multi-jurisdictional events.
    The norm in public health is for all three levels of 
government to work in tandem--local, State, and Federal 
government working together in what I call the public health 
enterprise, providing each other support and filling in gaps, 
to provide a cohesive response. I do want to take a second to 
thank the Centers for Disease Control for their on-going work 
here in the State of Texas, for their expertise, the help in 
our laboratory, the epidemiologists that are here in the State 
of Texas, here in Dallas right now.
    This cooperative effort is not always easy, and it is not 
always executed perfectly, but this partnership will provide 
the best results and serve to best protect the public's health. 
In this particular incident, Dallas County Health and Human 
Services is the lead of the investigation and the response 
effort.
    The Department of State Health Services and the Centers for 
Disease Control became very deeply involved early on given the 
significance of this deadly disease. In fact, our State 
laboratory at the Department of State Health Services recently 
qualified to test for Ebola in Austin and is one of 13 State 
laboratories able to do so. For this reason, we were involved 
very quickly, providing consultation about the possibility of 
testing and diagnosis and diagnosing the case in our 
laboratory.
    As you know, we are still in the midst of this response. 
Forty-eight individuals are being monitored for symptoms of 
Ebola due to the risk of exposure. Ten of those individuals are 
considered high-risk. Our response won't be over until we can 
confidently rule out Ebola infection in each of these 
individuals. I want to reassure Texans and the folks in Dallas 
right now that none of these individuals are sick at this 
point, but keep in mind that the symptoms can become evident 
anywhere from 2 to 21 days after exposure.
    As with all response efforts here in Texas, we are learning 
new lessons for improving our preparedness for outbreaks and 
for future disasters. At the end of each event, the Department 
of State Health Services immediately initiates an after-action 
review to determine what went well, what could be improved, and 
how those improvements should be made. The after-action process 
will include local, State, and Federal responders to ensure 
that we are looking at all aspects of this response.
    In the mean time, two themes are apparent. First, we know 
that disease reporting systems work and is key to public health 
workers quickly stopping the spread of disease. Providers and 
facilities must be aware of the responsibility. We as an agency 
must do our part to reinforce this responsibility through 
reminders, through updates, and to easy-to-use reporting 
systems.
    Second, providers must be aware of outbreaks world-wide so 
that they know what diagnoses are possible based on that very 
important travel history. Until the West Africa outbreak is 
over, Ebola must be in the differential diagnosis of those 
individuals who recently arrived from one of the outbreak 
countries. Again, as an agency we must do our part to remind 
providers and facilities about outbreaks in other countries 
through our current communication chains, by harnessing Federal 
reminders, and by keeping health care providers armed with up-
to-date procedures and guidance.
    The importance of taking a travel history cannot be 
understated given the interconnected world in which we live. 
After the Ebola response ends and there has been time to 
thoroughly evaluate the entire event, we will complete an 
analysis of the event in our plan to improve response efforts 
going forward.
    In support of this effort and to improve the response in 
Texas, our Governor, Rick Perry, has announced the formation of 
the Texas Task Force for Infectious Disease Preparedness and 
Response to assist and enhance the State's capabilities to 
respond to outbreaks such as we are in right now. I am a member 
of this task force, and I look forward to working on this 
important effort with others who have expertise in fields like 
epidemiology, preparedness, and response.
    For now, we are focusing on our immediate job, ensuring 
that there are no more exposures related to this case in 
Dallas. We know that we can complete this job successfully. We 
know this because the science is sound. Ebola spreads through 
the direct contact with bodily fluids, and there is very little 
risk otherwise. Individuals are not contagious until they have 
symptoms.
    Ebola does not thrive in the environment, and it is easily 
killed. Infection control is prevalent in United States 
hospitals. We have the supplies, the equipment, and the 
protocols to minimize the chance of disease spread within our 
hospitals. Prevention in the community is simple: Maintaining 
hand-washing hygiene and to avoid direct contact with people 
who are medically suspected or known to have Ebola. Most 
importantly, we know that we can and will successfully complete 
this job because we have done so in the past.
    The dependable results of sound public health measures have 
been proven on diseases like tuberculosis, measles, and Middle 
East Respiratory Syndrome. We have a history in public health 
of successfully containing the spread of disease and protecting 
the public, and I am confident we will do the same here with 
this case of Ebola. Thank you, sir.
    [The prepared statement of Dr. Lakey follows:]
                   Prepared Statement of David Lakey
    On October 8, 2014, Thomas Eric Duncan passed away as a result of 
contracting the Ebola virus in Liberia. Mr. Duncan was provided 
therapeutic care at Texas Health Presbyterian Hospital in Dallas, 
Texas, but he was unfortunately unable to recover from this often fatal 
disease.
    Mr. Duncan's death is a reminder of the importance of disease 
prevention and control, and provides additional meaning to efforts in 
Texas to prevent further exposure to the disease. The goal in Texas is 
to continue to minimize risk, thus reducing the likelihood of another 
Ebola death within the State.
    Every sympathy and concern is extended to Mr. Duncan's family, as 
they both grieve for their loved one and worry for their own health.
                    background: ebola case in dallas
    On September 30, 2014, the Department of State Health Services 
(DSHS) Laboratory and Centers for Disease Control and Prevention (CDC) 
tested a specimen for Ebola virus, and found it positive. This is the 
first Ebola patient to be diagnosed in the country.
    The patient contracted Ebola in Liberia, and was not symptomatic 
when travelling into the United States. Ebola is only communicable when 
an infected person is ill with symptoms. During the incubation period, 
when no symptoms are present, a person is not infectious.
    Texas Presbyterian Hospital received the patient, and contacted the 
Dallas County Health and Human Services on September 28, 2014, after 
the patient was transported to the emergency room by ambulance. He had 
previously presented at the hospital on September 26, was evaluated, 
provided medications, and discharged. Dallas County contacted DSHS and 
the CDC, to allow for coordination. Texas Health and Safety Code, 
Chapter 81, requires that Viral Hemorrhagic Fever (Ebola) be 
immediately reported to the local health department, which in turn 
notifies State and Federal partners, as warranted.
    Once Ebola was suspected as a possible diagnosis on the 28th, 
Dallas County began a public health investigation to determine if 
others were exposed to the virus while the patient was symptomatic. 
After the patient's diagnosis, DSHS and CDC staff were on-site to 
provide assistance in the epidemiological investigation. The initial 
investigation identified 114 individuals who may have had contact with 
the patient. Additional investigation narrowed this number down, and a 
total of 48 contacts of varying risk were identified for monitoring. 
The investigation is on-going.
    Ebola symptoms can become evident between 2 and 21 days after the 
initial infection. However, 8 to 10 days is the most common time frame 
for Ebola symptoms to become apparent. Ebola is only transmittable 
through direct contact with blood or body fluid, or exposure through 
contaminated objects, such as needles. Direct contact requires exposure 
through broken skin or unprotected mucous membranes.
    By determining whether contact with the patient occurred, and 
whether possible contact was direct or indirect, investigating 
epidemiologists concluded that 10 individuals should be considered 
high-risk exposures. All 48 identified contacts were placed under 
monitoring for symptoms, with regular visits from local, State, and CDC 
health department officials.
    The 48 individuals will be monitored until they have passed the 21-
day threshold for presentation of symptoms.
                infectious disease surveillance in texas
    The State of Texas is divided into eight DSHS health service 
regions. In areas where a local health department exists, DSHS health 
service regional offices provide supplemental or supporting public 
health services. In areas where there is no local health department, 
DSHS health service regional offices act as the local health authority.
    Local health departments are of varying size, resources, and 
capacities. While some health departments, like Dallas County, support 
a full array of services, others have more limited functions. 
Approximately 60 health departments in Texas are ``full service,'' 
while 80 offer fewer services. DSHS' role is to fill in, as needed, 
core public health services not offered at the local level.
    For infectious disease, DSHS health service regions ensure that 
disease surveillance occurs in every Texas county through the continual 
and systematic collection, analysis, and interpretation of health data. 
This effort is dependent on disease reporting by providers, which is 
required by law. Currently, in Texas, over 60 conditions are subject to 
mandatory reporting, including: Food-borne, vector-borne, respiratory, 
and sexually transmitted diseases. Viral Hemorrhagic Fever, or Ebola, 
is an immediately-reportable disease in Texas.
    In order to allow real-time monitoring of disease surveillance 
data, the CDC provides and maintains the National Electronic Disease 
Surveillance Network (NEDSS) for use by local, regional, and State 
health departments. NEDSS is used by nearly every local health 
department in the State, and allows DSHS to identify unusual increases 
or pattern shifts in disease numbers.
    In concert with NEDSS, Electronic Laboratory Reporting (ELR) has 
improved the timeliness and comprehensiveness of diseases reporting. 
ELR electronically links laboratory test reports to NEDSS, allowing 
immediate access by DSHS or the local health department with legal 
jurisdiction.
         infectious disease investigation and response in texas
    Timely disease reporting to the public health system is imperative 
for quick mobilization of public health investigation and response 
efforts. Since Texas is a home-rule State, epidemiological 
investigations begin at the local level, unless there is no local 
health department. This local responsibility aids in effective 
epidemiological investigations by ensuring that investigations are 
based on close understanding of the community and its residents. While 
local entities have the statutory responsibility to lead infectious 
disease investigations, State and CDC guidance is available and widely-
used.
    More complicated or wide-spread events can increase the State and 
Federal roles. If an outbreak involves multiple jurisdictions, the 
State role becomes more prominent. If, at any time, an investigation 
goes beyond local capabilities, the State may take the lead. In turn, 
if an investigation exceeds State resources, the State may ask the CDC 
for assistance. Additionally, the CDC leads multi-State investigations. 
No matter the level of outbreak, the norm is for all three levels of 
Government to work in cooperation, with varying levels of State and 
Federal involvement depending on the size and type of infectious 
disease event, and the resources and expertise of the local entity. 
Throughout the event in Dallas, the State and local authorities have 
been supported by CDC, both in the field and by home office staff.
    Support provided by the State and CDC can include a number of 
options, depending on the scope of an investigation and local needs. 
This support might consist of subject-matter expertise and on-site 
assistance; State or CDC laboratory testing; provision of personal 
protection equipment; or mobilizing of DSHS Rapid Assessment Teams or 
CDC Epi-Aids. The State and CDC can also assist with administering 
questionnaires and interviews to cases and potential contacts, 
inspecting relevant hospital facilities or restaurants, and helping 
examine pertinent records.
    In cases of large-scale outbreaks, the State Medical Operations 
Center (SMOC) at DSHS may be activated. The SMOC is staffed by DSHS 
Community Preparedness, Infectious Disease, and Communications staff. 
Its function is to ease the flow of information among multiple 
jurisdictions, provide dependable tracking of events, and facilitate 
requests for resources and supplies from local jurisdictions. For the 
Ebola case and investigation in Dallas, the SMOC has been activated.
            successful infectious disease response in texas
    The public health response system in Texas, led by local entities 
and supported by State and Federal government, has a long history of 
successful outbreak responses. Texas has effectively contained events 
involving disease like Tuberculosis, measles, hepatitis, and Middle 
East Respiratory Syndrome (MERS).
    As an example, DSHS disease investigators are currently assisting 
the local health authority in El Paso, Texas, to track a number of 
exposures to Tuberculosis (TB) that occurred through a health care 
worker in the labor and delivery unit of a local hospital. This 
situation is a prime example of how, under the current system, all 
levels of government successfully work together to respond to an 
infectious disease event.
    Once the index case was identified, local and State health 
department investigators meticulously examined hospital records to 
determine infants, parents, coworkers, and volunteers who were at risk 
of exposure. This investigation identified an initial 3,227 
potentially-exposed newborns, and 69 potentially-exposed health care 
workers. Together, public health workers evaluated the index case's 
history to determine where exposure may have actually occurred. Then, 
they prioritized potential contacts by level of risk, decided on a 
contact investigation protocol specific to this incident, and executed 
the contact investigation. The CDC has been on-site to provide 
assistance, and home office CDC staff has provided expertise and 
advice. International coordination took place due to the city's 
proximity to the U.S.-Mexico Border; interstate coordination with New 
Mexico was also necessary.
    While the investigation is not yet complete, its results are 
already evident. Public health investigators were able to narrow down 
the initial 3,227 number to 757 infants who had some level of risk of 
exposure. Follow-up with parents occurred, and testing was recommended, 
as appropriate, for potentially-exposed children. Additionally, DSHS 
gave providers guidance on treatment algorithms for possible cases. Of 
the 503 infants tested, six have tested positive for TB infection, and 
are being treated to ensure they do not develop active TB. Of the 58 
health care workers tested, four tested positive for TB infection, and 
public health follow-up will ensure that these positive cases do not 
develop into a risk for further community exposure.
 initial lessons learned: ebola case and investigation in dallas, texas
    The Ebola investigation is on-going, but events like the TB 
exposure in El Paso and past infectious disease events reveal key 
themes to successful prevention and control of disease outbreaks in 
Texas and in the country.
    The crux of infectious disease response is reporting. Providers 
must be aware of what diseases are reportable to their local health 
department, and promptly report contagious disease through the 
reporting system. Provider awareness of this responsibility allows for 
more effective disease surveillance, and more timely response to 
developing infectious disease events. DSHS works to reinforce this 
requirement through reminders, updates, and by making the reporting 
system user-friendly.
    Secondly, the Ebola case in Dallas highlights the need for 
providers to vigilantly take travel histories, and streamline sharing 
of this information while a patient is being diagnosed. Providers must 
be aware of outbreaks worldwide, to inform their consideration of 
patient travel history. Until the Ebola outbreak in West Africa is 
over, Ebola must be a differential diagnosis for those who have 
recently traveled from one of the outbreak countries. At the same time, 
moving forward, providers must be aware of what other outbreaks are 
occurring internationally. Electronic notifications from the CDC help 
providers stay informed, and these messages can be strengthened through 
State and local-level communications.
                        after-action assessments
    After the response to the Ebola case and investigation comes to a 
close, DSHS will perform an after-action review of the response to this 
situation. Throughout the event, responders keep in mind how the 
response flows, what difficulties are encountered, and what successes 
are achieved. After the response, a thoughtful assessment brings all 
these experiences into one evaluation. An after-action review is 
essential to close out any response effort, in order to improve future 
responses. The assessment will include input from local, State, and 
Federal responders who were part of the effort, and will analyze each 
part of the response. The assessment will determine what worked, what 
can be improved, and how those improvements can be made. The final 
result will be enhanced preparedness plans for future infectious 
disease events.
    In addition, Texas Governor Rick Perry has formed a Texas Task 
Force on Infectious Disease Preparedness and Response, the purpose of 
which is to assess and enhance the State's capabilities to respond to 
outbreak situations. The task force is composed of 17 members, headed 
by infectious disease and Ebola experts, and will be supported by DSHS 
and other State agencies. The Task Force will evaluate infectious 
disease response in Texas, and determine what recommendations can be 
made for improvements, either through agency or legislative action. The 
Task Force will make its report to the Texas State Legislature in 
December 2014.
                               conclusion
    The response to the Ebola case in Dallas is on-going. Conclusion of 
this event will allow a systematic review of the response efforts, and 
the Governor's Task Force on Infectious Disease Preparedness and 
Response will facilitate an evaluation of the public health response 
system as a whole. It is evident from a long history of success that 
public health interventions work, and that infectious disease 
investigation and follow-up can stop the spread of disease. However, 
each infectious disease event provides a new opportunity to make 
improvements to disease investigation response and coordination among 
public health entities. The current focus is on ensuring that no more 
Texans are exposed to the Ebola virus. When that mission is complete, 
the focus will shift to recommending and implementing improved plans 
for future infectious disease response in Texas.

    Chairman McCaul. Thank you, Dr. Lakey.
    The Chairman recognizes Dr. Giroir.

 STATEMENT OF BRETT P. GIROIR, M.D., EXECUTIVE VICE PRESIDENT 
 AND CEO, TEXAS A&M HEALTH SCIENCE CENTER, AND DIRECTOR, TEXAS 
   TASK FORCE ON INFECTIOUS DISEASE PREPAREDNESS AND RESPONSE

    Dr. Giroir. Mr. Chairman, Members of the committee, thank 
you for inviting me to testify before you today. By training I 
am a critical care physician and formerly served in the Federal 
Government as director of the Science Office at DARPA and also 
on the Defense Threat Reduction Advisory Committee where I 
chaired the biological and chemical panel.
    On Monday, October 6, Governor Perry named me as the 
director of the Texas Task Force on Infectious Disease 
Preparedness and Response. The task force includes 
internationally-recognized biomedical experts joined by State 
agency CEOs, not only from Health and Human Services, but also 
from transportation, environmental regulation, public 
education, and diverse other areas.
    Why such diversity? Because the Dallas case proves that an 
effective response requires much more than public health 
professionals alone. For example, waste disposal was 
complicated by broad challenges, including decontamination 
decisions, temporary housing, availability of containers, 
vehicle logistics and availabilities, and permitting for 
transportation and disposal spanning multiple jurisdictions. 
Cleaning a single apartment generated 140 55-gallon containers 
of Class A hazardous waste, each of which then needed to be 
transported to an incinerator licensed for such disposal.
    We believe that the response and coordination of local, 
State, and Federal resources in Dallas has been very good, but 
there will be areas for improvement and lessons learned. Our 
task force has already been very active and has identified 
seven major areas for assessment and recommendation. These 
include hospital preparedness for patient identification and 
isolation; command and control, including education and 
activation of the incident command structures, implementation 
of epidemiological investigations and patient monitoring; 
decontamination and waste disposal; complexities of patient 
care, including use of experimental therapies; care of contacts 
being monitored by public health officials; and as highlighted 
in the Spanish case, we have also added management of domestic 
animal exposures.
    Now, I would like to respectfully offer three suggestions 
for consideration by Congress and the President on how to 
improve our preparedness and response. The first is to 
reestablish the special assistant to the President for 
biodefense. Doing so would restore leadership, accountability, 
and consistent prioritization at the highest level of 
Government. This position had existed both under the President 
Clinton and President Bush administrations, and I would refer 
you to Congressman Thornberry and Congressman Langeven's letter 
to the President on April 22, 2014 about this very subject.
    Point No. 2, restore funding to hospital preparedness 
programs. Our Nation's public health infrastructure has been 
significantly impeded by cuts to the Federal Hospital 
Preparedness Program, which has been reduced from approximately 
$500 million per year in fiscal year 2007 and 2008 to $230 
million today. There should also, however, be clear metrics for 
success, accountability for that success, and close integration 
with FEMA emergency management programs.
    Point No. 3, set clear deliverables and accountability for 
new vaccines and therapies. In terms of the availability of 
medical countermeasures against Ebola and many other threats, 
our country is woefully deficient. This relates both to 
scientific and technical obstacles, but also a lack of 
prioritization, accountability, and funding that is based on 
outcomes. As the Government is now prioritizing Ebola, it is 
critical that we backfill all funding that has been redirected 
from other biodefense priorities. We should not fight the 
battle against Ebola at the cost of forfeiting the broader war 
against other menacing diseases, such as pandemic influenza or 
Middle Eastern Respiratory Syndrome.
    On a final note is that the Texas A&M Health Science Center 
is home to one of three BARTA-funded National centers to 
develop and manufacture vaccines and medical countermeasures 
against chemical, biological, radiological, and nuclear 
threats. Each center, including our own, will be responsible 
for producing 50 million pandemic vaccine doses within 4 months 
of receipt of the referenced strain. Our center and the others 
are also fully capable of supporting development and 
manufacture of vaccines and therapeutics against Ebola if 
requested by the Federal Government.
    In closing, thank you, Chairman McCaul, and the Members of 
the committee for your leadership and for engaging on this 
critical aspect of National security.
    [The prepared statement of Dr. Giroir follows:]
                 Prepared Statement of Brett P. Giroir
    Chairman McCaul and Members of the committee: I am Dr. Brett 
Giroir, chief executive officer of Texas A&M Health Science Center, and 
professor in the Colleges of Medicine and Engineering. By training, I 
am a critical care physician-scientist with specific experience in 
treating life-threatening infectious diseases. I also have experience 
in the Federal Government as director of the Defense Sciences Office at 
the Defense Advanced Research Projects Agency (DARPA) and chair of the 
Chemical and Biological Defense Panel of the Department of Defense 
Threat Reduction Advisory Committee. In addition, earlier this week, 
Governor Perry named me director of the Texas Task Force on Infectious 
Disease Preparedness and Response.
    The risk of infectious disease outbreaks is real, and these 
outbreaks are inevitable given the interconnected nature of the world 
we live in. An outbreak anywhere becomes a threat everywhere. Given our 
location along the U.S. border, our experience with major natural 
disasters, and our unique assets such as the Galveston National 
Laboratory and the Texas A&M Center for Innovation in Advanced 
Development and Manufacturing (CIADM), Texas is on the front lines of 
public health preparedness and protection.
    In response to the first case of Ebola diagnosed in the United 
States, Governor Perry swiftly established the Task Force on Infectious 
Disease Preparedness and Response to assess and manage the risk in 
Texas and to prospectively plan for future infectious disease threats--
whether natural or the result of bioterrorist attacks. The Task Force 
includes internationally-recognized infectious disease and public 
health experts, seasoned biodefense leaders, and State agency 
professionals across major areas including health and human services, 
emergency management, public safety, transportation, environmental 
quality, public education, and housing and community affairs. The 
members of this task force volunteered in order to serve the people of 
Texas, and as a result, the Nation, and each of us has accepted this 
call to duty from the Governor for that sole purpose.
    There is no question that there will be opportunities for increased 
performance across many of the complex elements that have been brought 
together to effectively contain Ebola within Texas. Remember, this was 
the first Ebola patient to be diagnosed in the United States. If there 
is room for improvement, we will work to assure that Texas learns, 
documents, disseminates information, and implements optimal changes to 
further protect our citizens--and that the United States, as a whole, 
benefits from the process. The Texas Task Force took action right away, 
meeting for the first time immediately after the Governor issued the 
executive order, and we have been actively engaged in assessments and 
discussion since that time. We have preliminarily identified six areas 
of focus that have been prominent in the current Ebola response, and we 
believe that these areas will have implications for many potential 
disease outbreaks should they arrive in the United States. These areas 
include:
    1. Hospital Preparedness and the Potential Role of Improved Rapid 
        Diagnostics.--The Task Force will focus on the initial 
        identification of a patient, or potential patient, and the 
        education and preparedness of diverse health care professionals 
        essential for this key step in the containment process.
    2. Command and Control Issues.--The Task Force will focus on 
        processes related to the initial activation of the Incident 
        Command Structure, integration of local, State, and Federal 
        resources, development of a common operating picture, and the 
        unique differences of a public health challenge, such as an 
        Ebola patient, compared to the challenges experienced in 
        natural disasters such as hurricanes.
    3. Organization and Implementation of Epidemiologic Investigations 
        and Monitoring.--The Task Force will assess opportunities for 
        improved integration of disease tracking, data and information 
        synthesis, and potential opportunities for automated 
        technologies and scalable common data platforms that could be 
        shared at the local, State, and Federal levels.
    4. Decontamination and Waste Disposal.--The Task Force will review 
        and assess a plethora of issues faced in this area, including 
        but not limited to: Determining what could be decontaminated, 
        versus contained-hauled-incinerated, availability of 
        appropriate containers, logistics of transport, and complex 
        permitting issues across multiple levels of jurisdiction.
    5. Patient Care Issues.--The Task Force will examine how to improve 
        information flow to front-line care providers, including 
        information on new drugs, their risks and potential benefits, 
        and how they might be accessed under investigational protocols.
    6. Care of Patients Being Monitored.--The Task Force will examine 
        the diverse needs of individuals under monitoring or controlled 
        monitoring, including the needs for basic necessities, such as 
        food, clothing, and housing, as well as potential needs for 
        social services and/or counseling. Due to the rich diversity of 
        the Texas population, cultural competency in communication and 
        interactions are important aspects of this area.
    The Task Force will submit initial draft assessments and 
recommendations by December 1 for consideration by the Office of the 
Governor and Texas Legislature, so that actions requiring statutory 
changes could be proposed in the 2015 legislative session. In the mean 
time, the Task Force is committed to insuring that the teams on the 
ground have all necessary expertise and resources at their disposal to 
respond to the potential for additional Ebola cases in Texas, and to 
begin the process of developing an infectious disease preparedness and 
response plan to complement the State Emergency Management Plan already 
in place and proven highly effective in response to natural disasters.
    Regarding the current situation here in Dallas, the response and 
coordination of local, State, and Federal resources has generally been 
very good, but the Task Force will seek opportunities for improvement 
at all levels of collaboration and integration. Looking forward, the 
issues at hand are highly dependent on the larger security and 
preparedness system. State and local planning is critical, but so is 
clear and defined support to local and State authorities from the 
Federal Government, including the Centers for Disease Control (CDC) and 
Office of the Assistant Secretary for Preparedness and Response (ASPR). 
While there have been lessons learned, the successes in controlling 
this potentially dangerous situation are a testament to the incredible 
skill and dedication of all those on the ground in Dallas, who in my 
mind are nothing less than National heroes.
     gaps in hospital preparedness and public health infrastructure
    It is important to understand that our State's and the Nation's 
public health infrastructure has been subject to significant funding 
reductions in the Federal Hospital Preparedness Program (HPP), which is 
intended to provide funding and support to improve surge capacity and 
enhance community and hospital preparedness for public health 
emergencies. These funds are expressly for enhanced planning at the 
State and local level, for increased integration across the public and 
private health care sectors, including hospitals, and other health care 
organizations and providers, and for improving infrastructure for 
public health emergencies. It should come as no surprise that hospitals 
require public funding to train and prepare for what are low-
probability yet high-consequence, and potentially catastrophic, events.
    HPP is meant to provide the foundation and core for exercises and 
ability to respond and get information out so that the nurse or 
physician on the front line would contemplate Ebola or anthrax in their 
differential diagnosis. HPP has been cut significantly in recent years 
by the Federal Government, and these actions have had clear, 
identifiable consequences here in Dallas. In fact, during the Federal 
Budget compromise last year, HPP funds were diverted to fund the 
Biomedical Advanced Research and Development Authority (BARDA) rather 
than use another funding source that was suggested by Congressional 
leaders. While we are very thankful this action allowed BARDA to 
continue operations (especially since the importance of its mission has 
been made abundantly clear during this Ebola response) robbing Peter to 
pay Paul has left us less far less prepared than we could have been, 
and indeed should have been. This must change if we are to be prepared 
for public health emergencies, now and in the future.
   guidelines for health preparedness and technological field support
    In January 2012, ASPR issued ``Healthcare Preparedness 
Capabilities,'' providing National guidelines for health care system 
preparedness. Unfortunately, several of the critical capabilities 
identified in the report remain problematic areas in our public health 
preparedness and response infrastructure.
    For instance, ASPR recommendations address the ability to 
coordinate multiple agencies and their decision making, to provide 
incident information sharing, to manage resource implementation, to 
provide an inventory management system, and to notify stakeholders of 
health care delivery status. In reality, the incident command team does 
not have the necessary technology in place to provide data tracking and 
analysis that would support the prescribed common operating picture 
across the multiple layers necessary to coordinate an effective and 
integrated response. Currently, information is housed on individual 
laptops and other devices, being reported manually, and compiled once 
or twice daily for the Texas Department of State Health Services 
Commissioner, Dr. David Lakey, who is leading the response in Dallas, 
and to whom we all owe a debt of gratitude, along with his colleagues 
in the CDC and other responders, who are working around these 
technological coordination challenges to the degree possible.
    Another critical capability outlined by the ASPR report, 
Information Sharing, is to ``Provide health care situational awareness 
that contributes to the incident common operating picture.'' This 
critical capability has not been realized in the current Ebola 
scenario. In short, our public health infrastructure has not kept pace 
with technological and communications breakthroughs that are now wide-
spread, and also has not yet incorporated tools to facilitate data 
collection, analysis, communication, and decision making. This reality 
must be acknowledged by ASPR leadership, and a strategy to address 
these significant challenges should be developed in partnership with 
the caregivers at the epicenter of the current Ebola containment 
mission.
     national inventory of potentially available ebola therapeutics
    Another major gap is the lack of any sort of inventory of candidate 
therapeutics to treat Ebola patients who are brought to the United 
States for treatment or who are diagnosed in our country. The fact of 
the matter is that we had a person fighting for his life on American 
soil and no easily available information about drugs available to 
administer. This is not a new issue; Dr. Keith Brantley received ZMapp 
in August by hearing about it from a colleague, not from U.S. Federal 
authorities. Unfortunately, because of a number of issues as further 
described in this testimony, ZMapp was not available to be given to Mr. 
Duncan.
    The Federal Government should provide a timely and frequently-
updated list of all possible medical countermeasures to treating 
physicians or to appropriate State public health officials. This list 
should include a concise summary of risks and potential benefits, 
instructions for how to obtain these therapies, and also should insure 
that there are specific research protocols in place to capture the 
meaningful data that will be generated through the use of these drugs. 
Today, physicians and patients often must track down the companies 
directly and ask for the drug candidates, or officials such as myself 
use personal contacts within the Government to provide as much 
information as possible to the hospital treatment team. This is both 
inefficient and time-consuming--and thus leaves patients and doctors 
less than optimally equipped in this struggle for life and death of a 
critically-ill patient. This is completely unacceptable given the more 
than decade-long effort the Federal Government has undertaken to 
evaluate and advance medical countermeasures.
    In terms of availability of therapies or vaccines against Ebola, 
our country is woefully and indeed frighteningly deficient. While it is 
true that the mainstay of Ebola treatment is supportive care, that is 
only the case because we have little else to offer. It is my personal 
assessment after experiences in both the academic and Federal sectors 
that this deficiency relates less to scientific and technical 
obstacles, than it does to the lack of Federal prioritization of the 
efforts; lack of clear Federal leadership accountability; and 
difficult, if not oppressive, contracting procedures that are often at 
odds with the iterated National strategy and objectives.
            special assistant to the president on biodefense
    When Congress created the assistant secretary for preparedness and 
response role in 2006 as part of the Pandemics and All Hazards 
Preparedness Act, ASPR was intended precisely for the kind of situation 
we face today with Ebola. The Nation was to be provided with a Senate-
confirmed assistant secretary to take an all-hazards approach to bring 
to bear all necessary resources, regardless of where they belong on the 
Federal Government's organizational chart. That resource exists today 
in ASPR, but what is critically lacking is a White House Special 
Assistant to prepare for and lead such responses. Unfortunately, that 
position was eliminated by the current administration in January 2009.
    We commend Chairman W. ``Mac'' Thornberry and James Langevin, 
Ranking Member, of the House Armed Services Committee Subcommittee on 
Intelligence, Emerging Threats, and Capabilities, for their April 22, 
2014 letter to the President on this very topic, in which they call for 
the appointment of a Special Assistant to the President for Biodefense. 
This position has existed under both the Clinton and Bush 
administrations but was eliminated early in 2009. The letter notes that 
``there are at least 12 separate Government agencies with biodefense 
responsibilities.'' As pointed out in a 2001 U.S. Government 
Accountability Office report, ``Opportunities to Reduce Potential 
Duplication in Government Programs, Save Tax Dollars, and Enhance 
Revenue,'' there are more than ``two dozen Presidentially-appointed 
individuals with some responsibility for biodefense.''
                         contracting authority
    ASPR, which is housed within the U.S. Department of Health and 
Human Services, oversees BARDA and the Office of Acquisitions 
Management, Contracts and Grants (AMCG). Several years ago an 
administrative decision was made to centralize all contracting under 
AMCG, and remove it from under BARDA's responsibility. While this made 
sense at the time, in practice, this has significantly slowed BARDA's 
efforts to move medical countermeasures through the manufacturing 
pipeline. Returning contracting authority to BARDA would certainly 
clear the way for the development of medical countermeasures, including 
experimental Ebola therapies. I want to specifically state that my 
team, and indeed most if not all of the scientific and technical 
community, has great respect for the leadership and technical expertise 
of BARDA. Without BARDA, the country would be gravely behind the curve 
without even the basic National response infrastructure to address this 
problem, or ever-present global challenges such as pandemic influenza.
                 texas a&m ciadm and ebola therapeutics
    As you know, the Texas A&M Center for Innovation in Advanced 
Development and Manufacturing is a public-public-private partnership 
with the U.S. Department of Health and Human Services and 1 of 3 
Government-funded biosecurity centers designed to enhance the Nation's 
preparedness against pandemic influenza, and chemical, biological, 
radiological, and nuclear threats by accelerating the research and 
development of vaccines and therapeutics, and rapidly manufacturing 
these products at scale in cases of National emergencies. The Texas A&M 
CIADM is responsible for producing 50 million vaccine doses within 4 
months of a declared influenza pandemic and receipt of the viral 
strain. It is also responsible for having the capabilities to 
manufacture, at scale, vaccines or biological therapeutics required for 
an outbreak, such as Ebola, if requested by the Federal Government. Our 
team is made up of leading academic, non-profit, and commercial 
partners including GSK.
    The Texas A&M CIADM represents a long-term, strategic initiative--
sponsored by BARDA--to assure preparedness by creating indispensable 
infrastructure and staff capabilities to rapidly respond against highly 
diverse threats. The CIADM will deliver on several critical objectives, 
including:
   Ensure the United States can develop and manufacture life-
        saving vaccines and therapies quickly, flexibly, and cost 
        effectively at scale;
   Improve the ability to protect the health of Americans in 
        response to emergency situations; and
   Train an expert workforce that can fill the needs of 
        National biosecurity for the next generation.
    The Center stands ready, and if called upon, will compete for 
manufacturing of a wide range of vaccines or therapeutics required by 
the U.S. Government, including products against Ebola. Texas A&M Health 
Science Center also has a proprietary vaccine candidate now in 
preclinical evaluation that holds promise as one of the weapons against 
this growing global threat.
    In closing, I thank you Chairman McCaul, and the Members of the 
committee for your leadership and for engaging on this important series 
of challenges that I have outlined. The members of the Texas Task Force 
and Texas A&M Center for Innovation want to be seen as your partners in 
solving the current Ebola situation in Texas and building a resilient 
and prepared homeland that can overcome threats, regardless of the 
source. I am honored and privileged to serve as resource to you now and 
going forward.

    Chairman McCaul. Thank you, Dr. Giroir. Let me say the 
Governor, I believe, made an excellent choice appointing you to 
be the head of this task force. Thank you.
    Dr. Giroir. Thank you, sir.
    Chairman McCaul. Judge Jenkins.

  STATEMENT OF HON. CLAY LEWIS JENKINS, JUDGE, DALLAS COUNTY, 
                             TEXAS

    Judge Jenkins. Well, thank you, Chairman McCaul, 
Congresswoman Sheila Jackson Lee, Members of this committee, 
and my friends from the Texas delegation who are here with us 
today. Thank you for your support in this challenging response.
    Local government has treated everyone involved in the Ebola 
with dignity, and compassion, and as fellow human beings, not 
merely as disease contacts. In interacting with Louise and 
those three young men, it was important that I followed all CDC 
protocols to avoid any chance of spreading that virus. But it 
was important that I not move that family wearing a hazmat 
suit. It was important for them to see me as a fellow human 
being face-to-face, and for me to converse with them as equals. 
That is a basic tenant of leadership, and it is in keeping with 
modern medicine.
    Louise Troh and those three young men have been handling an 
extraordinarily scary, sad, and difficult situation with grace. 
Louise and Eric's 19-year-old son, Karsiah, is a fine young 
man, forced to deal with the loss of his father without being 
able to hug and hold his mother. The death of Eric Duncan is 
the loss of a father, a fiancee, a son, and a person that was 
loved by an extended family.
    Forty-eight people were found to be potentially exposed, 
disease contacts, by the excellent epidemiological and disease 
detection work performed by Dallas County, the State of Texas, 
and the Federal Government. For these 48 people and their 
families, this remains a tense and anxious period. They all 
need our thoughts and prayers, thankfully all without symptoms 
or fever on this the 12th day of monitoring.
    We are one team, one fight, and we are committed to working 
together. We activated our Dallas County Emergency Operations 
Center, and we are operating under the incident command system 
with Federal, State, county, and city assets. Many partners, 
but one team, one team and one fight. Simply put, there is no 
other way to stop Ebola.
    There is a lot of fear out there, and I understand why. 
Ebola is a scary, terrible disease. However, there is a 0 
percent chance of contracting Ebola without coming into contact 
with the bodily fluids of a symptomatic Ebola victim. People 
who have been exposed to Ebola but have no fever or symptoms 
cannot transmit the virus.
    We must not allow fear and panic to weaken our resolve, nor 
force us to abandon the values that that have built this great 
country. Everybody has a job to do in this outbreak. The 
Federal, State, and local governments are doing their job. I 
urge Congress to pass the appropriations necessary to fight 
Ebola in Africa, which is the best way to stem the epidemic, 
protect humankind, and for you to perform your important role 
in the strengthening and streamlining of Ebola response in the 
United States.
    We are doing something that has not been done before, and 
we cannot fail. We will contain Ebola in Dallas, Texas. It is 
only a matter of time before the next case comes to our shores. 
Help us win this fight. We must win now. Work with us to fight 
this disease abroad and strengthen our public health security. 
Thank you.
    [The prepared statement of Judge Jenkins follows:]
                Prepared Statement of Clay Lewis Jenkins
                            October 10, 2014
    Local government has treated everyone involved in this Ebola crisis 
with dignity and compassion as fellow human beings; not merely as 
disease contacts.
    In interacting with the family, it was important that I followed 
all CDC protocols to avoid any chance of spreading the virus. It was 
also important that I not move the family while wearing a hazmat suit; 
for them to see me face-to-face and for me to converse with them as 
equals.
    That is a basic tenet of leadership and in keeping with modern 
medicine.
    Louise Troh and the three young men have been handling an 
extraordinarily scary, sad, and difficult situation with grace. Louise 
and Eric's 19-year-old son Karsiah is a fine young man forced to deal 
with the loss of his father without being able to hug and hold his 
mother.
    The death of Eric Duncan is the loss of a father, fianceee, son, 
and person loved by an extended family.
    Forty-eight people were found to be potentially-exposed disease 
contacts by the excellent epidemiological and disease-detection work 
performed by Dallas County, the State of Texas and the Federal 
Government. For these 48 people and their families, this remains a 
tense and anxious period. They need all of our thoughts and prayers. 
Thankfully, all are without symptoms or fever on this twelfth day of 
monitoring.
    We are one team, one fight, and we are committed to working 
together.
    We activated our Dallas County Emergency Operations Center and are 
operating under the Incident Command System with Federal, State, 
county, and city assets. Many partners, but one team.
    One Team, One Fight! Simply said, there is no other way to stop 
Ebola.
    There is a lot of fear out there and I understand why. Ebola is a 
scary, terrible viral disease. However, there is a 0 percent chance of 
contracting Ebola without coming into contact with the bodily fluids of 
a symptomatic Ebola victim. People who have been exposed to Ebola but 
have no fever or symptoms cannot transmit the virus. We must not allow 
fear and panic to weaken our resolve nor abandon the values that built 
this great Nation.
    Everybody has a job to do in this outbreak. The Federal, State, and 
local governments are doing their jobs. I urge Congress to pass the 
appropriations necessary to fight Ebola in Africa which is the best way 
to stem the epidemic, protect humankind, and for you to perform your 
important role in strengthening and streamlining the Ebola response in 
the United States.
    We are doing something that has not been done before and we cannot 
fail. We will contain Ebola in Dallas, Texas. It's only a matter of 
time before the next case comes to our shores. Help us, help us win 
this fight. We must win now. Work with us to fight this disease abroad 
and strengthen our public health security.

    Chairman McCaul. Thank you, Judge.
    The Chairman recognizes Dr. Troisi.

 STATEMENT OF CATHERINE L. TROISI, PH.D., ASSOCIATE PROFESSOR, 
DIVISION OF MANAGEMENT, POLICY, AND COMMUNITY HEALTH CENTER FOR 
          INFECTIOUS DISEASES, THE UNIVERSITY OF TEXAS

    Ms. Troisi. Thank you. Chairman McCaul, Ranking Member 
Jackson Lee, and Members of the committee, I am Catherine 
Troisi, an infectious disease epidemiologist at the University 
of Texas School of Public Health, and I have also practiced 
public health at the local level. I am a member of the American 
Public Health Association and the Texas Public Health 
Association. Adequate funding of all levels of public health 
system is a top priority for these organizations.
    I would like to start with a definition of ``public 
health,'' a term that is sometimes confused with ``medical 
care.'' ``Public health'' is defined as ``all organized 
measures to prevent disease, promote health, and prolong life 
among the population as a whole.'' While medical care is 
concerned with the individual, public health's patient is the 
community.
    I would argue that this definition of ``public health'' 
puts it in the realm of public safety. Just as police and 
firefighters protect communities from crime and blazes, public 
health protects communities from disease. Indeed, of the 30 
years of added life to the U.S. life expectancy during the last 
century, 25 of these are due not to medical advances, but to 
public health interventions, such as sanitation, immunizations, 
workforce safety, tobacco control, et cetera. It has been said 
that health care is vital to all of us some of the time, but 
public health is vital to all of us all of the time.
    I hope that I have convinced you of the importance of 
public health efforts in maintaining and promoting the health 
of our Nation and the world. This cannot be done without 
adequate resources. I am sure that you are much more familiar 
than I with the negative effects of spending caps and 
sequestration on public health agencies, such as the CDC. 
Federal funding for public health has declined in recent years, 
and this has affected flow-through funding to States and 
locals. Adjusted for inflation, CDC funding has decreased more 
than $1 billion since 2005, 15 percent.
    At the State level, the Association of State and 
Territorial Health Officials reports that budget cuts continue 
to affect the health of Americans. Health departments in 48 
States have had budgets cut since 2008, with 95 percent of 
departments reducing services that they offer. The Trust for 
America's Health and the RWJ Foundation released a report 
showing that the majority of States reached only half or fewer 
of key indicators of policies and capabilities to protect 
against infectious disease threats. Texas scored 4 out of 10. 
One of the indicators, increased or maintained level of 
funding, was not met by 33 States.
    The same trends can be found at the local level. The 
National Association of County and City Health Officials 
reported that over one-quarter of local health departments 
experienced a budget cut in the current fiscal year, and this 
has been happening over at least the last 6 years. Almost half 
of these had reductions in services. Overall, State and local 
public health departments, the boots-on-the-ground providers of 
public health, have lost over 51,000 jobs since 2008. This 
represents 20 percent of public health jobs at the State and 
local level.
    Ebola is a frightening disease with horrific symptoms, and 
concern is naturally high that spread may occur in the United 
States. However, this is highly unlikely. To be infected, you 
must have physical contact with bodily fluids from someone with 
symptoms. We know how to stop transmission by using barrier 
nursing practices, such as gloves, disinfectants, and patient 
isolation.
    Unfortunately, many countries in Africa do not have the 
resources to provide for these precautions. Ebola is a major 
concern for the affected countries, and the fear and loss of 
life are devastating on a humanitarian level. The danger is 
that we will be fixated on this virus and not on other 
pathogens that have outbreak potential, such as flu, SARS, and 
MERS-CoV, among others. Other pathogens, such as measles and 
pertussis, periodically cause outbreaks due to lack of immunity 
among those not vaccinated. Then there is the on-going 
syphilis, food-borne illnesses, HIV, tuberculosis, meningitis, 
enterovirus D68 infections that we fight every day in public 
health.
    So what can we do to prepare for potential pandemics? 
Congress must begin to prioritize public health funding and not 
just when a crisis occurs. Critical to the capacity to respond 
to any type of outbreak, routine or otherwise, are 
epidemiologic and laboratory capabilities. These involve 
disease surveillance and reporting, case investigation, 
outbreak response and control, contact management, and data 
analysis synthesis and communication.
    The disease-of-the-month type of response limits our 
ability to react to threats, and disease-specific funding 
streams tie public health hands when prioritizing activities. 
While we are appreciative of the increased funding to combat 
Ebola, and adequate response to the initial outbreak would have 
mitigated spread. The U.S. funding for WHO activities have 
decreased one-third from 2010 to 2013.
    In summary, public health is on a par with police and fire 
protecting the community from disease. In order to provide this 
protection, we need on-going adequate funding to make sure our 
epidemiologists and laboratories have the resources they need 
to quickly identify and stop infectious disease outbreaks.
    Thank you for the opportunity to testify about public 
health and our ability to deal with public health threats.
    [The prepared statement of Ms. Troisi follows:]
               Prepared Statement of Catherine L. Troisi
                            October 10, 2014
    Chairman McCaul, Ranking Member Thompson, and Members of the 
committee, my name is Catherine Troisi. I am an infectious disease 
epidemiologist at the University of Texas School of Public Health and, 
in addition to my years in academia, I have practiced public health at 
the Houston Department of Health and Human Services. I am also a member 
of the American Public Health Association, a diverse community of 
public health professionals who champion the health of all people and 
communities. Adequate funding at all levels of our public health system 
is a top priority for the association
    Thank you for this opportunity to talk about public health, its 
role in disease outbreak detection, and recent trends in resources for 
these important public safety efforts. I'm delighted to remind the 
Members from Texas that the University of Texas School of Public Health 
has regional campuses in Austin, Brownsville, Dallas, El Paso, and San 
Antonio, fulfilling our mission to improve and sustain the health of 
people by providing the highest quality graduate education, research, 
and community service for Texas, the Nation, and the world; to provide 
quality graduate education in the basic disciplines and practices of 
public health; to extend the evidence base within those disciplines; 
and to assist public health practitioners, locally, Nationally, and 
internationally, in solving public health problems.
    I'd like to start with a definition of public health, a term that 
is sometimes confused with medical care. Public health has been defined 
by the U.S. Centers for Disease Control and Prevention (CDC, the 
Nation's public health agency) as ``the science of protecting and 
improving the health of families and communities through promotion of 
healthy lifestyles, research for disease and injury prevention and 
detection and control of infectious diseases.'' There are a couple of 
concepts in that definition I'd like to emphasize. The first is that 
public health is science-based and the corollary of that is that we 
should employ techniques that have been proven to be of value. The 
second is the idea of protection which implies action before disease 
occurs. Public health has two main functions--disease prevention and 
health promotion. As our grandmothers said ``an ounce of prevention is 
worth a pound of cure''. The last concept in this definition that I 
want to emphasize is that of communities. While traditional medical 
care is concerned with the individual, public health's ``patient'' is 
the community. Individual interventions can be the mandate of public 
health, e.g., immunizations, but the overall goal is to protect the 
community. One specific function of public health agencies, largely 
limited to governmental public health, is detection of outbreaks of 
infectious diseases and mitigation of spread.
    With these definitions in mind, what are public health tasks? The 
Institute of Medicine has broken these into three core functions--
assessment, policy development, and assurance. In simple terms, this 
means that public health is responsible for evaluating and responding 
to health problems in the community as well as prioritizing these 
efforts, developing policies to protect communities' health, and 
assuring that all populations have access to appropriate and cost-
effective prevention services. I would argue that this academic and 
functional definition of public health puts it in the realm of public 
safety. Just as police protect communities from crime and fire fighters 
from the devastations of fire, public health protects communities from 
disease. Indeed, of the 30 years of life expectancy added to the 
average U.S. life expectancy in the 20th Century, 25 of these are due, 
not to medical care, but to public health interventions, such as 
sanitation, immunizations, control of infectious diseases, tobacco 
control, etc. It's important to emphasize that we talk about the 
``public health system'' which consists of all organizations involved 
in protecting and improving the health of the community, whether 
Governmental, medical, non-profit, educational, social services, etc. 
However, given the scope of these hearings and the fact that it is 
Governmental public health that is largely concerned with detecting and 
controlling infectious disease outbreaks, I'm going to be talking about 
governmental local, State, and National public health.
    I hope that I have convinced you of the importance of public health 
efforts in maintaining and promoting the health of our Nation and our 
world. Obviously, this cannot be done without adequate resources. 
Public health activities occur at the Federal, State, and local level 
and are funded as such. However, the CDC and other Federal agencies 
provide flow through funding for many public health activities at the 
State and local level. I'm sure that you are much more familiar than I 
with the negative effects of spending caps and sequestration on public 
health agencies such as the CDC over the past few years. However, in a 
nutshell, Federal funding for public health has been relatively flat-
funded and has shown a significant decline in recent years (Figure 1). 

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Figure 2 shows the declining level of terrorism preparedness and 
emergency response funding allotted to CDC for activities at the 
National, State, and local levels and for the Strategic National 
Stockpile (www.cdc.gov/fmo/topic/Budget%20Information/index.html). 
Following infusion of after 9/11, levels have been on the decline.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    This situation is also reflected at the State level. The 
Association of State and Territorial Health Officials (ASTHO) reported 
in September of this year that budget cuts continue to affect the 
health of Americans. Health departments in 48 States, three 
territories, and the District of Columbia have had budget cuts since 
2008, with 95 percent of State or territorial health departments 
experiencing reduced services. Approximately 11,000 public health jobs 
have been lost in State health departments (http://www.astho.org/
budget-cuts-Sept-2014/). The Trust for America's Health and Robert Wood 
Johnson Foundation released a report last December showing that the 
majority of States reached half or fewer of key indicators of policies 
and capabilities to protect against infectious disease threats. Texas 
scored 4 out of 10. One of the indicators (increased or maintained 
level of funding for public health services from fiscal years 2011-12 
to fiscal years 2012-2013) was met by only 17 States (Texas was one of 
these 17 States), meaning that 33 States had decreased funding. Budgets 
in 20 States decreased 2 or more years in a row and 16 States had 
decreased budgets 3 or more years in a row (http://
healthyamericans.org/report/114/).
    Not unexpectedly, these trends in budget cuts can also be found at 
the local level. The National Association of County and City Health 
Officials (NACCHO) administers a biannual survey of local health 
departments (http://www.naccho.org/topics/infrastructure/lhdbudget/
upload/Survey-Findings-Brief-8-13-13-2.pdf). Over 1 in 4 local health 
departments experienced a budget cut in the current fiscal year and, as 
shown in Figure 3, this has been an on-going declining trend.
    Data from the 2013 survey show that the size of the public health 
workforce has decreased since 2008 when best estimates were 190,000 
(range of 160,000 to 219,000) to 139,000 (range of 139,000 to 185,000), 
representing a total of 48,300 jobs lost. Almost half (41%) of local 
health departments Nation-wide experienced some type of reduction in 
workforce capacity, with, 48 percent of all local health departments 
reducing or eliminating services in at least one program area. Overall, 
State and local public health departments, the ``boots on the ground'' 
purveyors of public health, have lost over 51,000 jobs since 2008, 
representing one in five public health jobs.


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Now I'd like to put on my infectious disease expertise hat. The 
news coming out of West Africa is alarming. Almost 7,500 cases of Ebola 
with almost 3,500 deaths have been reported with many more suspected. 
Ebola is a frightening disease with horrific symptoms and concern is 
naturally high that further spread may occur. Is there a possibility 
that the next pandemic (defined as a world-wide epidemic) will be 
caused by Ebola? By looking at the characteristics of viruses that can 
spread world-wide, we can see that while there are some viruses capable 
of causing pandemics, Ebola is not one of them, and our undue anxiety 
over spread in the United States is diverting attention from true 
public health concerns.
    Characteristics of a pandemic virus include:
   many people are susceptible to becoming infected;
   people can transmit the virus before they have symptoms;
   the virus causes severe symptoms and deaths;
   the virus is easily transmitted from person to person.
    While Ebola has the first characteristic and certainly causes many 
deaths, it is lacking the two important ones--spread before symptoms 
occur and easy transmission. To become infected with Ebola, you must 
have physical contact with blood or bodily fluids from someone with 
symptoms. Unlike other viruses like influenza, people with Ebola are 
NOT infectious before symptoms appear. We know how to stop transmission 
by using barrier nursing practices such as gloves, disinfectants, and 
patient isolation. Unfortunately, many countries in Africa do not have 
the resources to provide for these precautions in their hospitals and 
so spread of Ebola is occurring in the health care setting. Adding to 
the problem are cultural practices where families prepare bodies of 
Ebola victims for burial, inadvertently becoming exposed to the virus. 
The conditions for spread of the Ebola virus in the United States and 
other resource-rich countries do not exist and the only danger is that 
we may be fixated on this virus and not on ones that could actually 
cause world-wide harm.
    Given these characteristics, there are viruses that have outbreak 
or pandemic potential (or have caused these in the past) that public 
health agencies need to be on the look-out for--viruses such as 
influenza, SARS (severe acute respiratory syndrome), and MERS-CoV 
(Middle East Respiratory Syndrome), among others. Other ``common'' 
viruses such as measles and pertussis periodically cause outbreaks due 
to lack of immunity among those not vaccinated. Influenza is a virus 
that has caused pandemics in the past and has the potential to do so 
again. The virus can mutate so much that it's like a new virus no one 
has experienced before and so no one is immune. The great influenza 
pandemic of 1918 killed more people than World War I. There was concern 
in 2009 (when a new influenza virus appeared that looked like the 1918 
virus) that we would again see a major influenza pandemic. While many 
people got infected, we were ``lucky'' that the virus did not kill more 
people than we typically see each flu season--although that number can 
be very high and the very young, seniors, and those with underlying 
illness are particularly susceptible. In Texas alone, over 2,300 people 
were hospitalized with 20 deaths in children last year. Many more were 
sick with the disease. Indeed, estimates are that up to 49,000 deaths 
occur Nation-wide each year due to seasonal influenza. Scientists are 
carefully monitoring some new influenza viruses that have been 
transmitted from birds to people, killing more than half of those 
infected, and although so far these avian flu viruses have not spread 
easily from person to person, the viruses could mutate to allow this to 
happen. Should this occur, a pandemic, with resultant high number of 
deaths, is almost inevitable.
    MERS-CoV is caused by a virus currently occurring throughout 
countries in the Middle East. Although the disease spread through the 
air, as of right now, the virus does not appear to transmit easily from 
person to person (camels and/or bats are the most likely source of 
infection). While the chances of Ebola becoming airborne are 
exceedingly small (no pathogen has changed the way in which it is 
spread), it is more likely that small changes in the RNA of MERS-CoV 
could allow the virus to spread from person-to-person in a more 
efficient manner. Should this happen, the likelihood of a pandemic 
increases dramatically.
    So what can we do to prepare for potential pandemics? Public health 
agencies such as CDC are constantly monitoring infections around the 
world to determine if new viruses are appearing. State and local health 
departments also are involved. Ebola virus is a major concern for the 
affected countries and the fear and loss of life are devastating on a 
humanitarian level. But we do not have to fear spread of the virus to 
the United States or other resource-rich countries. We would better 
spend our time preparing for diseases such as influenza which do have 
the potential to cause pandemics around the world, including the United 
States.
    Congress must begin to prioritize public health funding and not 
just when a crisis occurs. Level or reduced funding for public health 
activities means that the same or less amount of money must cover 
prevention activities for an increased population. As recent outbreaks 
of food-borne illnesses, vaccine-preventable diseases, hospital-
acquired infections, and emerging infectious diseases have shown, the 
threats remain and we need our public health community adequately 
funded to respond to these threats. While we are appreciative of the 
increased funding to combat Ebola contained in the recent continuing 
resolution signed by President Obama, an adequate response to the 
initial outbreak would have mitigated spread within Africa. According 
to a report by the Congressional Research Service, U.S. funding for 
World Health Organization (WHO) activities have decreased about one-
third from 2010 to 2013. As seen in the U.S. public health system, this 
decreased funding resulted in WHO job losses and the ability to respond 
to emergencies such as Ebola.
    Thank you for the opportunity to testify before you today about 
public health and our ability to deal with public health threats. I am 
happy to answer any questions you may have.

    Chairman McCaul. Thank you, Doctor. The Chairman recognizes 
himself for questions.
    Judge Jenkins, you mentioned that we have never encountered 
this before. I agree, this is new territory. In fact, in this 
county we experienced the first fatality due to Ebola in the 
United States. There is a lot of fear amongst not only 
residents here, but across the State and across America about 
this. We in Dallas County witnessed janitors wearing Tyvek 
suits in our schools. This really hits home.
    So my question to Dr. Lakey and Dr. Giroir, what can you 
tell us here today, what can you tell the people of Dallas 
County, and the State of Texas, and the United States of 
America to alleviate these fears?
    Dr. Lakey. Thank you. I think the first thing, and I will 
repeat what I have already said, that we know the science. The 
CDC knows the science about this virus, that unless somebody is 
symptomatic, it is not contagious, that it is not spread in the 
air.
    We are doing a lot of work right now to make sure that we 
do everything we can to prevent another Texan to be exposed to 
this virus. I believe this is a safe community. I feel safe 
enough. I have talked to the schools, I have talked to the 
emergency managers, I have talked to the hospitals, a wide 
variety of individuals and systems in Dallas and in Texas. One 
of the things that I told the schools, you know, I am a father. 
I would very comfortable with my kids going to these schools 
right now. They are not going to get Ebola from going to the 
schools right now.
    We know the 48 individuals that had contact. We are 
monitoring them very closely. The kids that had contact, we are 
giving them home-based schooling to address this risk. But 
unless you have symptoms, you are not going to spread this 
disease. So, we take this very seriously. The monitoring is 
going very well, again, partners from the local level, the 
State level, the Federal level working together. Those 48 
individuals that we are monitoring very closely, none of them 
are symptomatic.
    Chairman McCaul. Dr. Giroir, you have just been appointed 
the head of this task force. What are your plans to deal with 
this threat and deal with this fear amongst the population?
    Dr. Giroir. Well, first of all, I want to reiterate exactly 
what Dr. Lakey said, and I agree with every one of his points, 
that the transmission is, as he said, only by close contact 
with bodily fluids of an infected symptomatic person. Among the 
activities of this response, the ones that went very, very well 
were the identification of the contacts and institution of the 
appropriate monitoring. So we are very comfortable that that 
was done in a very effective and efficient way, and we will 
find ways to even improve on that even further. So all of these 
will be part.
    One area that we will focus on in the task force is to make 
sure that all our potential notifiers really understand because 
a person with Ebola may not just walk into a major tertiary 
hospital. They may walk into their pharmacist, or they may walk 
into their local nurse, or their public health official.
    So one thing we are going to have very, very early is a 
quick and rapid understanding to make sure we are educating all 
the potential people who could be the first contact with the 
patient, because the key to this whole success is 
identification of that patient and institution of monitoring, 
just like Dr. Lakey and the CDC team have done.
    Chairman McCaul. Dr. Giroir, in your testimony you 
mentioned there were issues involved in decontaminating the 
apartment in question, Mr. Duncan's apartment, including the 
needs for permits to transport the waste. Are you confident 
these issues have been resolved?
    Dr. Giroir. They were resolved. I am confident they have 
been resolved. A lot of it was by brute force and by working on 
issues as they came from the leadership that was there on the 
ground. What we want to do is make that much easier and much 
more facile the next time so that the leadership within the EOC 
can focus on the specific tasks at hand. Remember, next time it 
may not be 1 patient. It may be 5 patients, 10 patients with 
hundreds of contacts. So it was resolved effectively, but we 
have lessons learned. Maybe Dr. Lakey would want to comment on 
that.
    Dr. Lakey. I think that is right. This was a challenge, the 
first time you had to dispose of 140 55-gallon barrels, and 
they had to be put into another type of barrel, and have 
special permits from the Department of Transportation. I think 
we saw for this issue those barrels were burned today. They are 
gone, but I think this is an on-going issue we need to look at 
as a Nation. An event like this, how can we transport Class A 
medical waste and get rid of it quicker than what we could here 
in the State of Texas?
    Chairman McCaul. Lastly, Dr. Giroir, you mentioned that 
this senior assistant for biodefense existed under both the 
Clinton and Bush administrations. I am not quite sure why that 
was eliminated under this administration. Is it, again, one of 
your recommendations that that position be reinstituted?
    Dr. Giroir. Again, I have no idea what are the reasons in 
the organization, but it is a strong recommendation that I have 
and a number of groups have for this position. You know, there 
is talk about Ebola czars or whatever, but this should not be a 
one-off. This should be a priority that transcends whatever 
disease is coming around the corner.
    I know personally when I was at DARPA and the special 
assistant to the President called all the agencies in, all of a 
sudden it just was not a meeting where everybody had to have 
consensus and, you know, kind of figure out what everybody 
wanted to do and agree on the lowest common denominator. It was 
directives and leadership from someone who was in the White 
House.
    I personally felt that made an enormous difference to 
organize our initial responses, whether that be in Africa or to 
write a pandemic flu plan. I personally feel, and I think you 
would get a lot of support, that that is the 
institutionalization at the highest level of a person 
responsible that you could turn to and we could depend on.
    Chairman McCaul. So you knew who is in charge.
    Dr. Giroir. You knew who was in charge. The other comment 
is absolutely Health and Human Services has a huge part of 
this, but the Department of Defense also does. There are 
parallel programs. Homeland Security, as you know, identifies 
what is on the threat list that has to be transmitted. So this 
is bigger than one agency. There are 11 agencies funded in the 
biosecurity, biodefense areas, and there needs to be someone in 
charge. That is what this recommendation really is.
    Chairman McCaul. Thank you. The Chairman recognizes the 
Ranking Member.
    Ms. Jackson Lee. Again, Mr. Chairman, let me thank you for 
this very important hearing, and let me thank my fellow Texans 
for setting a standard which the world can watch. Even as I 
pose these questions, it is at the backdrop of a great deal of 
thanks to all of you.
    I wanted to just read just an excerpt from this morning's 
newspaper, which indicates that 6 U.S. military planes arrived 
in the Ebola hot zone. This article is making a statement in an 
article that Sierra Leone, as I indicated, they are pleading 
for our help. One of the African leaders said, ``It is a 
tragedy unforeseen in modern times.''
    I do not want to, as I indicated, create hysteria. I want 
to be on alert. I think the important point to be made at this 
hearing for all of you is that all of those who may have been 
exposed will be watched and monitored for the full 21 days and 
maybe until the end of the month. Dr. Lakey, is that accurate?
    Dr. Lakey. We will be monitoring everyone exposed for the 
full 21 days.
    Ms. Jackson Lee. There are articles in the paper that 
indicate if they have not shown any signs in 10 days, then they 
are okay. I think that is a false premise that should be 
corrected by those who may perceive that. But you are saying 
that everyone will be monitored, is that correct?
    Dr. Lakey. All 48 contacts that we identified that have a 
risk of being infected with Ebola are being monitored daily. 
They have temperature checks twice a day. An epidemiologist 
sees them every day. I checked with them this morning. All of 
them are asymptomatic, yes.
    Ms. Jackson Lee. Let me thank Dr. Giroir. I did not 
indicate to you because one of my Baylor doctors and emergency 
doctors indicated that panels should be created across the 
Nation, so let me thank the State of Texas for creating that.
    But let me make this point. As I indicated, six planeloads 
of our best and our brightest military personnel, they have to 
come home. I frankly do not believe that we are prepared, and I 
will tell you why. I ask the Chairman if I could submit into 
the record an article, ``Even After Dallas, Hospitals Still 
Lagging Preparation for Ebola Patients, Say U.S. Nurses.'' I 
ask unanimous consent.
    Chairman McCaul. Without objection, so ordered.*
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    * The information has been previously included in this document.
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    Ms. Jackson Lee. I particularly want to bring to your 
attention that one-third say their hospital has insufficient 
supplies of eye protection, feel shields, or side shields with 
goggles and fluid resistant impenetrable gowns. Dr. Lakey and 
Dr. Giroir, this is not condemnation. The CDC has done an 
amazing job. They are our theoreticians. They are the ones with 
theory and doing the research. But do we have a problem as we 
see the fluidness of people moving around the country, around 
the world, with making sure that every hospital that can afford 
the resources be prepared? Is that something that is necessary?
    Dr. Lakey. I will start, and then, Dr. Giroir, you can 
finish. I do not think preparedness is something you do and 
then you are done. You have to continue to work to be prepared. 
You have to continue to educate health care providers about 
exotic diseases and how do you respond to a major disaster.
    As I tell folks, unfortunately the unthinkable can happen. 
We are dealing with Ebola right now. While I have been in this 
chair I also responded to Hurricane Ike. We responded to H1N1, 
major events, and you have to have a strong public health 
system to do that. So, hospital preparedness funds and the 
other----
    Ms. Jackson Lee. So it would be important for us to make an 
assessment of whether equipment is in places where this may 
happen. I say that, Mr. Chairman, because an airplane was 
quarantined in Las Vegas just a few hours ago thinking there 
was an Ebola patient and it happened not to be. But ambulances 
and all, which is based upon people's fear, and that is what we 
need to do is to quell it, but we need to convince people that 
we are prepared.
    Let me go quickly to Ms. Troisi on this funding situation. 
Do we need to ramp up our funding? Do we need to end the 
sequester? Would Medicaid be helpful here?
    Ms. Troisi. I personally feel that, yes, we do need more 
funding for public health because as Dr. Lakey just said, 
public health is there all of the time. We should not be just 
be responding to crisis, and if you have a good system in place 
when a crisis does occur, you are better prepared.
    Ms. Jackson Lee. Medicaid expansion might help as well.
    Ms. Troisi. Medicaid expansion would certainly help people 
who----
    Ms. Jackson Lee. I only have a few minutes. Thank you 
very----
    Ms. Troisi [continuing]. Who do not have insurance.
    Ms. Jackson Lee. Thank you for your grace, Judge Jenkins, 
and your heart. We know how you lead in this county. Thank you 
for treating these individuals with dignity. But let me just 
say you expended dollars, 140 55-gallon barrels. What can we do 
to prepare for returning military personnel that may be all 
over America coming home as heroes, but having been in the hot 
spot of Ebola, and may, in fact, themselves be impacted coming 
to counties like Dallas County. What do you see that we would 
need to do in being prepared if that was to happen?
    Judge Jenkins. Well, as far as the disease, the military I 
think has a good preparedness as people come home. It is very 
important to me that as our military men and women come home--
Dallas County is the third choice in the country by popularity 
for them to return to--that we get them good jobs. You are on 
the right track that we need health care for people. We need 
Medicaid expansion. We need good jobs for our returning 
military.
    The best thing that we can do to fight Ebola is to fight 
Ebola at its source overseas before it gets here.
    Ms. Jackson Lee. Thank you, Mr. Chairman. May I just add 
this to the record? It shows the kind of attire that should be 
used dealing with ``Suiting up for Ebola.'' I ask unanimous 
consent to place this in the record.
    Chairman McCaul. Without objection.
    Ms. Jackson Lee. I ask for these two documents, including 
``Ebola Outbreak Preparedness and Management,'' prepared by 
Doctors Without Borders*, to be put into the record.
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    * The information has been retained in committee files and is 
available at: http://www.medbox.org/ebola/ebola-outbreak-preparedness-
management/toolboxes/preview.
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    Chairman McCaul. Without objection, so ordered.
    [The information follows:]
    
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Jackson Lee. I thank the gentleman.
    Chairman McCaul. The Chairman recognizes the gentleman from 
South Carolina, Mr. Sanford.
    Mr. Sanford. Thank you, Mr. Chairman. Judge Jenkins, I do 
not know your story, but based on what I just heard, if you 
walked into an apartment with Ebola was there and somebody just 
died, I admire your courage, your humanity, your leadership in 
terms of just walking in without glove in hand, and shaking 
hands with folks, and giving them a hug as the case might have 
been. So I admire that.
    But I want to go back to Dr. Lakey's comment. Well, in 
fact, everybody said the same thing. Everybody said you cannot 
get this disease unless it is from an infected party, a human 
contact. You are not going to get it out of the drapery over 
here. You are not going to get it out of the floor. You are not 
going to get it through the air, right? I mean, everybody has 
consistently said that.
    Yet what we just heard was 140 55-gallon drums of hazardous 
waste were taken out of the apartment, which is to say unless 
the guy lived in a mansion, and I do not think he did, they 
flat-out stripped that apartment, in essence, down to the 
studs. I mean, they took out the carpet. They took out the 
drapes. They took out everything, threw it in. You had Class A 
hazardous material wherein you are having to fight permits in 
terms of getting it out.
    Again, the folks back home are saying this does not connect 
for me. It is the same disconnect. We are told you are 
completely safe, but by the way, we are going to go to this 
guy's apartment that died, and we are going to strip it down to 
the studs. I mean, 140 55-gallon drums would fill this entire 
floor area right here. So which one is it? Is it really more 
hazardous than we think, or did they make a mistake in a degree 
of overkill, if you will, and drag out 140 55-gallon drums?
    Dr. Lakey. I can start, and then if any of the other 
panelists want to chime in. That would be great. We feel 
confident in the science that this is spread through contact 
with bodily fluids.
    Mr. Sanford. I understood that. Then why all the 55-gallon 
drums?
    Dr. Lakey. The challenge was in this apartment, you know, 
if he threw up, if there was other bodily fluids on curtains, 
et cetera, it had to be taken care of. There is a perception 
related to the apartment. You know, no one was going to rent 
that apartment unless you had done all you can do in order to 
decontaminate it. Because it was a Level A agent----
    Mr. Sanford. I mean, you are not in the real estate 
business. You are not worried about who is going to rent the 
apartment next.
    Dr. Lakey. But we needed to decontaminate the apartment, do 
everything we could to fully decontaminate----
    Mr. Sanford. Okay. But then you are going to the 
decontamination side, which is then it takes more than, as I 
have written it down, physical contact with an affected party. 
That is what is consistently said over and over and over again.
    Dr. Giroir. I think most of the leadership was concerned 
about blood, bodily fluids, other excretions that could have 
been in places in the apartment, such as in the bathroom, or 
rugs, or things like that. The data really show that the Ebola 
virus is very wimpy on surfaces, that it really goes away very 
quickly. It does not live very long at all. But if there is 
tissues, bodily fluids----
    Mr. Sanford. So, I mean----
    Dr. Giroir. So I believe there was a conscious decision to 
overly decontaminate and overly do waste removal because this 
was the first patient in the country. It was approached with an 
abundance of caution. For example, a toilet can be 
decontaminated, but do you want to sit there and decontaminate 
the toilet and have every question, or do just want to pick the 
toilet up, put it in a drum, and get rid of it, and be done? We 
had the luxury of only having one apartment to do, and I think 
with an abundance of caution----
    Mr. Sanford. Understood. Let me just follow up because I 
see I am down to a minute.
    Dr. Giroir. Yes, sorry.
    Mr. Sanford. The same question then in a different light in 
terms of the disconnect that I seem to be hearing from folks 
back home. A number of you all have talked about public health 
and the need to prioritize spending. We are well on our way to 
spending about a billion dollars in these three countries and 
sending in the military, which is a very expensive way of 
dealing with the problem. If, in fact, it is not as lethal and 
it could be handled by health care professionals rather than 
cranking up C-17s and sending them across the Atlantic, why not 
have health care professionals do it rather than $750 million, 
because we could then allocate some of the resources that 
Sheila Jackson Lee was just alluding or some of the other 
resources that are around the world given the crop up in Spain 
and other places?
    Judge Jenkins. Sir, can I take a stab at that? It is 
extremely lethal. Fifty percent of the people in the world who 
get this disease die. The disconnect in what the visuals are on 
television is this. My contact and other officers' contact were 
with people who are being monitored to see if they become 
symptomatic. Their bodily fluids cannot transmit Ebola. The men 
in hazmat suits----
    Mr. Sanford. I understand that. I have run out of time, but 
I am still curious as to are we doing overkill then, spending a 
billion dollars with the military rather than having health 
care professionals. But I see I have run out of time, Mr. 
Chairman. Thank you, sir.
    Chairman McCaul. Thank you, sir. The Chairman now 
recognizes Mr. Swalwell from California.
    Mr. Swalwell. Thank you, Chairman, and thank you to the 
officials for being here today, and thank you for what you are 
doing in this fight to keep Ebola from spreading here in the 
United States. I would just have to say just to follow up on my 
colleague from South Carolina, I certainly understand what he 
is saying, and I certainly understand, Dr. Giroir, the position 
that you are in and Dr. Lakey, which is on one hand if you have 
the case in America, people are watching it. We are in this 
Twitter, Facebook era where everything you do is going to be 
exponentially multiplied and told to the rest of the world.
    But perhaps if the science is true that it can only be 
spread by direct bodily contact by somebody who is presenting 
the symptoms, if we are, as you said, Dr. Giroir, overly 
decontaminating, we could be our own worst enemy, and that by 
overly decontaminating, we are creating this perception that it 
is something that perhaps could be airborne.
    So, I guess, my first question is, if you could just tell 
the public, you know, I will just go down the line, and each of 
you could pick one myth that you would like to dispel based on 
your expertise to the public, because my colleague from Texas, 
Congresswoman Jackson Lee, she is right. There is a plane right 
now in Vegas that people are just getting off because someone 
was coughing and sneezing, and people started freaking out and 
tweeting that they have Ebola. They were tweeting at Delta who 
was the carrier, and you can just imagine what that scene was 
like. So if I could just go down the line. One myth that you 
would like to dispel for the American public.
    Dr. Lakey. The first myth would be that the individuals 
that have been exposed but have no symptoms, that there is a 
risk. That is causing, I think, discrimination related to those 
individuals, and that is a myth that needs to be changed.
    Mr. Swalwell. Great, thank you. Dr. Giroir.
    Dr. Giroir. Again, just to reemphasize what everyone has 
said is that you have to be in close contact with the blood and 
body fluids of a person who is actively symptomatic. Again, if 
there were bodily fluids left on a carpet and you go there in a 
couple of hours, you know, there is a concern about that. But--
--
    Mr. Swalwell. Dr. Giroir----
    Dr. Giroir. Yes?
    Mr. Swalwell [continuing]. If Mr. Duncan had, as you said, 
perhaps thrown up in the apartment, how long would that bodily 
fluid be active, meaning if it was decontaminated, it was left 
there for days, weeks, months, how long would it be active?
    Dr. Giroir. Do you want to answer that?
    Dr. Lakey. I cannot tell you exactly how long it would be 
active in carpet. I cannot give you specific----
    Ms. Troisi. There was a study just published. It was not 
specifically on carpet, but showing it lasts a couple of hours 
on surfaces at ambient temperature.
    Mr. Swalwell. Okay, thank you. Judge, how about a myth that 
you would like to dispel? You were right there on the front 
lines.
    Judge Jenkins. Well, in the interest of repetition, and if 
people from the Dallas-Fort Worth area are watching, there is 
zero risk of you becoming infected from anyone who has come in 
contact with me or any first responder. We would never put your 
family and your children at risk. We follow CDC protocols. When 
we follow more than that, it causes panic.
    Mr. Swalwell. Ms. Troisi----
    Dr. Giroir. The task force does believe that there is 
significant opportunity to create less drums of waste moving 
forward. When you have an on-going relationship with a specific 
decontaminating contractor that you have set this up 
prospectively, that we do believe that there are really good 
opportunities to do less than was done. But on the first case 
in an acute situation, these situations were made by the 
incident command structure. I happened to be in the command 
post that day, but these were made by the incident commanders, 
and I fully support sort of the overabundance of caution in the 
first case.
    Mr. Swalwell. Thank you, Doctor. Ms. Troisi, if you had a 
myth you could dispel.
    Ms. Troisi. Yes. Again, as everyone has said, Ebola is hard 
to get. You have to have direct contact. Whereas 1 person with 
measles typically infects 18 other people, with Ebola it is 2 
other people.
    Mr. Swalwell. Thank you. So, Mr. Chairman, it sounds like 
to me, you know, fighting Ebola in West Africa has to be our 
primary goal, but also fighting myths at home just to prevent 
hysteria also has to be a priority. I yield back. Thank you.
    Chairman McCaul. The Chairman now recognizes Mr. Clawson.
    Mr. Clawson. Since I am from Florida, not from Texas, I 
would like to defer my time to Mr. Barton. I have got a 
question or two, but I will follow the Texans I think is the 
right way to go here.
    Chairman McCaul. We admire that as Texans. Mr. Barton.
    Mr. Barton. Well, I appreciate my colleague from Florida. 
Today is my day to pick up my 9-year-old son from daycare, so I 
am very appreciative----
    Mr. Clawson. That is a priority.
    Mr. Barton [continuing]. That I get to go next. Our first 
panel we focused on National and international issues, and my 
questions were directed primarily to why let people come into 
this region from the center of the disease, which is over in 
Africa. Well, this panel is a little bit different ball game. 
You have to deal with what is on the ground. It is not your 
issue how the people that might have the disease get into the 
United States. They are here. We have had a case here in 
Dallas, Texas, and the State of Texas has responded, Dallas 
County has responded. Some of the local hospitals have 
responded.
    So my first question would be to you, Dr. Lakey. Dr. Merlin 
indicated that 114 people had been identified as having some 
significant contact with the individual who has since passed 
away from Ebola. Are you confident that your agency and CDC has 
everybody under observation who needs to be under observation?
    Dr. Lakey. Yes. I have talked to the CDC, the director here 
on the ground, and the other epidemiologist. They started out 
with 114, and then they took histories and talked to 
individuals, and they felt that those individuals, that there 
were 48. Now, I would say, yes, there are always rumors, and 
when there are rumors, we track them down to see if there is 
any truth to any of those rumors. That happens in every 
response.
    But 48 individuals from all the analysis that the 
epidemiologists have had, the discussions linked with those 
individuals and with Mr. Duncan before he died indicated those 
48 individuals, and those were the individuals that continue to 
be monitored. At the same time, I would say, yes, we are 
confident. We also understand that you always have to have a 
little humility when you are in a disaster. We prepare that if 
there was somebody else that was unreported, that we are ready 
for those individuals, too. So, that is my answer, sir.
    Mr. Barton. Do you have all the authority that you need to 
have to monitor, if necessary, quarantine and restrict 
individuals so that they do not transmit this disease to 
somebody else? Are there any restrictions on the State of 
Texas' Department of Health Authority to handle this situation?
    Dr. Lakey. This is one issue that I have been in the midst 
of, and I have the ability to put in a control order, and I put 
in three control orders. I do not take that lightly. I only did 
that because I had to ensure that we could monitor individuals 
effectively. If there was something that made me think that I 
could not do that, I put in a control order.
    Now, my control order, though, is written documentation to 
that individual. It does not give the ability for the police to 
deter that individual. If the individual leaves, then you have 
to go get an Attorney General's opinion. The Attorney General 
Office goes to get a judge's opinion that then can give the 
ability for law enforcement to detain that individual.
    Mr. Barton. Is that the State of Texas Attorney General?
    Dr. Lakey. That is the State of Texas. So as I was 
discussing with some folks, I have more ability in my position 
to detain somebody for a short period related to mental health 
issues than I have with an infectious disease issue, like 
Ebola, initially because my order is written documentation, and 
only when they break that do I have the ability to get the 
police to detain that individual.
    Mr. Barton. So if Judge Jenkins, or the mayor of Dallas, or 
any other locally-elected official wanted to do something, they 
would come to you or your designee, and you would make the 
determination unless you felt it took a law enforcement action, 
which you would go to a district judge----
    Dr. Lakey. Yes, sir.
    Mr. Barton [continuing]. Who then would issue the proper 
authority for law enforcement to take whatever action you deem 
necessary.
    Dr. Lakey. The local health authority has that ability. 
This is a special situation, so I am here.
    Mr. Barton. So you are saying that the Dallas County Health 
Department has this authority. Either you have it, or they have 
it, or share it?
    Dr. Lakey. We both have it because we use it for 
tuberculosis, same type of control order. But that does not 
give us the power to detain until the individual breaks that 
control order. So you always have the possibility, and we have 
been doing this with putting the police out there so we do not 
lose an individual. But you have the ability that somebody 
could break that control order, and then you have to find them 
again.
    Mr. Barton. Now, how much longer do you have to monitor 
these 48 individuals before they are off the watch list and you 
can say with 99 percent confidence that there is no threat here 
in the DFW area, another 10 days?
    Dr. Lakey. We are monitoring them for 21 days. We are at 
day number 12 now.
    Mr. Barton. So 9 more days. If we do not develop a case, if 
they do not become symptomatic in the next 9 days, then we can 
safely say there is no danger immediately in the DFW area, is 
that correct?
    Dr. Lakey. That is correct. It gets a little bit 
complicated because the policies for overseas related to Ebola, 
they go two incubation periods, so 42 days. It is a little 
different situation since we know this one individual, but we 
will monitor the contacts for 21 days. If there is anybody that 
was exposed, we monitor 21 days after that. So the individual 
patient, 21 days.
    Mr. Barton. I want to thank you, Mr. Chairman, for letting 
me participate. I also want to compliment the DFW Airport 
Authority for hosting this and putting it together so quickly. 
Finally, much has been made of the 140 barrels of hazardous 
waste material that has been collected and was incinerated 
today. The company that did that is in my Congressional 
district, and I want to commend that private-sector company for 
working with the local officials in such a conciliatory and 
cooperative fashion. They were willing to cut some of the red 
tape and so some things that needed to be done. With that, 
thank you for chairing this hearing and having it here in the 
DFW area.
    Chairman McCaul. It has been a real honor to have you, sir, 
and good luck with that 9-year-old boy.
    [Laughter.]
    Chairman McCaul. The Chairman now recognizes the gentlelady 
from Texas, Ms. Eddie Bernice Johnson.
    Ms. Johnson. Thank you very much, Mr. Chairman, and let me 
thank you for the hearing, and thanks to everyone who took the 
time to come today. I especially want to thank the panel. I 
cannot tell you how much appreciation I have for the type of 
leadership that you put into play when this happened. It could 
have been a lot worse. I am not certain it could have been much 
better, but I appreciate everything that you have done. I do 
not see anything that we left undone. I think that if there is 
a question, it might have been related to what happened between 
the first contact of the patient in the hospital, and that is 
not anything we are discussing today.
    But what comes to mind is how well we can respond and how 
much we can over-respond sometimes if we do not use education 
and common sense and professionalism. Now, we have talked about 
stacking up a lot of equipment, goods, and supplies, which I 
think it is totally unnecessary. I do think we should be ready, 
but I also think we have to be concerned about expiration dates 
and how much we are stacking up for something that might not be 
necessary. So it does take some professional approach to 
determine what is going to be necessary to have a degree of 
readiness for any communicable disease.
    We all are aware of the cuts. We all are aware that many of 
the cuts that we need to address. Sometimes we have overdone 
it. But I also want to remind everyone that when you ask for 
more airports to be added and more different other things to be 
added, that that is also another cost. So I just want you to 
know that when you ask for DFW to be included, I want to make 
sure that you include the budget for DFW to be included as 
well.
    It is clear that we have dealt with and are dealing with a 
very serious disease that is affecting West Africa. We have 
done, I think, the best we could do with all of the anxiety 
that people experience with having one in this country. There 
are some other communicable diseases that are common in this 
country that we have not yet addressed quite as well, but we do 
have that ability.
    But my caution is not to let our anxiety and the lack of 
clear education cause us to spend much more than what we need 
to. I went to the Department of Transportation to get 
permission for these goods to be disposed of, and I am 
delighted to be able to have done that. I do not know, and I 
cannot make a judgment at this point, how much was overdone or 
under done, but I think that I can be very clear in my 
appreciation to say that we did what we thought we needed to do 
for safety, for education, and to alleviate anxiety, and we 
will probably continue to do that. My caution is that we not 
overdo and over spend because we are still trying to address 
anxiety rather than the disease itself.
    But at this point, I do not have any further questions, but 
just to express my appreciation to both the committee, the 
persons who came today, and to all of you who are on the front 
lines. And to say that I do not know anything else that I would 
have expected of our leadership from our Governor, to all of 
you who responded, to our local officials. I think that we did 
the best we could under the circumstances. It is a very new 
thing. I am not saying that we were perfect, but I am not sure 
that I can tell you what else you could have done. So thank 
you, Mr. Chairman, for having the hearing.
    Chairman McCaul. Thank you as well. The Chairman recognizes 
Dr. Burgess.
    Mr. Burgess. Well, thank you, Mr. Chairman. This has been a 
very important afternoon, and I am certainly thankful that you 
let me participate. There will be another hearing on this 
subject next Thursday in Washington in the Energy and Commerce 
Committee. I spent the day yesterday in a field hearing in 
Raleigh-Durham on vaccine development. This is for people who 
think that we are not paying attention to this. I just want to 
underscore that.
    I also just want to mention that I realize the CDC was on 
the previous panel, and it is easy to be critical of the 
Federal agencies. But I would also say that it is the CDC that 
goes afield and does the work. Yes, the World Health 
Organization is there, but I will tell you the global outreach 
and resource network of the World Health Organization would be 
nothing without the participation of the CDC. They have borne 
the lion's share of this burden overseas and in the United 
States. The United States taxpayer has borne the lion's share 
of this burden, and I do hope that other global partners will 
step up because fighting the disease, you know, on the fronts 
in Africa is extremely important.
    We were told by all the experts that this would burn itself 
out, March/April time frame, and then when it did not, of 
course it was so much more established that it is now. As I 
pointed out on Mr. Thompson's graph, were are in the 
exponential phrase. It is very, very difficult to control a 
disease in the exponential phase.
    But we have also, I think, lost an opportunity here at home 
to provide that public trust or that public confidence, and 
that is going to be hard to get back, and that is why so much 
of the discussion that you heard with the earlier panel dealt 
with how do we deal with people coming in. Okay, no direct 
flights. It turns out there are 125, 150 people a day who come 
from those countries in Africa to this country. Perhaps we 
should increase the surveillance period. Yes, that would cost 
some additional money, but, you know, it is the old deal, a 
stitch in time saves nine.
    We are paying an enormous amount of money for the fact that 
someone got through, the problem has happened, and then the 
whole cascade. Then as a consequence to that, and, Dr. Lakey, 
you and I discussed this, I mean, this problem does not stop at 
the county line. One of your employees, Judge Jenkins, one of 
my constituents, who had a problem the other day, and once that 
threshold is reached again, the entire cascade has to happen 
yet again with all of the concern and all of the expense.
    Dr. Giroir, I would be interested in your thoughts because 
you have participated at the Federal level before. Is there not 
something more we can do at the beginning phase of this when 
people are coming into this country to hold people a little 
longer, to keep a little tighter surveillance, and not have to 
bear the expense at Judge Jenkins' level and Dr. Lakey's level?
    Dr. Giroir. Again, international travel is really not my 
area of expertise, but I do want to underscore as in any 
situation like this, the further you push this event to the 
left, the better you are going to be. So the earlier you 
identify the individual, if that is going to be in the hospital 
in the emergency room that first time or when they go to the 
pharmacist, that first identification is very important.
    The earlier you do that and the further you push that back, 
that is where it needs to be done because by the time you close 
down a 24-bed ICU, you activate all of the EOCs, that is really 
not the way you want to attack this. It would be great----
    Mr. Burgess. It is the most expensive way.
    Dr. Giroir. It is the most expensive and the least 
effective way. So you get it at its origin in Africa, this 
disease in Africa. There will be other diseases in other parts 
of the world, and maybe we will originate some that the other 
parts of the world will deal with as well. It is not an African 
issue. It is a world issue. But again, I agree with what you 
said. You get it as close to the source as possible. You do not 
try to play catch-up once it is here and it is out.
    Mr. Burgess. Dr. Lakey, you referenced an after-action 
report. I referenced that in my earlier discussion with the 
earlier panel. Is there actually a report that is going to be 
produced by the State?
    Dr. Lakey. We do that after every major event. We did it 
after H1N1. We did it after Hurricane Ike. It is part of our 
policy. We are a learning agency, and we have to learn from our 
experience. So, yes, we do an after-action after every major 
event.
    Mr. Burgess. Well, I am sure Mr. McCaul would like you to 
share that with the Homeland Security Committee. I would just 
ask that we just share that with the Energy and Commerce 
Committee as well.
    Dr. Lakey. Absolutely.
    Mr. Burgess. Then, Judge Jenkins, finally, again, your 
employee, my constituent, who had a problem the other day, and 
not to get into the details or specifics of that. But is there 
a contact number that someone has who might have a concern 
about this who was in that, not the primary group, the 48 
people that you are talking about, but in, say, a secondary or 
even a tertiary group where they can talk with someone before 
having to pull the lever of going to an urgent care center or 
an emergency room. Is there an intake place that they have 
available to them?
    Judge Jenkins. There is, and your constituent and my 
employee, I spoke to him this morning, and I spoke to his wife, 
and I spoke to the head of his association. What I told him is 
that he has my full support. He and his family acted 
appropriately on the information they were given by someone 
outside. They were given information that we were unaware of at 
the incident command structure, and they acted on that.
    The information within the incident command structure would 
be different, and we have had a meeting now with all law 
enforcement at the agency level, at the association level, to 
let them speak to infectious disease doctors from the other 
Dallas area hospitals that are unaffiliated with the Government 
or Presbyterian Hospital and get their questions answered. We 
have set up a location for them to receive care should they 
have any sorts of concern.
    But let me make something very clear to the public. There 
is a 0 percent chance that I or my deputies or my first 
responders contracted Ebola because I and my deputies and my 
first responders did not come into contact with any bodily 
fluids of Mr. Duncan.
    Mr. Burgess. I appreciate that. I do hope that this 
information will part of that after-action report as it is all 
incorporated when you look back at the entire series of events.
    Judge Jenkins. Congressman, I also want to stress that we 
want a complete after-action. To the extent permitted by law, I 
want that to be public.
    Mr. Burgess. Yes, I agree. Thank you, Mr. Chairman. Thank 
you for holding the hearing.
    Chairman McCaul. Thank you, Doctor, for your expertise. The 
Chairman recognizes Ms. Jackson Lee for the purpose of 
introduction of a document into the record.
    Ms. Jackson Lee. Let me thank you, Mr. Chairman. I would 
like to add into the record a letter dated October 8, 2014 
officially requesting for the enhanced screening and CDC at 
Bush Intercontinental, and I would add that I join on DFW as 
well. Let me conclude, Mr. Chairman. I know there is one more, 
I think, testimony coming. Two more. Just to say that I want to 
thank all these gentleman. I am stepping away for an airplane. 
I want to give my appreciation and thanks, and I want to thank 
Commissioner Jenkins for, again, your grace and humanity.
    To the others, I will put into the record, Mr. Chairman, my 
question about contagion units as well as my question regarding 
the idea of the panels that the Governor was astute in putting 
in this State, whether they would be appropriate. Again, this 
hearing is not just for Ebola, but to be prepared for any 
episode that we might come in contact with, and I thank the 
witnesses very, very much. I thank this community very, very 
much. I yield back.
    Chairman McCaul. Without objection, so ordered with respect 
to the document.
    [The information follows:]
         Letter from Honorable Jackson Lee to Director Frieden
                                   October 8, 2014.
Dr. Tom Frieden,
Director, Centers for Disease Control and Prevention, 1600 Clifton 
        Road--Mailstop E-92, Atlanta, GA 30329-4027.
    Dear Dr. Frieden: As a Senior Member of the House Committee on 
Homeland Security and the Ranking Member of the Subcommittee on Border 
Security, I am pleased that the Centers for Disease Control, the 
Department of Homeland Security's U.S. Customs and Border Protection 
Agency, and the United States Coast Guard are coordinating to establish 
a new level of screening for international air travelers during the 
global Ebola health crisis that is impacting the United States. I 
understand this coordinated effort will add new screening protocols 
beginning Saturday, October 11, 2014 for passengers with flight 
itineraries where travel originated in the countries of Guinea, 
Liberia, or Sierra Leone. Additionally, I am aware that the Centers for 
Disease Control and the Department of Homeland Security announced new 
layers of entry screening at Hartsfield-Jackson Atlanta International 
Airport, Newark Liberty International Airport, John F. Kennedy 
International Airport, Dulles International Airport, and Chicago O'Hare 
International Airport.
    As a Member of Congress representing, Houston Texas, the 4th 
largest city in the nation, I am requesting that George Bush 
Intercontinental Airport be included on the list of airports to receive 
the enhanced Ebola screening protocols for those passengers whose 
flight itineraries indicate that the air travel originated in the 
countries of Guinea, Liberia, or Sierra Leone. The George Bush 
Intercontinental Airport serves the Houston area and is a major 
originating and connecting hub for international air travelers. From 
January to August 2014, there have been 99,452 West African passengers 
traveling into and out of the George Bush Intercontinental Airport with 
a total of 1,856,421 international travelers. I am requesting that 
George Bush Intercontinental Airport be added to the list of airports 
receiving new layers of entry screening.
    The new layers of entry screening that should be followed at the 
George Bush Intercontinental airport include: (1) Customs and Border 
Protection agents greeting passengers and escorting them to a 
quarantine area where they will answer questions from a detailed 
questionnaire; (2) United States Coast Guard trained medical staff 
conducting a preliminary health screening by checking temperatures with 
a contact free thermometer; and (3) Centers for Disease Control staff 
making further health assessments to determine whether a passenger 
should go to a hospital. Further, these passengers will be provided 
with information on signs of the illness and information on self-
quarantine and who to contact for medical assistance. If a passenger's 
answers to the questionnaire indicate that future follow up and 
tracking should be done, they will referred to a county health 
department for follow up medical assessment.
    I am available to speak with you regarding the George Bush 
Intercontinental Airport and the status of their level of preparedness 
as well as the hospitals and first line health care providers serving 
the city of Houston.
            Very truly yours,
                                        Sheila Jackson Lee,
                                                Member of Congress.

    Chairman McCaul. Mr. Clawson is recognized.
    Mr. Clawson. Thank you for your service. Thanks for coming 
here today. I am not from Texas, but I can see you all are very 
competent in what you do and very knowledgeable, and I am very 
appreciative for you coming here today.
    A few years ago I got off a plane from India for my 
business. It was the monsoon season, and there were big dang 
mosquitoes everywhere. About a week later in the United States 
I became very ill with a hemorrhagic illness and went to the 
hospital, and was ordered tested for malaria and a few other 
things, but was not tested for chikungunya for that matter or 
any of the other illnesses that, by the way, are getting closer 
and closer to our country and to Texas.
    So when the incident happened in Texas, I really was not 
surprised because just from my own experience, it seemed to me 
that this idea that the folks in our emergency rooms could have 
enough first-hand knowledge of the different hemorrhagic 
infectious diseases around the world and match them with the 
travelers. I had told my doctor that I was coming from India, 
and it was the monsoon season. It feels like a really hard task 
that you are up against because the first line has got to be 
100 percent, and it is a complicated world.
    So I draw two conclusions or questions from that. How do we 
get that knowledge at the hospital level really ingrained, and 
second, whatever you all are learning here because you are on a 
steep learning curve, right? How do we get it to other States 
and areas like mine so that we do not have to re-learn tough 
lessons? Will you all respond to that a little bit?
    Dr. Lakey. I will start, and then I will hand off. I think 
you are right. I think we have to be prepared for the next 
event. I would not be surprised if we have something like this 
somewhere else in the United States. We were just unfortunate 
here in Texas.
    I think a lot of the things that you saw happen here could 
happen in other places with somebody not fully understanding 
the travel history, not making the link of what is going on 
halfway around the world, and making the first diagnosis of a 
tropical disease here in the United States. So we have to learn 
from one another.
    So some of those things that we do, there is an 
organization of the folks that do my job across the United 
States. We have had multiple phone calls related to this 
strategic plan issue, chikungunya, et cetera, and we share 
information rapidly between each other. There is a Council of 
Epidemiologists across the United States. They have had those 
types of meetings. We have to educate here in the State of 
Texas. We have had multiple phone calls with all the hospitals, 
all the EMS providers, all the emergency managers across the 
State of Texas. We will share our after-action report and share 
that information with our colleagues across the United States. 
But we take that very seriously.
    I think also to reiterate some of the comments that were 
made earlier, I do not think you ever get done with 
preparedness. So, those funding streams for hospitals to be 
prepared or for public health emergency preparedness really are 
essential for hospitals, for clinicians, for public health 
individuals across the United States so they know how to 
recognize when something like this occurs and have the 
expertise to respond quickly. Those funds have been reduced 
over the last several years, and they are essential to a health 
department like mine to be able to respond effectively to an 
event like this.
    I guess the other thing I would add is that many years ago 
there were dollars that went to academic institutions to 
provide disaster education, and those funds have also been 
decreased over the last several years.
    Dr. Giroir. It is always very difficult for a low-risk, 
high-consequence event to have everyone thinking about those 
events. After you have the first event, everybody is thinking 
about those events. We have done this in the past with the 
college meningitis. There was a big outbreak in North Texas, 
and the mortality rate went down many-fold just by education, 
but it is not just education. It is really getting on the 
ground and making sure people understand how to act on that 
education.
    I can say our task force, we can say all the good things, 
but you do not know until you ask the people who are on the 
front line. So we have a formal process we will be announcing 
to seek information from the Texas Medical Association, Nurses 
Association, Pharmacy Association, Public Health Association, 
the first responders, the Rural and Community Health 
Association, because not everybody lives in an urban area. We 
are a rural State.
    So we want to seek a lot of input in how we could best 
educate the diverse groups and make that on-going. It may be as 
simple as, I do not know if this is simple or effective, but we 
all have continuing medical education, you know, 24 hours every 
2 years. Have 15 minutes, just a 15-minute on-line that it does 
not matter whether you are a nurse, a doctor, or a pharmacist, 
that says what is circulating--what do you need to worry about? 
It takes 15 minutes, and at least you reach everybody during 
that basis. But we will be exploring all those efforts.
    Mr. Clawson. Well, let us hope that we can get everybody in 
the country in those jobs having that 15 minutes, right, 
because it seems like a pretty important 15 minutes.
    Dr. Giroir. Yes, sir.
    Judge Jenkins. Can I answer that from the perspective of 
what you could take home to your local governments for them to 
do immediately?
    Mr. Clawson. It would be very helpful.
    Judge Jenkins. Yes, sir. Every county that you represent 
needs to have a protocol for identifying people who have 
recently traveled to West Africa and have certain symptoms, and 
then quarantine them into a private room, and take appropriate 
precautions. We had that in Dallas County. It was not followed 
in this case.
    At some hospitals, the electronic medical records have 
artificial intelligence that would trigger that. That would be 
a good best practice for large hospitals. The incident command 
in a box for Ebola, that is not just a game plan. You have 
actually contacted those cleaning guys and those apartment or 
home residences you are going to move people to, and they are 
actually going to clean up after Ebola, and actually going to 
take contact families into their premises. There is going to be 
a security perimeter around that to keep out onlookers.
    Where we fell down is not that David and I could not white 
board what needed to happen. It was the length of time it took 
to make it happen, and it took a phone call from me to a member 
of the faith community after we exhausted every housing source 
in Dallas County, 2.5 million people. It took a call to the 
faith community and asking them to clear out an area and do 
this for us, and that is not any way to have to do this.
    Chairman McCaul. Thank you. The Chairman recognizes Mr. 
Farenthold.
    Mr. Farenthold. Thank you very much, Mr. Chairman. You did 
a great job of getting a bipartisan panel. We have an Aggie and 
somebody from The University of Texas here.
    [Laughter.]
    Mr. Farenthold. So we have a great bipartisan panel.
    Chairman McCaul. I am going to stay out of that one.
    Mr. Farenthold. Mr. Jenkins, I want to follow up on what 
Mr. Clawson was asking. You know, listen, yes, I think you did 
a phenomenal job, the humanity that you showed, and I join you 
in my sympathy for Mr. Duncan's family. But my question is, you 
talked a little bit about what all the counties need to be 
doing, actually having the places. Can you take maybe a minute-
and-a-half and just give me your top 5 things that the county 
judges and all the other Texas counties ought to be thinking 
about and doing?
    Judge Jenkins. You need to make sure you have protocols and 
that our hospitals have been training with repetition. You need 
to activate your medical societies so that they are training 
with that repetition and interactions with your hospitals. Then 
on your instant command in a box, you need to have that laid 
out and ready to go on a moment's notice.
    You need to have places for people to move to, people to 
clean things up. Your first responders need to know what the 
protocols are to handle these situations. You need to have a 
messaging plan to keep people calm and have them follow the 
science. You need to bring in your schools early and your faith 
community early and help them be messengers. You need to 
empower all of your school boards, your city councils in your 
suburban areas. You need to do that in the first 24 hours.
    Mr. Farenthold. All right. Mr. Giroir, we have heard a lot 
about the failure of this information to get down to the front-
line folks in the hospital. I mean, that was kind of the big 
screw-up here I think. I get hundreds of emails every day. I 
used to be a computer guy. I would get somebody from the 
Computer Emergency Response Team. I get all sorts of 
information like that in my inbox. When I have got a busy day, 
that just is the first thing that does not get read are the, 
you know, the emails with important updates.
    You talk about a 15-minute continuing medical education, 15 
minutes every 2 years. Does not this change more than every 2 
years? I mean, that probably would not be enough. I mean----
    Dr. Giroir. No, it certainly would not.
    Mr. Farenthold. How do you get around that? I mean, 
everybody knows about Ebola if they have turned on their 
television newscasts now. But what happens early on when the 
next one comes?
    Dr. Giroir. Right, and I think you are exactly right. We do 
not know if the information did not get to the people in the 
emergency room or they did not act on the information in the 
correct way. That will be something in the future.
    But you are correct that the best way to approach any 
problem, and you do it in hospitals all the time, is to create 
processes that you cannot get around. As the judge said, the 
Texas Senate heard testimony of one of the large hospitals, 
Parkland, where it is an automated record that if you are from 
West Africa, it literally lights up on every screen, and it has 
to go to a higher-level supervisor in order to make sure that 
it is appropriately handled. Those kinds of fail-safe 
mechanisms do not rely on individual emails or education, but 
it is a multifaceted approach.
    Mr. Farenthold. How do you get away from the reluctance? 
Again, I am an old computer guy. There is nobody who hates 
computers more than doctors. I mean, every doctor I know has 
complained about electronic medical records and the expert 
systems.
    Dr. Giroir. But we do educate providers. We do keep them 
up. There are continuing medical educations. There are 
conferences. There are meetings. There are other ways to reach 
people. But there is no single solution. This is going to be a 
comprehensive education solution that spans many, many 
disciplines because, again, not everybody goes to a hospital 
ER. They may show up at a pharmacist, or a public health 
professional, or a nurse, or from promotoras in the colonias. 
We have to have this widespread. It is a challenge, there is no 
doubt.
    Mr. Farenthold. All right. Finally, I think everybody on 
the panel has said that funding needs to be restored for a 
variety of projects. What else can we do as Congress to help 
with this beyond kicking up the budgets? Is there legislation 
we need to do? Are there holes? What else is there to do 
besides spend some more money? Go ahead, Judge.
    Judge Jenkins. Streamline the process for permitting for 
waste. Empower public health officials and executives. I serve 
as the director of homeland security and emergency management 
for Dallas County. Give us the power to do this quicker. We are 
working under laws that clearly were not set up for Ebola.
    Mr. Farenthold. Anybody else?
    Dr. Lakey. I would agree. I talked a little bit about the 
ability of a health authority to be able to detain an 
individual, understanding that you do not want that to be very 
broad, an emergent issue, to be able to do this. We talked 
about funding. The health alert networks, the basic abilities 
to do surveillance activities, monitor individuals, having 
exercises that take place in hospitals, the requirements for 
continuing medical education, those types of things.
    I guess the other idea that I would have is I was able to 
participate this summer with the Institute of Medicine looking 
at how we can we improve the ability to do research in the 
middle of a disaster. I think you need to think about how can 
we facilitate that in an emergent event to rapidly be able to 
take investigational drugs, to monitor them appropriately, and 
to decrease that time that it took to get research done and 
investigational medicines out.
    Mr. Farenthold. I see, Ms. Troisi, you look like you want 
to answer.
    Ms. Troisi. Yes, really.
    Mr. Farenthold. I do not have a lot of time, but if the 
Chairman will----
    Ms. Troisi. No, I will add one thing, is that disease-
specific funding hampers public health's ability to prioritize 
what needs to be done. Many times communities that have one 
problem have another problem, but the funding streams are such 
that you can only deal with problem A, not with problem B with 
that specific funding. So non-restricted funds would be good.
    Mr. Farenthold. Thank you very much.
    Dr. Giroir. Money is important, but accountability for the 
funds, money spent right, is equally as important as the amount 
of money, and that takes leadership across agencies. I think 
there is tremendous duplication even in my area between DoD and 
DHHS that could be easily streamlined for less money.
    The third thing I would say, and I am on the other side of 
this now, is that probably the onerous Government contracting 
procedures probably double the time and increase the costs by 
30 or 40 percent than what they need to be. Congress has given 
special contracting authorities to certain agencies to allow 
that to be expedited, and they are not being expedited in their 
fullest. We can get more for the money we spend right now.
    Mr. Farenthold. Thank you.
    Chairman McCaul. We thank the witnesses for this hearing, 
for being here. It has been very informative, and not only in 
terms of identifying the threat and how to best contain and 
control it, but also to debunk some of these myths out there in 
terms of Ebola and how it is transmitted. I think that will go 
a long way in alleviating some of the panic and the fears out 
there in the general population.
    So the record will stay open for 10 days. Members may have 
additional questions to submit in writing.
    With that, Ms. Jackson Lee is recognized.
    Ms. Jackson Lee. Thank you so very much. On behalf of Mr. 
Thompson, I want to also express my appreciation to the 
Chairman and to all of you. I think in addition to debunking, I 
think there has been given comfort that health professionals 
across America, we cannot have hearings with every county and 
State, but that there is a preparedness and a readiness to be 
prepared, and the recognition that we may not have rural 
hospitals before us.
    Texas Presbyterian may be the one in the eye of the storm 
and people are looking into how that treatment was. But at 
least you have given a pathway for our hospitals and medical 
facilities to reach out for information, to determine if they 
have the right amount of equipment, and as well, to raise 
questions such as the kind of containment units.
    Again, I am going to push this idea of regional panels. Dr. 
Giroir, I think it is an excellent idea, and we have learned a 
lot from hearing what Texas has done. Thank you all so very 
much. Thank you, Dr. Lakey----
    Chairman McCaul. With that, the committee is adjourned.
    [Whereupon, at 4:01 p.m., the committee was adjourned.]


                            A P P E N D I X

                              ----------                              

          Questions From Honorable Lamar Smith for Toby Merlin
    Question 1. In understanding that there may be some accuracy 
questions or concerns around reliance on a non-contact thermal 
thermometer, what steps will the CDC or other agencies take to achieve 
secondary/confirmatory screening to ensure optimal accuracy and quality 
and potentially more precision in readings?
    Answer. Response was not received at the time of publication.
    Question 2. Could you provide the committee with background on the 
decision process that went into the choice of the thermometer(s) that 
will be utilized?
    Answer. Response was not received at the time of publication.
    Question 3. Will the temperature screeners be maintaining the 
recommended distance barrier (3 ft.) for evaluation and if so, how will 
they use the infrared devices effectively?
    Answer. Response was not received at the time of publication.
         Questions From Honorable Beto O'Rourke for Toby Merlin
    Question 1a. The Center for Disease Control and Prevention (CDC) 
provides grant funding to ensure that public health departments are 
prepared for emergencies. What are the audit and accountability 
mechanisms for CDC Public Health Emergency Preparedness (PHEP) grants?
    Was any of the PHEP funding spent in Texas and specifically in 
Dallas?
    Question 1b. If so, how was this funding spent and why did this not 
prevent the mistakes that occurred in Mr. Eric Duncan's case?
    Question 1c. Given the public health errors made in Dallas with 
regards to Mr. Duncan's case, what procedural changes does CDC 
recommend?
    Answer. Response was not received at the time of publication.
    Question 2a. There was a 4-day delay from when Mr. Duncan was 
diagnosed and when he received the experimental treatment. What effect 
did this have on Mr. Duncan's death?
    I understand that CDC cannot mandate the specific type of care, but 
what are your thoughts on the efficacy of the treatment Mr. Duncan 
received?
    Question 2b. Was the hospital adequately prepared?
    Answer. Response was not received at the time of publication.
         Questions From Honorable Eric Swalwell for Toby Merlin
    Question 1. Dr. Merlin, at the October 10 hearing I asked you about 
the budget of the Centers for Disease Control and Prevention (CDC). I 
inquired if the CDC's budget was adequate or if it needed to be 
increased. And, I asked what would be done with this additional funding 
if it were needed. You answered that you would defer to the CDC 
director and Department of Health and Human Services (HHS). Having had 
time now to consult with the director of the CDC and anyone at HHS, how 
would you answer my questions about the adequacy of the CDC's budget 
and what would be done with extra funds if they were considered needed?
    Answer. Response was not received at the time of publication.
    Question 2a. I followed up my question about the general CDC budget 
with a question about the budget of just your part of CDC, the Division 
of Preparedness and Emerging Infection. You said you would have to get 
back to me. Please now provide information about the budget of the 
Division of Preparedness and Emerging Infections. Specifically, include 
the level of funding your division has received between fiscal year 
2005 and fiscal year 2015. Please also note the effect of 
sequestration.
    Do you consider these levels of funding adequate to accomplish your 
mission?
    Question 2b. If not, what have been the negative effects of these 
insufficient amounts?
    Answer. Response was not received at the time of publication.
    Question 3a. Dr. Francis Collins, head of the National Institutes 
of Health (NIH), recently said the following in talking about the 
impact of budget cuts on finding a vaccine for Ebola: ``Frankly, if we 
had not gone through our 10-year slide in research support, we probably 
would have had a vaccine in time for this that would've gone through 
clinical trials and would have been ready.''
    Do you share Dr. Collins's view?
    Question 3b. Why or why not?
    Answer. Response was not received at the time of publication.
         Question From Honorable Lamar Smith for John P. Wagner
    Question. What type of precautions will the involved agencies be 
taking to protect the screeners at the airport (i.e. will they all use 
personal protective equipment (PPE) to include gloves, surgical masks). 
And if so, will that differ from the precautions they plan to take for 
the screeners of those passengers who have an elevated temperature?
    Answer. U.S. Customs and Border Protection (CBP) Office of Field 
Operations (OFO) has received guidance from the Department of Homeland 
Security (DHS) Office of Health Affairs (OHA) and Centers for Disease 
Control and Prevention (CDC) on Ebola entry screening and the 
requirements for the use of Personal Protective Equipment (PPE) for 
enhanced Ebola screening. OFO has distributed this guidance to the CBP 
employees at the ports of entry (POE) processing international 
travelers arriving from or transiting through the countries affected by 
the Ebola virus outbreak.
    DHS guidance on Ebola entry screening outlines the requirements of 
PPE use, including proper procedures for putting on (donning), taking 
off (doffing), and wearing PPE. DHS guidance outlines the required PPE 
that must be worn when an employee is in close proximity to a traveler 
from a country of concern. In addition, the guidance outlines the 
additional required PPE to be worn by an employee when working in close 
proximity to a traveler from a country of concern who is exhibiting 
symptoms consistent with the Ebola virus.
    PPE has been made available to all CBP employees at the five 
designated POEs where enhanced Ebola screening is being conducted along 
with OHA guidance which includes the Job Hazard Analysis and PPE 
Assessment. CBP has deployed formal training to CBP employees 
conducting enhanced screening on the donning and doffing of PPE and 
will be implementing additional training on PPE and enhanced screening 
protocols.
    CBP is in the process of deploying additional PPE to all POEs, and 
all POEs have been instructed to maintain a 60-day supply of PPE at 
each location.

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