the last two months the dallas county human department of health services communicated with us and plans were put in place for a possible case of he bowl a we have also providing the august 27th dallas county health department algorithm and screening questionnaire. at 10:30 p.m. on september 25th. mr. duncan present today texas health presbyterian dallas emergency department with a fever of 101. abdominal pain, dizziness, nausea and headache. symptoms that could be associated with many other illnesses. he was examined and went numerous tests over a period of four hours. during his time in the e.d. his temperature spiked 103 fahrenheit but later dropped to 101.2. he was discharged early on the morning of september 26 and we have provided a time line on the notable events of mr. duncan's initial emergency department visits. on september 28th, mr. duncan was transported for the hospital

by ambulance once he arrived at the hospital, he met several of the criteria of the ebola algorithm. that time the cdc was notified. the hospital followed all cdc and texas department of state health services recommendations in an effort to insure the safety of patients, hospital staff, volunteers, nurses, physicians and visitors. protecting tiff equipment included water immaterial permeable gowns, eye protection and gloves, since the patient had di diarrhea, shoe covers wee shortly added. we notified the human health services department and infectious special disease specialists arrived shortly after -- >> doctor could you -- >> diagnosing the u.s. and texas health dallas, later that same day. cdc officials were notified and they arrived on our campus october 1st. >> doctor could you -- one moment, please.

>> we are going way overtime here and we want to hear some of the details, can you wrap up a lot of members want to question questions on the details. >> taking all the steps possible the safety of our workers, patients and community. we'll continue to make changes and learnings emerge, moreover we were determined to be an agent of change across the u.s. healthcare system by helping our peers benefit from our experience. texas health resources and organization with a long history of excellence, our mission and ministry will continue and we will emerge from the trying times stronger that ever have been for the opportunity to testify, and i'll obviously be glad to answer any questions from the commit. >> i thank you, we'll be recognizing the persons on this committee for questions and we'll keep a strict time on this as well. let me start off here with

dr. frieden, a second nurse affected with bola. who shared the flight with the worker. the worker was hospitalized in dallas and isolated the next morning. she tested positive for abel a day later. now the plan is to transfer her to emery hospital in atlanta for treatment. texas health presbyterian said that it can care for a maximum of three ebola patients at a high-risk people with protective equipment during the time they care today a patient with ebola. on -- let me ask this, then. what specifically did she tell you? now, we know mr. duncan's medical team was under the same object -- was not under the same observation travel restrictions as people he came in to contact with. so what specifically did she tell you her symptoms were or what was happening?

>> i have not seen the transcript of the conversation. my understanding is she reported no symptoms to us. >> let me and another question quickly. with regard to the new patient being transferred to nih, will people who come in to contact with her be under any travel restrictions? >> according to the guidelines that the people who will be coming in to contact with her will be physicians, nurses and others who will be in personal protective equipment. therefore they are not restricted. >> why is she being transferred in nih and way from texas? >> on to give the state of the art care in a containment facility in highly trained individuals capable of taking care of her. >> has her condition dear or 80ed or improved? >> it has not. transfusion from the first american to be infected with ebola

dr. we have a limited capacity of beds to do this type of high level our total right now is two beds she will occupy one of them. >> you remain opposed. now, is this the opinion of cdc, is this your opinion, or us the someone advise you? does any other agencies? where did this opinion come from, that that's of high importance? >> my sole concern is to protect americans. we can do that by continuing to take the steps we are taking here. >> well, to someone advise you on that? someone else outside of yourself? somebodien else advise you that's the position? >> my recollection of that conversation is that

that discussion was in the context of our ability to stop the epidemic at the source. >> but we can get supplies and medical personnel and so stopping -- i have heard you say this on multiple occasions that we have 1,000 plus persons per week, coming to the united states from hot zones. am i correct on that? >> coming from those areas. >> there are approximately 100 to 150 per day. >> okay. >> now, the duncan case has seriously impacted dallas and northern ohio, what i don't understand if t administration insists on bringing ebola cases in the united states, clearly you have determined how many infection cases the u.s. public can handle, n.i.h. can handle two of these, do you know the number overall. >> our goal is for no patients. >> i understand, but as long as we don't restrict travel, and we aren't quarantining people, and not limiting their

travel, we still have a risk. and so these issues of surveillance and containment, i don't understand. and this is the question the american public is asking why are we allowing folks to come over here, and why once they are over here there is no garn teen. >> our fundamental mission is to protect americans. right now, we are able to track everyone who comes in. but you aren't stopping them from being around other people. even so, they are not limited from travel, they are not quarantined because they can still show up with symptoms they can still bypass other questions that they referred to. so -- and this is what happened with the nurse who went to cleveland. so i am concerned here, is this going to be maintain position of the administration, there will be no travel restrictions. >> we will consider any options to better protect americans. >> thank you. i now give five minutes. >> thank you,

mr. chairman. dr. freeden i have some questions for you, and dr. varga for you, and i would appreciate yes or no answers because i have a lot to move through, and only a short amount of time. docken tor, spring of 2014, ebola began spreading through west africa, causing increasing concern within the international public health community, correct. >> correct. >> ebola has an incubation period of 21 days and is not contagious until the person with the virus begins to be symptomatic, beginning often with a fever, correct? >> between two and 21 days. >> ebola is transmitted through contract with the body fluids including vomit, blood, and the virus concentrating more heavily as the patient becomens sicker, increasingly greater risk to those that may come in contact with them. >> correct. >> now the c.d.c. has developed guidance for ever hospitals to follow, if patients present with symptoms consistent with

ebola, and distributed them to hospitals around the country in the summer of 2014, correct? >> correct. >> now dr. varga, can you hear me? >> yes, ma'am. >> your hospital received the first cdc health advisory about ebola on july 28th and this advisory was given to the directors of your emergency department, and signnage was posted in your emergency room, is that right? is that right? >> was this given to personnel, and was there person to person training for the staff at that time? >> yes or no? >> it was glymph to the emergency department. >> was with there training? >> no. >> on august 1st, your hospital received an email from the cdc specifying how to care for patients and advising intake personnel to ask a question about travel history from west africa, is that right. >> that's correct. now, on september 25th, almost two months after

the first advisory received be i the hospital, thomas eric duncan showed up at texas presbyterian with a five tear spiked up to 103, and he told the personnel he had come from liberia, despite this, the hospital 7 him home, is that right. >> that's not completely correct. >> . >> the hospital staff nurses and everybody else wore protective equipment, is that right? >> that's correct. >> and then eventually shoe covers were put on too, do you know how long that took him to put shoe covers on. >> i don't. >> now, because ebola is highly contagious, when the patient is symptomatic, they have to shield them from any contact with bodily fluids is that right. >> correct. >> now i have a slide i'd

like to put up, and i got it from the new york times today, it is the photo of the people in the various protective gear. the first one on the left, shows what they are supposed to wear when they come in contact with -- when they are not having contact with the bodily fluids. the second one shows what they are supposed to have with the bodily fluids. so i want to ask you, is what they were wearing at first, before the ebola was diagnosed that first set of protective gear? >> i am sorry i can't see the picture right now. >> i was told you would be able to. what should they have been wearing offing that protective gear before the ebola was diagnosed. >> i can't make out the details but the recommendations vary as to the risk, as to whether the patient is having diarrhea orvilleing and they exposed healthcare workers. >> well, this guy, he had

diarrhea and vomiting, so in your testimony people should have been completely covered is that right? >> you don't know if they should have been completely covered and he. >> if the patient had die radioyeah or vomiting then additional coverage is recommended. yes. >> now my other question i want to ask, and i have to get dr. varga, i will have to get your testimony since you can't see my chart. subsequently a number of people healthcare workers, were butt into this group this protective work, is that right? is. >> nina was admitted to the hospital, is that right. >> yes. >> then on october 13th,

amber vincent, she presented with a fever, and she was told by your agency she could board the plane, is that right? one more question. >> that is my understanding. >> now, your protocol -- i need to correct that, i have not reviewed exactly what was said, but she did contact our agency, and she did board the plane. >> and she says she was told to board the plane. >> -- >> that -- >> your august 22nd protocol says people who are being monitored should not travel by cheerble conveyances. >> that's what they say. >> people who are in what is called controlled -- controlled movement, should not board commercial answerer. >> right, and that's people who have had close contact with these patients, right? >> the -- >> that's what your guidance say. >> the guidance say people healthcare workers with appropriate personnel protective equipment don't need to be, but people without the appropriate personal protective equipment do

need to travel by controlled. >> generally -- >> you need to -- >> i just asked for the record, the interim guidance stated october 22nding, the interim guidance dated august 1st, and interim -- and the cdc health advisory dated july 28th be included. >> without objection, we will include it in the record. to get back to this,en as a follow up to the question, because your comments you just made to us was that if she was wearing appropriate protective gear, it's okay to travel if she was not, she should not have traveled and you just told us we don't know. >> chairman of the committee. >> .

>> 150 folks a day, into the u.s. from west africa, so it is -- the conditions as you talked abouten, exit screening, all folks from there are exit screens so it is perfectly conceivable that someone even after 14 days can exit screen, they are okay, no fever, and, in fact, get to their destination, perhaps in the united states, and have the worst, is that right. >> as i look at the legal language, does the president, does have the he that will authority to

impose a travel ban because of health reasons including ebola, is that not correct. >> i don't have the legaller pecks tease. >> we can share that with you. but he does not only an executive order from president bush issues but also legal standing as well, so if you have the authority, and it is my understanding, again, that a number of african countries around west africa, around these three nations, in fact, have imposed a travel ban from those three countries into their countries is that not true? is. >> as i read in the press earlier this week, has issued a travel ban from

folks coming from west africa. you aware of that. >> i don't know the details of what other countries have done, i know some of the details and some have been in flux. >> well, i guess the question i have is if other questions are doing the same, and as you say the fundamental job is to protect american citizens, why cannot we move to a similar ban. for folk whose may or may not have a fever knowing, in fact, that the exposure rate 14 days 15 days is well within the 21 with days. in terms of screening from u.s. airports, it seems to be that this is a fail system that has been put into place at this point. >> mr. chairman, may i give a full answer. >> i looken forward to it. >> right now we with know

who is coming in. if we try to eliminate travel, the possibility that some will travel over land. two we with need have a record of where they have been before, a passport or travel status, as they traveled from one with country to another. >> borders can be porous, may i finish? especially in this part of the world. we won't be able to check them for fever when they leave, we can't check them for fever when they arrive, we with won't be able to take a details history. when they -- we wouldn't be able to obtain detailed information can which we do now.

but email adescrieses cell phone numbers addresses so we with can identify and locate them. >> we wouldn't be able to impose controlled release conditional release on them, or active monitoring if they are exposed or to in other ways. >> my time is expired and i know i have a swift gavel to my left, but i just -- i just don't understand, if we -- if we have a system in place, that requires any airline passenger to require overseas with to make sure they are not on the anti-terrorist list that we can't look at one's travel history and say no. not until this situation, you are right. until it is we should not be allowing these folkens in period.

>> time has expired. >> recognize for five minutes. >> thank you mr. chairman. dr. freeden, you have a difficult job, in fact all of the colleagues were involved in different agencies have a difficult job, because this is a tags moving issue. you are trying to educate them with partial authority, in fact the cdc can't even do anything in the state, they have to be invited in by the state. you can't tell the states to follow your guidance, you can give them guidance. so you are dealing with a fast moving situation. and you have to strike a balance about informing the public and keeping fit panicking on the other. so let's go to basics. the people are frightened

rabbit getting ebola, what insurances can we give them that this won't be a widespread epidemic. >> the concern for ebola is first and foremost among those caring for people, that's why we are so concerninged about infection control anywhere. >> so we have to make sure that we monitor healthcare workers, because they are exposed to people who have ebola. the questions have been raised what about these people coming in from africa where the countries are the epidemic is taking place. you have been asked why don't we just restrict the travel either directly or indirectly

from anybody coming in from those countries. i would like to put up on the screen, a map to show the passenger flows from those countries. that nonshows if you are looking at those particular countries they can go to any country in europe, they can go to turkey, egypt, saudi arabia, china, india, they can to go to other countries in africa. and then from those other countries come to the wrights. so i suppose we can set up a whole apparatus to make sure that somebody didn't really travel from nigeria, or cameroon, or sin gal, or sierra leone to make sure they didn't get here from any of those countries. that could be their emphasis, but it seems to me what you are saying ising that we want to monitor people before they leave those countries.

to see if they have this infection, and we want to monitor when they come into these ones to see whether they have this infection. is that what you are proposing to do. >> that's what we are doing. we are able to screen on entry, we are able to determine the risk level. if people come in by going over land to another country, and then entering without knowing that they were from these three countries we would lose that information. currently we have detailed locating information. with with tate and local health departments so they can do the follow up they decide to do. >> do you -- yes wouldn't put a travel ban in, it sounds like we always say seal off our borders don't let those people come in, now that's usually reference to the immigration matter, not public health.

particularly, might be a tangential issue, but we know certain countries. why not stop it? they just articulated very clearly, it's certainly understandable how they may come to rah conclusion that the best approach will be to just seal off the border from those countries. we are dealing with with something now that we with know what we are dealing with. if you have the possibility of doing those lines that you showed that's a big web of things we don't know what we are dealing with. what we know is if can spread if there's contact with body fluids of somebodien showing the symptoms, or someone who has been exposed to that individual.

wouldn't we also not know where they are coming from if they are going their way to hide it, to fight the epidemic in west africa and worst epidemic becomes in west africa, the greater it will be a problem all over the world including in the united states. >> time has expired? is that your position. >> thank you mr. chairman, i want to make sure i heard you right, that we with cannot have flight rerestrictions because of a porous border. so do we need to worry about having an unsecured southern and northern border? is that a big part of the problem. >> i was referring to the border of the three countries in africa. >> you are referring to that border not ours. >> mr. wagner, would it help y'all the border patrol if we with secures

the southern border and eliminated illegal entry? >> well, travel is coming across the southern border like the northern border. we are going to ask them their travel, where they are coming from, how they arrived in h the country. >> yes or no would be sufficient, i need to move on. i want to come backing to you, i would with remind you that a week before last, when i was at the c.d.c., and i thank you for letting me come down, that i recommend do a quarantined in the effected region, and hold people there, and i still think that is something we should consider. quarantining people for 21 with days before they leave that region, it helps every country. i want with to go backen to an issue that we talked habit at the cdc in the subsequent phone call, and that is the medical waste. and you assured me that stage cared protocols were being followed for dispose sol after this

waste, and we know that 25 years ago, hospitals could incinerate their waste, epa regulations now prohibit that, and the waste has to be trucked, and they outsource the care of this medical waste, and it results in that going to central processing centers. so is ebola as contagious as a patient with ebola? >> ebola waste from ebola patients can be ready decontaminated. the virus itself is not particularly hardy, it is killed by bleach, by auto clavinging by a variety of chemicals. >> is ebola medical waste more dangerous than other medical waste. >> the severity of the infection is higher, so you want to be certain when you are are getting rid of it -- >> is the cdc assessing the possibility of

managing the waste, and does the c.d.c. allow off site disposal of ebola medical waste? my understanding is that the latter question yes, we with have worked very closely with with the both the department of transportation, as well as the commercial waste management companies to ensure that capability. >> so we with have an added danger? in having to truck this waste and move it to facilities are the employees at the processing centers being trained in how to dispose of ebola waste. >> we have detailed guidance for the disposal of medical waste. >> you and i talked a little bit about the troops from fort campbell that will be over there, are the american troops going to come in contact with any ebola patients or with those exposed to ebola, or included in any

of these controlled movement groups. >> as i understand it from the department of defense, their plans do not include any care for patients with ebola, or any direct contact with patients with ebola. that said, we would always be careful in country can because there is the possibility of coming in contact with someone with symptoms and being exposed to their body fluids and that's why the department of defense is being extremely careful to avoided that. >> so we are still going to rely on self-reporting. >> no. we are taking temperatures at many locations within the country. we are having a hand washing stations -- >> so you are moving away from self-reporting in because orangely i orange y you said our structure was based on self-reporting, and i found a quote from you from december 2011 at the george come stock lecture in t.b. research,

patients lie. about a third of patients don't take medication as prescribed and a third don't take them at all. can dill lewd yourself and think they are taking their. if we see people take their meds we believe they took them. now, doctor, reliant on self-reporting and making certain that people tell us the truth before they leave, and then that we catch the fever at the right time, if they can a temperature, we have to do better than this, we are here to work with you, and we expect a better outcome. >> take has expired. >> i'd like to thank the panel for joining us today. dr. freeden i was happy to hear you say we will consider any options to protect americans i think that's the purpose of everyone here today. i do want to ask you about texas.