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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 

Available via the World Wide Web: http://www.gpo.gov/fdsys/ 
(II) 

COMMITTEE ON HOMELAND SECURITY 

MICHAEL T. MCCAUL, Texas, Chairman 

LAMAR SMITH, Texas 

PETER T. KING, New York 

MIKE ROGERS, Alabama 

PAUL C. BROUN, Georgia 

CANDICE S. MILLER, Michigan, Vice Chair 

PATRICK MEEHAN, Pennsylvania 

JEFF DUNCAN, South Carolina 

TOM MARINO, Pennsylvania 

JASON CHAFFETZ, Utah 

STEVEN M. PALAZZO, Mississippi 

LOU BARLETTA, Pennsylvania 

RICHARD HUDSON, North Carolina 

STEVE DAINES, Montana 

SUSAN W. BROOKS, Indiana 

SCOTT PERRY, Pennsylvania 

MARK SANFORD, South Carolina 

CURTIS CLAWSON, Florida 

BENNIE G. THOMPSON, Mississippi 

LORETTA SANCHEZ, California 

SHEILA JACKSON LEE, Texas 

YVETTE D. CLARKE, New York 

BRIAN HIGGINS, New York 

CEDRIC L. RICHMOND, Louisiana 

WILLIAM R. KEATING, Massachusetts 

RON BARBER, Arizona 

DONALD M. PAYNE, JR., New Jersey 

BETO O’ROURKE, Texas 

FILEMON VELA, Texas 

ERIC SWALWELL, California 

VACANCY

VACANCY

BRENDAN P. SHIELDS, Staff Director 

JOAN O’HARA, Acting Chief Counsel 

MICHAEL S. TWINCHEK, Chief Clerk 

I. LANIER AVANT, Minority Staff Director 
(III) 

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 
Page

IV 

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 
(1) 

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 InTransit 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 
2 

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. 
3 

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 
4 

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 
5 

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 tradeoffs 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 for-
6 

ward 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:] 
7 

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 
8 

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; 
9 

• 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 
10 

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 
11 

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 
12 

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 
13 

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 
14 

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. 
15 

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. 
16 

• 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 
17 

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. 
18 

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. 
19 

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, 
20 

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 Libe-
21 

ria, 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 op-
22 

portunity 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 frontline 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? 
23 

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. 
24 

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. 
25 

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 
26 

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 
27 

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. 
28 

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 
29 

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 
30 

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. Eightyfive 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:] 
31 

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 
32 

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. 
33 

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 hard-
34 

er, 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 imple-
35 

ment 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. 
36 

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? 
37 

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 decisionmaking 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. 
38 

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 
39 

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 wellspent 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 caseby-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 
40 

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. 
41 

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. 
42 

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 
43 

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 
44 

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 
45 

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 
46 

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. 
47 

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:] 
48 

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. 
49 

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. 
50 

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 
51 

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 ex-
52 

perts. 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, Americantrained 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 relook 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. 
53 

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. 
54 

[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 
55 

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. Fortyeight 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 
56 

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 
57 

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 
58 

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 homerule 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, 
59 

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 
60 

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 
61 

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 
62 

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 
63 

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. Un-
64 

fortunately, 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 
65 

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 

fiance ́, 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 Fed-
66 

eral 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, fiance ́e, 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 
67 

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 flowthrough 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 Founda-
68 

tion 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 bootson-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:] 
69 

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, nonprofit, 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). 
70 

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. 

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 
71 

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. 

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 
72 

we may be fixated on this virus and not on ones that could actually cause worldwide 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. 
73 

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? 
74 

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 
75 

* The information has been previously included in this document. 

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.* 

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. 
76 

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. 
77 

* The information has been retained in committee files and is available at: http:// 

www.medbox.org/ebola/ebola-outbreak-preparedness-management/toolboxes/preview. 

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. 

Chairman MCCAUL. Without objection, so ordered. 

[The information follows:] 

Ms. JACKSON LEE. I thank the gentleman. 

Chairman MCCAUL. The Chairman recognizes the gentleman 

from South Carolina, Mr. Sanford. 
78 

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—— 
79 

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. 
80 

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. 
81 

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? 
82 

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. 
83 

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 
84 

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. 
85 

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? 
86 

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:] 
87 

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 
88 

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 
89 

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. 
90 

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. 
91 

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 
92 

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.] 
(93) 

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? 
94 

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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