of ebola. we provided the august 27th dallas county health algorithm and screening questionnaire. at 10:30 p.m., september 25, mr. duncan presented to texas health presbyterian dallas emergency department with a fever of 10 0.1, pain, nausea, and headache. symptoms associated with many other illnesses. he was examined and had numerous tests over a period of four hours. during his time in the ed, the temperature spiked to 103 degrees fahrenheit and later dropped to 101 preponderate 2. he was discharged early in the morning on september 26, and we have provided a timeline on the notable events of mr. dun can's initial emergency department visit. on september 28 th, he was transported to the hospital by ambulance. once arrive at the hospital, he met criteria of the ebola algorithm. at the time, cdc was notified. hospital followed all cdc texas

health services recommendations in effort to ensure the safety of patients, hospital staff, volunteers, nurses, physicians, and visitors. protective equipment included water and gowns, surgical masks, eye protection, and gloves. since the patient was having diarrhea, shoe covers were shortly thereafter added. we notified health and human services department and infectious specialists arrived on site thereafter. on september 30th -- >> doctor, could you -- >> confirmed the disease. diagnosed in the united states at texas health dallas, and later that day, officials were notified and arrived on campus october 1st. >> doctor -- could you doctor, one moment, please. >> doctors, nurses -- >> hold on a moment please, we are way over time, and we m to hear the details, but can you wrap it up? we have questions on the details, sir.

>> okay. >> thank you. >> thank you. in conclusion, i'd like to underscore we have taken all -- taken all the steps possible to maximize safety of the workers, patients, and community, and we'll continue to make changes as new learnings emerge. moreover, determined to be an agent of change in the u.s. health care system helping peers benefit from our experience. texas health resources is an organization with a long history of excellence and mission and ministry continue and will emerge from the trying times stronger than ever. thank you for the opportunity to testify, and i'll be glad to answer questions from the committee. >> thank you. we'll be recognizing each person on the committee for five minutes of questions. strict time on this. welcome to rf daily, this is the first congressional hearing into the u.s. response to ebola. six witnesses from different federal and state agencies as well as the hospital group at the heart of the story just wrapped up opening statements. let's listen as lawmakers start

asking questions here. >> did she, in fact, ask for guidance on boarding a commercial flight as far as you know? >> my understanding is that she did contact cdc and discussed with her a report of symptoms as well as other valuations. >> were you a part of the conversation? >> no, i was not. >> okay. was there a preplan suggesting limiting contacts with other persons? >> the protocol for movement and monitoring of people exposed to ebola identifies as high risk, someone who did not wear appropriate protective equipment during the time they cared for a patient with ebola. on -- >> well, what specifically did she tell you? now, we know mr. dun can's medical team under the drk was not under the same travel restrictions as people he came into contact with, so, specifically what did she say symptoms were, or what was happening? >> i have not seep the

transcript of the conversation. understanding is sthe reported no symptoms to us. >> all right. another question here quickly. with regard to the new patient transferred to nih, people who come into contact with her be under travel restrictions? perhaps you know that? >> well, according to the guidelines that the people who will becoming into contact with her will be physicians, nurses, and others who will be in personal protective equipment, and, therefore, they are not restricted. >> why transferred away from texas? >> to get the state of the art care in a containment facility of highly trained individuals that are capable of taking care of her. >> is her condition deteriorated or improved? >> no, it's not. i have not seen the patient yet. i will when she gets here, but at this point from the report we're getting from our colleagues in dallas is that the condition is stable, and she seems to be doing reasonably

well. i have to verify that myself when the team goes over. >> if other people come to dallas somewhere else, transfered to nih. there's a limited capacity of beds doing this high level care in containment. our total right now is two beds. she'll occupy one of them. >> thank you. doctor, when we spoke on the phone the other day, you were opposed to travel restrictions because in your words, cutting commercial ties hurt fledging democracies. is this the opinion of cdc, your opinion, or someone advise you within the administration or the 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're taking here as well as -- >> did someone advise you on that? someone outside of yourself? somebody else advise you that's the position to protect fledging democracies? >> my recollection of the 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 into the hot zones and so stopping planes -- i heard you say this on multiple occasions we have a thousand-plus persons per week coming into 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, i mean, the duncan case impacted dallas and northern ohio, but what i don't understand is if the administration insists on granting bringing ebola cases into the united states, clearly, you determined how many ebola cases the public can handle. nih can handle two of the beds. do you know the number overall in the country how many we can handle? >> our goal is for no patients -- >> i understand, but as long as we don't restrict travel and not quarantining people and not

limiting their travel, we have a risk. these issues of containment, i don't understand. this is the question america is asking, why allow people to come heerks and once they are here, why is there no quarantine? >> we have to protect americans. right now, we are able to track every who comes in. >> but not stopping them from being around other people, doctor. i understand that. i have high respect for you. the concern is the american people say, even so, they are not limited from travel, not quarantined for 21 days because they can have symptoms. they can bypass other questions that mr. wagner referred to in the thermometers there, and this is what happened with the nurse who went to cleveland. i'm concerned here in is this a maintaining administration that there's no travel restrictions? >> considering better options to protect americans.

>> i give five minutes to ms. degette. >> thank you, mr. chairman. i have questions for you, dr. frieden, and i appreciate yes or no answers in the short amount of time. in the spring of 20 14, ebola spread through west africa causing concern within the international public health community, correct? >> correct. >> ebola has an incubation period of 21 days, and not contagious until the person with the virus is symptomatic beginning often with a fever, correct? >> between two and 21 days, yes. >> ebola is transmitted through contact with the patient's bodily fluids like vomit, blood, feces, and saliva, and the virus concentrates heavily as the patient becomes sicker presenting greater risk to those who come in contact with them, correct? >> correct. >> now, the cdc has developed guidance for hospitals to follow if patients present symptoms consistent with ebola, and it distributed them to hospitals

around the country in the summer of 20 14, correct? >> correct. >> now, doctor varga, can you hear me? >> yes, ma'am. >> your hospital received the first advisory about ebola july 28 th, and this was beggiven toe director of the emergency departments and signs posted in the emergency room, is that right? >> yes, ma'am. >> was this information begin to the personnel, and was there person-to-person training in texas presbyterian for the staff at that time? yes or no? >> was given to the emergency department. >> was there actual training? >> no. >> on august 1st, your hospital received an e-mail from the cdc specifying how to care for patients and advising intake personnel how to from west africa, is that right? >> that's right. september 25th, two months after the first advisory received by

the hospital, thomas eric duncan shows up at texas presbyterian with a fever that spiked up to 10 3 and told the personnel that he had come from liberia. despite this, the hospital sent him home, is that right? >> that is not completely correct. >> he was sent home, right? >> that's correct. >> three days later on september 28th, he took a severe turn for the worst and brought back by ambulance. the hospital staff, nurses, and everybody else were wore protective equipment, is that right? >> that's correct. >> eventually put on shoe covers, do you think how long it took to put the covers on? >> i don't. >> because ebola's highly contagious when the patient is symptomatic, the gear has to shield them from any contact with bodily fluids, is that right? >> correct. >> now, i have a slide to put

up, and i got it from the times today, the photo of the people in various gear. so 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 a bodily fluids. the second one shows what they are supposed to have with the bodily fluids. i want to ask you, doctor, is what they were wearing at first before the ebola was diagnosed that first set of protective gear? >> sorry i can't see the picture right now. >> okay. i was told you would be able to. what should they have been wearing of that protective gear before the ebola was diagnosed? >> i can't make out the details, but there's risk whether the patient is having diarrhea or vomiting and may expo health care workers to -- >> well, this guy, he had diarrhea and vomiting.

so -- and your testimony, people should have been completely covered, is that right? >> i would have to look at exact details to know the answer to the question. >> you don't know whether they should have been completely covered in the patient had diarrhea and vomiting and come from west africa. >> if so, additional covering is recommended under the cdc recommendations, yes. >> now, my other question that i want to ask, and i'm beginning to have to get, doctor, your testimony, because you can't see the chart. now, subsequently, a number of people, health care workers, were put into this group, this protective work, is that right? people being monitored? and in object 10, presented with a fever, admitted to the hospital, is that right? >> yes. >> and then on october 13th, amber vinson self-monitoring

presented with a fever and told by the agency she could board the plane, is that right? i just have one more question. >> that is my understanding. >> now -- >> i need to correct that. >> okay. >> 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 may -- >> your august 22 protocols say that people who are being monitored should not travel by commercial convey, don't they? >> time expire. >> you can answer the question. >> that's what they say. >> people who are in what's called controlled ro eled movem should not board commercial airlines. >> right, people who had close contact with patients, right? that's what your guidelines say. >> guidelines say that people -- health care workers with appropriate personnel protective equipment don't need to be, but people without appropriate personal protective equipment do

need to travel by controlled transportation. >> the time expired. >> i just ask for the record interim guidance dated october 22. interim guidance dieted august 1st, and interim guidance -- cdc health advisory be included. >> without objection. doctor, i need you and other doctors in texas to get back to the committee and follow up the question. the comments made to us was that if she was wearing appropriate gear, she's okay to travel. if she was not, she should not have travelled, and you told us, we don't know. we have to find that out. it's an important question. i recognize mr. upman for five minutes. >> thank you, mr. chairman. most americans realize it is if you're exposed, you have 2 is 1 days. if you goon 2 is 1 days, you're virtually no risk of ebola if you go that far.

it's conceivable, then, after 14 or 15 days, you, in fact, can still get ebola, is that correct? >> yes. >> so i want to go back to the restricting of travel by nonu.s. citizens, 150 folks a day into west africa. conditions as you talked about, exit screening, all folks are exit screened. it's perfectly conceivable that someone even after 14 days can exit screen. they are okay, no fever, and, in fact, get to the destination, perhaps to the united states, and it -- and have the worst, is that right? >> yes. >> if our job is to protect the american public, administration, as i understand it -- i looked at the legal language, does the president, does have the legal authority to impose a travel ban

because of health reasons including ebola, is that not correct? >> i -- i don't have legal expertise to answer the question. >> i saw language earlier today, we could share that with you, but he does, from what we understand, and not only an executive order that former president bush issued when he was president, but also legal standing as well. and so if you have the authority, and it's my understanding, again, that a number of african countries around three nations in fact, imposed a travel ban from those three countries into their countries, is that not true? >> i don't know details of the restrictions. there are some restrictions. >> it's my understanding that they've said, no, and including even jamaica read in the press issued a travel ban from folks

coming from west africa. are you aware of that? >> i don't know the details of what other countries have done. i know some of the details and some of them have been in flux. >> well, i guess the question that i have is if other countries are doing the same and we have to protect american citizens, why not have a similar ban for those knowing they have a fever or exposure rate of 15 days is well within the 21 days, and rp and, in fact, knowing 150 folks come here a day, not 100% -- 94 % in terms of screening from u.s. airports, it seems to me this is not a fail safe system, it's not been put into please at this point. >> mr. chairman, can i give a full answer? >> i look forward to it. >> right now, we know who is

coming in. if we try to eliminate travel, we don't know they come in. that means we can't do multiple things. we won't be able to check them for fever when they leave. >> do we not have -- to interrupt, do we not have a record where they were before, ie a passport or travel status traveling from one country to the other? >> borders are porous -- may a finish? >> go ahead. >> in this part of the world, can't check for fever when they leave or check for fever when they arrive. we won't be anyone, as we do currently, to take a detail history to see if they were exposed when they arrive. when aarrive, we wouldn't be able to impose quarantine as we now can if they have high risk contact. we would not obtain detailed locating information, which we do now, including not only name and date of birth, but e-mail

addresses, cell phone numbers, address, addresses of friends, so that we can identify and locate them. we would not be able to provide all of that information as we do now to state and local health departments so they monitor them under supervision. we would not be able to impose controlled release, conditional release on them or active monitoring if they are exposed or to, in other words -- >> my time expired, and i know we have a swift gavel to the left, but i just don't understand, if we -- if we have a system in place that requires any airline passenger from coming in overseas with a date of birth to make sure they are not on the antiterrorist list, that we can't look at one's travel history and say, no, you're not coming here. not until this situation -- you're right -- it needs to be solved in africa, but until it is, we should not be allowing these folks in. period. >> gentleman's time expired.

recognize mr. waxman for five minutes. >> thank you, thank you, mr. chairman. you have a difficult job. in fact, all of the colleagues who are involved from the different agencies have a difficult job because this is a fast moving issue. you try to explain things to them and partial authority, and, n., the cdc can't do anything by the state, but have to be invited by the state. you can't tell the states to foll foll gui guidelines, but can just give them guidelines, it's a fast moving situation, and you have to strike a balance on informing the public on one hand and keep from panicking on the other. let's go to basics. if people are frightened about getting ebola, what assurances

can we give them that this is not going to be a widespread epidemic in the united states as you have said on numerous occasions? >> the concern for ebola is first and foremost among those caring for people with ebola. that's why we are so concerned about infection control anywhere and patients are cared for. second, in the health care system as a whole, to think about travel, those with a fever or signs of infection needs to be asked, where have you been in the past 21 days, and if they've been in west africa, immediately isolated, assessed, and cared for. >> we have to monitor health care workers, because they are exposed to people who have ebola. the questions have been raised, well, what about the people coming in from africa from the countries where ebola epidemic is taking place, and you've been asked, why not just restrict travel, either directly or indirectly from anybody coming

in from those countries. i want to put up on the skreep a map to show the passenger flows from those countries. hold it up here. looking at those particular countries in africa, they can go to any country in europe, turkey, egypt, saudi arabia, china, india, other countries in africa, and then from those other countries come to the united states. i suppose we could set up a whole bureaucratic apparatus to ensure they did not really travel from nigeria or cameroon or guinea or serra-leserra-leon of the other countries. that could be your emphasis, but

we want to monitor the people before they leave the countries to see whether they have this infek, a infi infection, and we want to monitor them before they leave to see if they have infection. is that what you propose to do? >> we are doing that. we get detailed locating information, determine the risk level. if people were to come in by, for example, going over land to another country, and then entering without our knowing that they were from these three countries, we would lose that information. currently, we have detailed locating information. we are taking detail histories and sharing information with state and local health departments to do the follow up they decide to do. >> do you agree on this point? >> i do. >> wow would not put a travel ban in. it sounds like you say, seal off the borders, don't let those people come in. that's usually reference to the immigration matter, not public health, particularly, might be a

tangential issue, but we know certain countries where the epidemic is originating, why not stop them? >> well -- >> from coming in. >> i believe you just articulated it clearly. it's understandable how someone might come to conclusion that the best approach would be to just seal off the border from those countries, but we're dealing with something now that we know what we are dealing with. if you have the possibility of doing all of those lines that you showed, that's a big web of things that we don't know what we're dealing with. >> so, what we know, is this epidemic can spread if contact with body fluids from someone showing symptoms of ebola or someone exposed to that individu individual. if we have a travel ban, doesn't that force people to hide their

origin? wouldn't we also not know where they are coming from if they go out of the way to hide a quarantine and efforts in west africa and the worst the epidemic becomes, the greater it's a problem all over the world includes the united states. >> the time expired. >> is that your position? >> okay. the time expired. we recognize the vice chair of the full committee for five minutes. >> thank you, mr. chairman. i want to be sure i heard right. you said to chairman upton that we cannot have flight restrictions because of a porous border. do we need to worry about having an unsecure southern and northern border? is that a part of the problem? >> referring to the border of the three countries in africa. >> oh, referring to that border, not our porous border. mr. wagner, help you all, border patrol, to secure the southern

board r and eliminated illegal entry. >> travel is coming across southern border like northern border. we'll ask travel history, where they are coming from, how hay arrived in the country there. >> yes or no was sufficient. i need to move on. i want to come back to remind you that a week before last at the cdc, and i thank you for letting me come down to follow up with you on committee work, that i recommended a quarantine in the affected region and hold people there, and i think that is something that he we should consider. quarantine people for 21 days before they leave that region. that helps every country. going back to an issue you and i talk about at the subs convince phone call, and that is the medical waste. you assured me standard protocols were being followed for disposal of the waste and know that 25 years ago,

hospitals could incinerate their waste. epa regular nations now prohibit that, and the waste has to be trucked and they outsource the care of this waste and results in that going to central processes centers. i have to ask you this, is ebola waste as contagious as a patient with ebola? >> ebola waste or waste from ebola patients can be ready decontaminated. the virus itself is not particularly hearty. killed by leech, by auto claifing, by a variety of chemicals. >> okay. is ebola medical waste more dangerous than other medical waste? >> severity of infection is higher. be certain when you rid of it, you handle it effectively. >> is cdc assessing the abilities to manage ebola waste

in patients, and does the cdc allow off-site di poe sal of ebola medical waste? >> my understanding is that the latter question, yes, worked closely with the department of transportation as well as commercial waste management companies to ensure that capability. >> so we have an added danger? in having to truck this waste and move it to facilities. are there employees of the processing centers trained in how to di pose of ebola waste? >> we have detailed guidelines for the depose sal. >> we talked about the troops from fort campbell over there, and i have some questions from constituents. are the troops coming in contact, those exposed to ebola or included in any of the

controlled movement groups? >> as i understand it, prosecute department of defense, plans do not include any care for patients with ebola or any direct contact with pashltients with ebola. that said, we are careful in country because there's 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 extremely careful to avoid that possibility. >> so we're still going to rely on self-reporting. >> no. we're taking temperatures at many locations within the country. we are having hand washing stations -- >> you're managing away from self-reporting because origin originally it was -- you said structure was built on self-reporting. we visited earlier, and there was a quote from you from test 2011 at the lecture in tv

resource. you said, it was right, patients lie, third of parties do not take medications as prescribed or don't take them at all. you can think they take medications or not. in control, it's the simple model, if people take meds, we believe it. relying on self-reporting and making certain people tell us the truths before they leave and then we catch the fever at the right time if they have a temperature, we have got to do better than this. we can do better than this. we are hear to work with you, and we expect a better outcome. i yield back. >> time expired. i recognize mr. brailey for five minutes. >> i thank the panel for joining us today. heap to hear you say consider any options to protect americans. that's the purpose of everyone here in the room today. i do want to ask you about texas. are you familiar with the con cement of event reporting? >> yes. >> has cdc done a root cause

seasonal sis of what happened in texas pes tierian and come up with an action plan on when we learn from that incident? we have the detailed hospital checklist for ebola preparedness, which we heard about here today, have there by any recommendations on changing, modifying, or updating this in light of what happened at texas presbyterian? we have a team of more than 20 of the top disease detectives in texas now. we were there, left the first day the patient was diagnosed. we identified three areas of particular focus. first is prompt diagnosis of anyone with fever or infection and travel history to west africa and we spoke about that issue. the second is contact tracing. the graphic that i provided earlier outlines what we are doing intensely, we are making sure every single contact of the first patient is

monitored, temperature taken by an outreach worker every day for 21 days. most of the way through the risk period. of the 48, none developed symptoms, none developed fever. we are now looking at contacts who health care wokkers who had contact as two individuals who became infected did, and thoughts with them and we're delighted mmih supports texas and emery university does that as well, and the third area is after identification and contact tracing is effective isolation. looking closely at what might possibly have happened to result in two exposures. >> if there are any new recommendations based upon analysis, this protocol that was sent out will be update and redistributed? >> we always look at the data to see what to do to better protect americans.

>> thank you. you were kind enough to share this graphic, and in it, you mentioned a company in ames, iowa, newlink, working on a vaccine that just went into phase one clinical trials this week, correct? >> that is correct. >> i talked to two employees yesterday, and i know they are working around the clock to help come up with a vaccine that will meet the protocol and standards for scale blt everyone is looking for. the who, department of defense, hhs, and public health organization in candidates called this the most advanced in the world. they requested contracts with hhs to expand manufacturing, to add a third site for manufacturing to complete the scientific studies required to scale up manufacturing, and complete safety study to provide manufactured vaccines equivalent to original vaccines and

identified companies to work as sub contractors. doctor, can you tell us what hhs is doing to make sure they move forward quickly as possible? >> thank you, sir. we reviewed proposals, looks favorable, and we will be in the next several weeks finalizing negotiations with them. prior to that, we have been helping them with submissions to the fda, providing assistance on site and at manufacturing sites working with them to expand their production with other companies incoming here in the united states. >> the hhs a involve on the other end because trials started were not only in collaboration with the department of defense, but we admitted our first vsv patient at all clinical center for phase one trial. it's not only in the testing, but also in the ultimate production. >> and it's my understanding, doctor, that the ultimate goal

is to expand the clinical testing into some of the affected regions in africa as well once we have an understandiunderstan understanding of some of the concerns identified earlier in your testimonies. >> that is quite correct. when i said that after we get through phase one on the trial, i talk about both vaccines, the smith and new link if they are safe and induce the response is appropriate, we'll expand them in larger trials in west africa. >> mr. wagner. question for you. we heard about the issue of travel restrictions. can you walk us through the strengths and weaknesses of that approach from your standpoint and border security? >> well -- >> time expired. give a quick answer. >> we have the ability to use the data that the airlines give us to be able to see where travel originates from. there's instances where the travelers may go to different

locations and might not see that, but through the questioning and our review of the passport, we can identify they've been to affected regions or come through a border, fly to canada, mexico, it's difficult for us to do it, but the possibility's there. the possibility is greater than we would miss one, so i do agree with what the experts say easier to manage and control when we know where people come from voluntarily, and not intentionally trying to deceive us. >> gentleman's time expired. key is voluntary. i recognize dr. burgess for five minutes. >> thank you, mr. chairman, and i would like to stay with what the chairman was talking about on the travel restrictions. the secretary of health and human services under the services act has authority to issue travel restrictions under the pandemic plan adopted in 2005. the president has the ability to issue a travel restriction, 2005 was geared towards the pandemic

bird flu, but amended this year to include this fever. i believe that authority very clearly exists. question is why the executive branch and why the agency will not exercise that authority, mr. chairman, i think, perhaps this committee should consider forwarding to the full house a request that we have a vote on travel restriction because people are asking us to do that, and they are exactly correct to make that request. the first nurse infect over the weekend now transferred away from presbyterian. yet, her condition has been serially reported in the news media as she is stable and been improving. is the reason she's removed because the personnel are no longer willing to stay at presbyterian to take care of her? >> presbyterian is dealing with a difficult situation, working very hard because of the events of the past week, they are now

dealing with at least 50 health care workers who may potentially been exposed. the magnificent of the individuals making sure that if any of them develop any symptoms whatsoever even the slightest. they come in immediately to be assessed so if they develop ebola, we hope no more will, but it's a possibility since two individuals did become infected, others may, that makes it quite challenging to operate and hospital and we felt it more prudent to focus on caring for any patients who come in, health care workers, or others who come in with symptoms effectively. >> i don't disagree, and we talked about this. fully in favor of individuals diagnosed they are taken care of in centers, and you know that somebody wants to do research on the virus, you can't go to a regular university setting to do that, but go to a laboratory

where they have the capability of protecting personnel not only doing experiments, but other personnel in the lab. is it possible to get a picture from the dallas morning news with the cdc recommended personal protective equipment? i think we had it there, and this not only shows personal protective equipment, but details the order in which it should be put on and removed. i note shoe covers are not included in this graphic, but there's a fair amount of exposed skein around the eyes and forehead, and, of course, the neck. now, this is going to be hard to see, but this it your picture in western africa, and as you can see, there is head to toe covering and goggles, and i believe, if i understand the circumstances correctly, you were just bout to be dosed with a near toxic dose of chlorine, is that not correct? >> yes. >> that's why you can't have

skin exposed because it's impossible to do the disinfection, if you will, after taking care of the ebola patient or being in an ebola ward, impossible to do the disinfection if there is skin exposed because exposed skin would be killed by the chlorine, and that would not be good for the person delivering the care. i mentioned this in the opening statement, and so concerned. we know the numbers in western africa go up on ebola. the rate is going to increase. we know that 10% of the cases are health care workers, and we know that 56% of those health care workers in western africa will succumb to the illness. that's a dire warning for anyone who's involved in delivering health care. i would just submit, well, dr. robertson, what kind of stockpile of this personal protective equipment do you have available to the health care workers on the front line, and bear in mind, no travel restrictions, so a new patient could come in tonight and go to

any hospital in the country and present themselves. are you going to be able to quickly deliver a stockpile of personal protective equipment like this? >> so we know talking to the manufacture manufacturers, there's no shortages right now and willing to deliver within 24 hours or less. >> let me ask this question. you know, what did you think the first patient was going to look like when you knew you had a patient zero at some point or it was a possibility. we had the gentleman who died in nigeria end of july who could have got on a plane to minneapolis, what do you think that was going to look like? what was patient zero going to look like, and now you see what it really looks like, what is the match up there? >> go ahead and answer quickly, thank you, doctor. >> our goal has been to get hospitals ready to specific types of personal protective equipment to be used as not simple, and there's no single right answer. there's a balance between

protective equipment that's familiar or less familiar, more flexibility and less flexible that's decontaminated more or less easily. the use of different types of protective equipment is something that, obviously, we're looking at very intensively now in dallas, in conjunction with the health care workers there. >> thank you. i. >> i have some questions and i begin by thanking health care professionals on the front line, and i want to insert in the record a letter from randy wooin garden from the american federation of teachers representing a bunch of -- many nurses into the record. i'd also like unanimous concept to put in the record the diary of paul farmer from partners and health who has, among other things, said the fact is that

weak health systems are to blame for ebola's rapid spread in west africa, and we know that west africa has 24% of disease burden, 3% of world health work force, one doctor in liberia for 90,000 people. i'd like to focus on what to do to help that infrastructure, but in my limited time, i want to focus on our infrastructure here. we have a vast infrastructure, hospitals, community health centers to point out too, where people present themselves. nurses. nurses aids. no one better than the united states, but do we have the ability to train and equip, as we've talked about in military terms in syria, do we have the ability really to train and equip? let me just put a couple things on the table. in terms of the nurses, i still

don't feel like we have a good answer of why nurse one and nurse two contracted ebola. is it because there was a problem with not following the protocols, or is there something wrong with the protocols, and how are we going to ensure that even if we have the best protocols in the world, that everybody knows how to use them? the congresswoman showed various protective gear our nurses are supposed to have, and yet two days, apparently, went by when they were not wearing shoe covers, necks were not covered, that skin, in fact, as dr. burgess talked about, was, in fact, exposed. even as we knew he had ebola. how are we going to make sure,

despite how we check at the airports -- i'm from chicago, i talked to the health director today, i know what we're doing -- but there's still the chance someone could present anywhere, so how come the nurses in dallas were not protected, and how are we going to make sure everybody can be? >> first, just to clarify one thing. the first couple days, 28th, 29th, 30th, were before his diagnosis was known. he had suspected ebola. the test was being drawn and assessed, but he had not yet been diagnosed with ebola, and in our team's review -- >> is that -- excuse me one second. congresswoman, were you saying otherwise? can i yield? >> if the gentle lady will yield, but presented with ebola symptoms, had been to the emergency room just a couple days earlier saying he was from africa. i believe the cdc protocols begin to the dallas hospital

said that people should be wearing that protective covering even before the official diagnosis. i would certainly hope -- thank you for yielding, and i certainly hope that here going forward, if a patient shows up saying he's from africa and he's vomiting, and he has diarrhea, that you do not say, well, we don't have the lab results in, you would start treating that person like they had ebola. >> absolutely. >> reclaiming my time. >> i just wanted to clarify the first couple days, the 28th and 29th, he was isolated for ebola. the diagnosis was confirmed on the 30th, on the 30th, we went a team there, and when we look -- to answer the question of those first couple days, there were some -- there was some variability in the use of personal protective equipment. the hospital was certainly trying to implement protocols. >> i know, but going forward, how are we going to ashsure jus try -- you know, how do you educate people, nurses -- the

nurses are saying they -- across the country -- that they have not been involved and that they are not trained properly or have the equipment. >> three phases. first, think ebola. anyone with travel history and symptoms. second, any time a patient is suspected, isolate them, contact us, and we'll walk you through to get care while we get tests done, and if confirmed, we'll be there within hours with the cdc ebola response team. >> my time expired. >> in response, when did you come up with that plan? what you just stated, the plans in terms of training for nurses. when was that decided? >> we look at our prepareness continuely, so awareness is something we are promoting in extensive ways -- >> i mean, she was asking specifically for those nurses. when was the plan put into place for the texas hospitals, you need to follow this protocol from this point on? >> the day the diagnosis was

confirmed, we sent a team to texas. >> thank you. >> first of all, i want to thank chairman murphy for calling the subcommittee back to baushz was to hold this response on the ebola outbreak and commend colleagues on both sides of the aisle. your unanimous attendance to the hearing. since time is very limited, of course, i'd like to get draeirey to my questions. this is a follow-on of what was asked, and i don't think we ever got around to an answer on that, and i'll direct the question, maybe first to dr. varga. as we know from new reports yesterday, there's a second health care worker who contracted ebola, ms. amber vinson. she's receiving isolated treatment in emery university containment unit in atlanta, we

must examine the protocols broke downs that resulted in the con trags -- contraction of ebola by two nurses directly in contact treating thomas duncan. doctor, in your written testimony, you say that the first nurse, ms. pham, to contract ebola, was using full protective measures urn the cdc protocol while treating mr. duncan. has your organization in texas identified where the specific breaches in protocol were that resulted in her infection, or are alternatively, the inadequacies of the protocol? >> thank you, sir. we are investigating currently

the source of this obvious exposure, and contraction of the illness. we've confirmed that care with n was wearing protective patient equipment through the whole period of time as dr. frieden already mentioned with the diagnosis of the ebola confir d confirmed, the level of personal protective equipment was elevated to the full hazmat style. we don't know at this particular juncture what the source or the cause of the exposure that caused nina to contract a disease was. >> dr. varga, i'm going to interrupt you for a second because the limitation of time. i want to know go to dr. frieden. dr. frieden, as dr. varga just

stated, health care personnel were following cdc protocols while treating mr. duncan, which include the use of so-called ppe, personal protective equipment. do the cdc guidelines, your guidelines on the use of ppe mirror current international standards that, by the way, are being adhered to, those international standards in west africa in those three countries, sierra leone, guinea and liberia? >> the international standards are something that evolve and change. we use different ppe in different settings. there's no single right answer. and this is something we're looking at very closely. our current guidelines are consistent with recommendations from the world health organization, is my understanding. >> yeah. i would think that there would need to be a, dr. frieden, i commend you for the job you're doing. and i know these are tough times

for all of us, but i think some consistency is what we need. and that brings me to my next question. and my last question. and, again, to you, dr. frieden. does the issue of elevated temperature. you know, is it 100.4? is it 101.5? is it 99.6? i think there's some great confusion because initially when people were screening, mr. wagner at the airports in west africa, the temperature threshold was 101.5. and then i think, now, the screens that we're doing at these five major airports including hartsfield international in atlanta. it's now 100.4. when mr. duncan came for the first time to the texas presbyterian hospital, his

temperature was, what, 100.1, and within 24 hours, of course, it was 103. so when mom and dad are out there, and their child has a temperature and this fall is flu season and they're going to the doctor, they're going to demand being checked for ebola. give us some guidelines on what is elevated temperature, and when should parents be concerned? >> well, first, parents should not be concerned about ebola unless you're living in west africa or the child has had exposure to ebola. and right now, the only people who have had exposure to ebola in the u.s. are people either providing care for ebola patients or the contacts of the three ebola patients. and i outline those in this sheet. for our screening of criteria, we're always going to try to have an additional margin of safety. and so we look at that, and we'd rather check more people and assess.

and so we're going to always have that extra margin of safety for our screening. >> thank you. and i yield back. thank you. >> i now recognize ms. caster for five minutes. >> thank you all for tackling this important public health issue of the ebola virus. i want to thank the experts at the centers of disease control and the nih and medical professionals across the country, especially those at emory university health care who have been proactive in containing and treating the virus. i agree with president obama and all of you, we have to be as aggressive as possible in preventing any transmission of the disease within the united states and boosting containment in west africa. but i also think we need to pause here. this is a wake-up call for america that we cannot allow nih funding to stagnate any longer. earlier this year in the budget committee, i offered an

amendment to the republican budget to restore the cuts to nih, the budget cuts that had been inflicted over the past two years and repair the damage of the government shutdown of last year, unfortunately, it did not pass on a party line vote. we will only save lives if we can robustly fund research in america and keep america as the world leader. i'd like to turn to some of that research that is going on now. it's going to be research that will be our longer term response to ebola. will be the vaccines to prevent the disease and the drugs to treat it. i want to walk through a basic point here. that the development of vaccines and treatments for ebola is different from the development of many other drugs. there's not a large private market for the drugs. so the development requires the leadership of our country.

and nih has been working on a vaccine for many years. and he reported today, they've moved into some phase 1 clinical trials. can you explain to us why government support is so important for developing ebola vaccines and treatments? >> well, when you have a product that you want to develop, that it is not a great incentive on the part of the pharmaceutical companies because of a disease whose characteristics is not a large market. we have the experience when you're dealing we merging and reemerging disease, be it influenza or be it a rare disease that could be used deliberately in bioterror or a rare disease like ebola that if you look prior to the current epidemic, there were 24 outbreaks since 1976. the total number of people in those outbreaks was less than 3,000. it was about 2,500. so we were struggling for years

to get pharmaceutical partners. ourselves and then we did get some pharmaceutical partners like we have now with. that's one of the reasons why we have barter. i showed the slide where the nih and the researchers at this end and then you have to push the envelope further to the product to derisk it on the part of the companies. companies don't like to take risks when they don't have a clear -- >> can you quantify a time line for ebola vaccine to be on the market? is it feasible for any vaccines to be approved in time to assist in the current outbreak? >> well, your question has a couple of assumptions. the first is that the vaccine is safe and it works. the second is going to be how long is this outbreak going to last at its level? if you look at the kinetics and

dynamics of the epidemic, it looks very serious. our response to it, when i say our, i mean the global response is not kept up with the rate of expansion. if that keeps up as the cdc has projected, we may need a vaccine to actually be an important part of the control of the epidemic itself as opposed to what the original purpose of it was, was to protect health care workers alone. but now if you have a raging epidemic, and to be quite honest with you, i cannot predict when that will be. if you have a lot of rate of infection, a vaccine trial takes a much shorter time to give you the answer. if it slows down, it's a much longer time. if you have a lot more people in your vaccine trial, it takes less time. if we have trouble logistically, which we might, of getting people into the trial, it might take longer. so i'd like to give you a firm answer. but we can't right now.

>> another, in addition to the vaccines, part of controlling the virus is early diagnosis and treatment. i know there are some diagnostic tests that are being developed. can you speak to the prospects of improved diagnostics that can assist in this outbreak? >> right. well, there are a couple of us, when i say us, i mean agencies working on diagnostics. played a major role in leadership. we have several grants and contracts out to try and get earlier and more sensitive diagnostics. >> thank you. >> thank you. now recognize mr. gardner for five minutes. >> thank you, mr. chairman. and i thank the witnesses for joining us today and the work you are undertaking. dr. frieden, i want to clarify something you had said earlier. i believe you mentioned that there are approximately 100 to 150 people a day coming into the united states from the affected areas. >> that's my understanding, yes. >> and to mr. wagner, you mentioned that we're screening 94% of those people?

>> as of today with the expansion to the four additional locations, that covers about 94%. >> of the 100 to 150, 94% being covered. that means somewhere between 2,000 and 3,000 people a year are coming into this country without being screened from the affected areas? >> well, they would undergo a different form of screening. we're still going to identify that they've been to one of those three affected regions. and we're still going to ask them questions about their itinerary. we'll coordinate with cdc and public health if they're sick. and we're also going to give them a fact sheet about ebola, about the symptoms, what to watch for, and most importantly, who to contact. >> would we be checking their temperature? >> we will not be checking the temperatures or having them fill out a contact sheet or about their -- >> so there's 2,000 to 3,000 people entering this country a year without checking their temperature, without having the contact sheet that 94% of those affected people. >> they're going to arrive at hundreds of dien