```

[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]

THE XDR TUBERCULOSIS INCIDENT: A POORLY COORDINATED FEDERAL RESPONSE TO 
                                   AN
              INCIDENT WITH HOMELAND SECURITY IMPLICATIONS

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

                              FULL HEARING

                                 of the

                     COMMITTEE ON HOMELAND SECURITY
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                              JUNE 6, 2007

                               __________

                           Serial No. 110-44

                               __________

       Printed for the use of the Committee on Homeland Security

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  Available via the World Wide Web: http://www.gpoaccess.gov/congress/
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                     COMMITTEE ON HOMELAND SECURITY

               BENNIE G. THOMPSON, Mississippi, Chairman

LORETTA SANCHEZ, California,         PETER T. KING, New York
EDWARD J. MARKEY, Massachusetts      LAMAR SMITH, Texas
NORMAN D. DICKS, Washington          CHRISTOPHER SHAYS, Connecticut
JANE HARMAN, California              MARK E. SOUDER, Indiana
PETER A. DeFAZIO, Oregon             TOM DAVIS, Virginia
NITA M. LOWEY, New York              DANIEL E. LUNGREN, California
ELEANOR HOLMES NORTON, District of   MIKE ROGERS, Alabama
Columbia                             BOBBY JINDAL, Louisiana
ZOE LOFGREN, California              DAVID G. REICHERT, Washington
SHEILA JACKSON-LEE, Texas            MICHAEL T. McCAUL, Texas
DONNA M. CHRISTENSEN, U.S. Virgin    CHARLES W. DENT, Pennsylvania
Islands                              GINNY BROWN-WAITE, Florida
BOB ETHERIDGE, North Carolina        MARSHA BLACKBURN, Tennessee
JAMES R. LANGEVIN, Rhode Island      GUS M. BILIRAKIS, Florida
HENRY CUELLAR, Texas                 DAVID DAVIS, Tennessee
CHRISTOPHER P. CARNEY, Pennsylvania
YVETTE D. CLARKE, New York
AL GREEN, Texas
ED PERLMUTTER, Colorado
VACANCY

       Jessica Herrera-Flanigan, Staff Director & General Counsel
                     Rosaline Cohen, Chief Counsel
                     Michael Twinchek, Chief Clerk
                Robert O'Connor, Minority Staff Director

                                  (ii)

                            C O N T E N T S

                              ----------                              
                                                                   Page

                               STATEMENTS

The Honorable Bennie G. Thompson, a Representative in Congress 
  From the State of Mississippi, and Chairman, Committee on 
  Homeland Security:
  Oral Statement.................................................     1
  Prepared Statement.............................................     3
The Honorable Peter T. King, a Representative in Congress From 
  the State of New York, and Ranking Member, Committee on 
  Homeland Security..............................................    32
The Honorable Gus M. Bilirakis, a Representative in Congress From 
  the State of Florida...........................................    47
The Honorable Christopher P. Carney, a Representative in Congress 
  From the State of Pennsylvania.................................    41
The Honorable Yvette D. Clarke, a Representative in Congress From 
  the State of New York..........................................    67
The Honorable Donna M. Christensen, a Delegate in Congress From 
  the U.S. Virgin Islands........................................    34
The Honorable Henry Cuellar, a Representative in Congress From 
  the State of Texas.............................................    67
The Honorable Bob Etheridge, a Representative in Congress From 
  the State of North Carolina....................................    45
The Honorable Al Green, a Representative in Congress From the 
  State of Texas.................................................    62
The Honorable Jane Harman, a Representative in Congress From the 
  State of California............................................    37
The Honorable James R. Langevin, a Representative in Congress 
  From the State of Rhode Island.................................    59
The Honorable Sheila Jackson Lee, a Representative in Congress 
  From the State of Texas........................................    64
The Honorable Nita M. Lowey, a Representative in Congress From 
  the State of New York..........................................    80
The Honorable Daniel E. Lungren, a Representative in Congress 
  From the State of California...................................    57
The Honorable Edward J. Markey, a Representative in Congress From 
  the State of Massachusetts.....................................    70
The Honorable Ed Perlmutter, a Representative in Congress From 
  the State of Colorado..........................................    50
The Honorable Loretta Sanchez, a Representative in Congress From 
  the State of California........................................    68
The Honorable Christopher Shays, a Representative in Congress 
  From the State of Connecticut..................................    43
The Honorable Mark E. Souder, a Representative in Congress From 
  the State of Indiana...........................................    35
The Honorable Ginny Brown-Waite, a Representative in Congress 
  From the State of Florida......................................    39

                               Witnesses

Mr. W. Ralph Basham, Commissioner, Customs and Border Protection, 
  Department of Homeland Security
  Oral Statement.................................................    27
  Prepared Statement.............................................    24
Accompanied by:
Mr. Jayson P. Ahern, Assistant Commissioner, Office of Field 
  Operations, Customs and Border Protection:
  Oral Statement.................................................    31
  Prepared Statement.............................................    24
Dr. Julie L. Gerberding, Director, Centers for Disease Control 
  and Prevention, Department of Health and Human Services:
  Oral Statement.................................................    57
  Prepared Statement.............................................    51
Dr. Jeffrey Runge, Chief Medical Officer, Department of Homeland 
  Security:
  Oral Statement.................................................    23
  Prepared Statement.............................................    24

                             For the Record

The Honorable Eliot L. Engel, a Representative in Congress from 
  the State of New York:
  Prepared Statement.............................................    15
Ms. Patricia A. Friend, International President, Association of 
  Flight Attendants-CWA, AFL-CIO:
  Prepared Statement.............................................    17
Prepared Statement On behalf of the undersigned organizations....    19
    Aeras Global TB Vaccine Foundation
    American Lung Association
    American Public Health Association
    American Thoracic Society
    Infectious Diseases Society of America

                                Appendix

Additional Questions and Responses:
  Responses from Dr. Julie L. Gerberding.........................    91

 
 THE XDR TUBERCULOSIS INCIDENT: POORLY COORDINATED FEDERAL RESPONSE TO 
            AN INCIDENT WITH HOMELAND SECURITY IMPLICATIONS

                              ----------                              

                        Wednesday, June 6, 2007

                     U.S. House of Representatives,
                            Committee on Homeland Security,
                                                    Washington, DC.
    The committee met, pursuant to call, at 10:04 a.m., in room 
311, Cannon House Office Building, Hon. Bennie G. Thompson 
[chairman of the committee] presiding.
    Present: Representatives Thompson, Sanchez, Markey, Harman, 
Lowey, Norton, Jackson Lee, Christensen, Etheridge, Langevin, 
Cuellar, Carney, Clarke, Green, Perlmutter, King, Shays, 
Souder, Lungren, Reichert, McCaul, Dent, Brown-Waite, Bilirakis 
and Davis of Tennessee.
    Chairman Thompson. The Committee on Homeland Security will 
come to order. The committee is meeting today to receive 
testimony on The Extensively Drug-Resistant Tuberculosis 
Incident: A Poorly Coordinated Federal Response to an Incident 
with Homeland Security Implications.
    Good morning. I would like to thank all of you for being 
here and thank our witnesses for appearing before us today on 
such short notice. I would also like to thank Mr. Langevin, the 
Chair of the Emerging Threats Subcommittee, for taking 
leadership on this issue.
    Last week when news of this incident broke, he brought the 
issue to my attention and stressed the importance of today's 
hearing. I appreciate his leadership on biopreparedness and 
related issues for the committee.
    Ladies and gentlemen, last week we dodged a bullet. That is 
pretty much how I feel after reviewing the efforts of the 
Centers for Disease Control and the Department of Homeland 
Security as they dealt with the case of the newlywed TB carrier 
Mr. Andrew Speaker over the last several months.
    But before I get into the facts of this case, I have got a 
fundamental question that I want the administration to answer: 
When are we going to stop dodging bullets and start protecting 
Americans? As you know, we were just very fortunate in this 
situation. The 9/11 Commission asserted that the terrorist 
attacks in 2001 were the result of a failure of imagination by 
the Federal Government. Our intelligence components weren't 
talking to one another. Intelligence information was 
stovepiped. There was a failure to connect the dots.
    The Department of Homeland Security was created to enhance 
the synergy and efficiency of homeland security efforts by 
several agencies, putting them in one department, but since, we 
have learned that the Federal Government's ability to secure 
the homeland is still grossly deficient in some areas.
    In 2005, the Department's response to Hurricane Katrina was 
characterized as a failure of initiative. Officials knew a 
hurricane was coming, and yet the Department's leadership 
failed to respond timely or effectively. Today I am wondering 
why we shouldn't characterize the actions of the Department and 
the CDC in a similar fashion.
    I have asked the witnesses to provide us with a timeline of 
events that began with the testing of a TB sample and ending 
with Mr. Speaker sneaking his way back into the United States 
unimpeded. DHS states in their testimony today that there was a 
single point of failure in this case: human error on the part 
of the Border Patrol agent who let Mr. Speaker cross into the 
U.S.
    But I have done my own timeline of actions and inactions of 
DHS and CDC, and it suggests that we should have connected more 
dots. Shrugging off a deeper analysis of this incident would 
only cause DHS to repeat its previous failures. For instance, 
after receiving the information about Mr. Speaker from CDC on 
May 22nd, why didn't the Atlanta office of Customs and Border 
Protection notify Customs and Border Protection headquarters or 
TSA officials about putting Mr. Speaker on the no-fly list? 
This would have ensured that Mr. Speaker's name was on the no-
fly list prior to his departure from Prague. Why did CDC wait 
so long before divulging Mr. Speaker's identity to TSA? Even 
though they already shared his information with CBP, this delay 
resulted in Mr. Speaker's name being placed on a no-fly list 
after he had already crossed the border. Why did TSA officials 
argue 4 hours about the propriety of placing Mr. Speaker on the 
no-fly list? Why did CDC think that Mr. Speaker would turn 
himself in to Italian medical authorities? If he was such a 
serious public health risk at that time, why didn't the CDC 
dispatch a plane to get him? Why didn't the CBP agent at the 
Champlain border crossing prevent Mr. Speaker from entering the 
U.S?
    I ask the witnesses, did these breakdowns result from a 
failure of initiative? It would be unfair, however, to 
characterize this as a total system failure. We saw a lot of ad 
hoc decisionmaking by a lot of very capable people throughout 
the different agencies who tried to do the right thing. Many of 
these informed decisions certainly helped the response effort. 
But the fact that the best decisions were made informally 
suggest that we still do not have adequate operational control 
over our components.
    For instance, I was surprised to learn that it took TSA 
almost 4 hours to come up with a legal argument to place a 
nonterrorist on the no-fly list. The Department should have the 
awareness of its policies and procedures to be able to make 
that decision with greater speed.
    DHS and CDC refer to an MOU in their testimony. 
Unfortunately, the committee has not been able to review that 
MOU to determine whether procedures were properly followed. 
Better or at least more complete policies and procedures may 
have made a difference in preventing Mr. Speaker from coming 
across the border.
    This committee will explore ways in which we can make 
improvements for the future. It is equally clear that the 
Federal Government must improve the way we communicate 
information about an infectious disease to the public. CDC's 
announcement last week caused minor hysteria throughout the 
United States and abroad. There was a lot of 
mischaracterization about the public health threat that Mr. 
Speaker posed to his fellow passengers.
    One thing that I have learned over the course of the week 
is that TB is a common disease. Five percent of the U.S. 
population has it, as does one-third of the world's population.
    So I would ask our witnesses to take some time to discuss 
XDR TB and the ways by which it can be communicated so that the 
American people can fully understand what risk, if any, Mr. 
Speaker posed to the public.
    I want to conclude my remarks by saying that I am not here 
to point fingers, I am here to conduct oversight and improve 
the Department of Homeland Security. We had another failure of 
initiative here. Thankfully, it appears that we dodged the 
bullet, but that is not always going to be the case. It is time 
for folks at DHS and CDC to start taking some responsibility.

   Prepared Statement of the Honorable Bennie G. Thompson, chairman, 
                     Committee on Homeland Security

    Ladies and gentlemen, we dodged a bullet.
    That's pretty much how I feel after reviewing the efforts of the 
Centers for Disease Control and the Department of Homeland security as 
they dealt with the case of the newlywed TB carrier, Andrew Speaker, 
over the last several months. But before I get into the facts of this 
case, I've got a fundamental question that I want this Administration 
to answer:
    When are we going to stop dodging bullets, and start protecting 
Americans?
    The 9/11 Commission asserted that the terrorist attacks in 2001 
were the result of a `failure of imagination' by the Federal 
government:
    Our intelligence components weren't talking to one another, 
intelligence information was stovepiped, and there was a failure to 
connect the dots.
    The Department of Homeland Security was created to enhance the 
synergy and efficiency of homeland security efforts by several agencies 
under one department.
    But since then we've learned that the Federal government's ability 
to secure the homeland is still grossly deficient. In 2005, the 
Department's response to Hurricane Katrina was characterized as a 
`failure of initiative.' Officials knew a hurricane was coming, and yet 
the Department's leadership failed to respond timely or effectively.
    Today, I'm wondering why we shouldn't characterize the actions of 
the Department and the CDC in a similar fashion. I've asked the 
witnesses to provide us with a timeline of events--that began with the 
testing of a TB sample and ended with Andrew Speaker sneaking his way 
back into the United States unimpeded. DHS states in their testimony 
today that there was a single point of failure in this case: human 
error on the part of the Border Patrol agent who let Mr. Speaker cross 
into the U.S.
    But I've done my own timeline of the actions and inactions of DHS 
and CDC, and it suggests that we should have connected more dots. 
Shrugging off a deeper analysis of this incident will only cause DHS to 
repeat its previous failures. For instance:
        (1) After receiving information about Speaker from CDC on May 
        22, why didn't the Atlanta office of Customs and Border 
        Protection notify CBP Headquarters or TSA officials about 
        putting Speaker on the `no-fly' list? This would have ensured 
        that Speaker's name was on the no fly-list prior to his 
        departure from Prague.
        (2) Why did CDC wait so long before divulging Speaker's 
        identity to TSA? Even though they already shared his 
        information with CBP, this delay resulted in Speaker's name 
        being placed on the no-fly list after he already crossed the 
        border.
        (3) Why did TSA officials argue for 4 hours about the propriety 
        of placing Speaker on the no-fly list?
        (4) Why did CDC think that Speaker would turn himself into 
        Italian medical authorities? If he was such a serious public 
        health risk, why didn't the CDC dispatch a plan to get him?
        (5) Why didn't the CBP agent at the Champlain border crossing 
        prevent Speaker from entering the U.S.?
    I ask the witnesses: did these breakdowns result from a `failure of 
initiative'?
    It would be unfair, however, the characterize this as a total 
system failure. We saw a lot of ad-hoc decision making by a lot of very 
capable folks throughout the different agencies who tried to do the 
right thing. Many of these informal decisions certainly helped the 
response effort.
    But the fact that the best decisions were made informally suggests 
that wee still do not have adequate operational control over our 
components:
    For instance, I was surprised to learn that it took TSA almost 4 
hours to come up with a legal argument to place a non-terrorist on the 
no-fly list. The Department should have the awareness of its policies 
and procedures to be able to make that decision with greater speed. DHS 
and CDC refer to a MOU in their testimony. Unfortunately, the Committee 
has not been able to review that MOU to determine whether procedures 
were followed properly.
    Better--or at least more complete--policies and procedures may have 
made a difference in preventing Andrew Speaker from coming across the 
border. This Committee will explore ways in which we can make 
improvements for the future.
    It's equally clear that the Federal government must improve the way 
we communicate information about an infectious disease to the public.
    CDC's announcements last week caused minor hysteria throughout the 
U.S. and abroad. There was a lot of mischaracterization about the 
public health threat that Mr. Speaker posed to his fellow passengers.
    One thing that I've learned over the course of the week is that TB 
is a common disease--5% of the U.S. population has it, as does 1/3 of 
the world's population. So I'd ask our witnesses to take some time to 
discus `XDR' TB and the ways by which it can be communicated, so that 
the American people can fully understand what risk--if any--Mr. Speaker 
posed to the public.
    I am not here to point fingers. I am here to conduct oversight and 
improve the Department of Homeland Security. We had another failure of 
initiative here. Thankfully, it appears that that we dodged a bullet.
    But that's not always going to be the case. It's time for the folks 
at DHS and CDC to start taking some responsibility.

        TUBERCULOSIS INCIDENT TIMELINE AND UNRESOLVED QUESTIONS

          Prepared by the House Committee on Homeland Security

                         (Last update: 6/5/07)

    DATE
    FACTS
    Discrepancies in the Record
    Questions about the Federal Response

Jan. 2007
    In January, Andrew Speaker, a 31-year old Atlanta lawyer, fell and 
hurt his ribs. He received an X-ray, revealing an abnormality in the 
upper lobe of his right lung. This suggested tuberculosis. Speaker 
began meeting regularly with Fulton County health officials for 
treatment.\1\

March 2007
    In early March, Speaker underwent a procedure to get a sample of 
sputum from his lungs. By the end of the month, lab cultures revealed 
he had tuberculosis (TB).\2\
    When should the CDC be notified about TB cases?
    Did health officials spend this time testing Speaker's TB diagnosis 
for drug resistance?

Thurs, May 10
    Health officials determined Speaker had a multiple-drug resistant 
(MDR) form of TB.\3\
    According to press accounts, Fulton County health officials called 
the Georgia Division of Public Health on May 10, but gave the 
impression that the problem was ``largely hypothetical.'' GDPH then 
made a call to the Centers for Disease Control.\4\
    Did the positive test for MDR-TB automatically trigger a test for 
Extreme Drug Resistant (XDR) TB?
    When was CDC notified about Speaker's case of MDR-TB? What is the 
formal procedure by which CDC is asked to perform this analysis?
    It is reported that CDC was called in to test for XDR-TB on 
Thursday May 17.\5\ Was this the proper protocol to follow? If not, why 
wasn't CDC asked to perform the analysis earlier?

Fri, May 11
    Fulton County health officials gave Speaker a ``verbal warning'' of 
the danger and the ``prohibition'' against travel.\6\
    According to Dr. Julie Gerberding, Director of the CDC, ``the 
patient really was told that he shouldn't fly.''\7\
    Fulton County health officials attempted to hand-deliver a medical 
directive to Speaker telling him not to travel.\8\

    In an interview with The Atlanta Journal-Constitution, Speaker said 
that Fulton County health officials told him they ``preferred'' he not 
travel.\9\
    According to Speaker, ``Everyone knew. . . The CDC knew, doctors 
knew, Kaiser knew. They said, `We would prefer you not go on the trip,' 
And that's when my father said, `OK, are you saying because he's a risk 
to anybody or are you simply saying it to cover yourself?' And they 
said, ``We have to tell you that to cover ourselves, but he's not a 
risk.'' '\10\
    According to a June 1 report, ``Doctors say they told Speaker not 
to travel. Speaker said CDC and other health organizations advised him 
against travel but didn't stop him.''\11\
    Dr. Steven Katkowsky, Director of Public Health and Wellness for 
Fulton County said, ``certainly the recommendation would be that if you 
have an active infection with tuberculosis, you ought not to be getting 
on a commercial airliner.''\12\
    On June 4, Dr. Katkowsky, said that the law presented ``kind of a 
Catch-22'' when it comes to restricting the activities of tuberculosis 
patients against their will. ``A patient has to be noncompliant before 
you can intervene,'' he said. ``There's no precedent for a court 
stepping in before a patient has proven himself to be non-
compliant.''\13\

    There appears to be confusion about what prohibitions health 
officials can place on an individual with an infectious disease. 
According to Dr. Gerberding, health officials ``usually rely on a 
covenant of trust to assume that a person with tuberculosis just isn't 
going to go into a situation where they would transmit disease to 
someone else.''\14\
    State and local health officials claim that they could not have 
prevented Speaker from flying abroad. However, state officials may 
authorize isolation and quarantine within their borders. States derive 
this authority from the ``police powers'' doctrine in constitutional 
law, which allows state governments to enact laws and promote 
regulations to safeguard the health, safety, and welfare of its 
citizens. As a result of this authority, individual states are 
responsible for intrastate isolation and quarantine practices, and they 
conduct their activities in accordance with their respective statutes. 
State and local laws and regulations regarding the issues of compelled 
isolation and quarantine vary widely.\15\

Sat, May 12
    Speaker departed Atlanta on Air France Flight 385.\16\

Sun, May 13
    Speaker arrived in Paris.\17\

Mon, May 14
    Speaker flew from Paris to Athens on Air France flight 1232.\18\

Wed, May 16
    Speaker flew from Athens to Thira Island on Olympic Air flight 
560.\19\

Thurs, May 17
    CDC called in to test for XDR-TB.\20\
    Georgia Division of Public Health notified that Speaker had flown 
overseas.\21\
    Was this the first time that CDC was contacted about testing 
Speaker's TB sample? If so, why?
    What office notified Georgia's Division of Public Health that 
Speaker flew overseas? Did GDPH notify CDC about Speaker's travel? 
(Note: this information was most likely obtained by Speaker's doctors, 
who were aware that he was traveling, but it remains unclear who 
notified the CDC about Speaker's travel.)

Mon, May 21
    Tests came back positive for XDR-TB.\22\
    Speaker flew from Mykonos to Athens on Olympic Air 655.\23\
    Speaker flew from Athens to Rome on Olympic Air 239.\24\

    Questions persist about the ability of the federal government to 
quarantine an individual. DHS officials told Committee staff that 
federal officials do not have the authority to quarantine.\25\ This is 
inaccurate. The President may issue an executive order for federal 
isolation and quarantine for the following communicable diseases: 
cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow 
fever, viral hemorrhagic fevers, and SARS.\26\ What are the policies 
and procedures to implement a quarantine/isolation, and what is the 
role of DHS?

Tues, May 22
    The CDC Division of Global Migration and Quarantine contacted the 
Assistant Port Director for the Atlanta office of the Customs and 
Border Protection (CBP).\27\
    CDC notified CBP Atlanta that Speaker posed a public health risk. 
CDC requested that CBP Atlanta attach a message to Speaker's 
passport.\28\
    FOUO: An Atlanta CBP officer entered a Treasury Enforcement 
Communications (TECS) Lookout record on Speaker at 12:46 PM. The 
officer also entered a TECS Lookout for Speaker's wife, Ms. 
Cooksey.\29\
    FOUO: This text note on the TECS system included instructions to 
``place mask on subject, place in isolation, well ventilated room if 
possible.'' The note indicated that Speaker ``has multiple resistant TB 
and is a public health risk.''\30\
    The note contained instructions that CBP contact Dr. David Kim of 
CDC upon encountering Speaker.\31\
    The Passenger Analysis Unit placed the text message on Speaker's 
passport.\32\

    Why did CDC wait a day to notify CBP about Speaker's condition? 
Didn't they know on May 21 that Speaker was no longer in the U.S.?
    It is unclear why CDC notified the local Atlanta CBP office rather 
than CBP HQ in Washington. Was there a policy or procedure in place 
requiring CDC to notify a ``local'' CBP office? Was there a policy or 
procedure in place that would have required CBP Atlanta to notify CBP 
HQ? Why didn't CBP Atlanta pass to CBP HQ the information they entered 
into the TECS database at this time?
    Similarly, neither CDC nor CBP contacted the Transportation 
Security Administration (TSA) at the time to place Speaker's name on 
the ``no-fly'' list. This shortcoming would have ramifications later, 
when Speaker's name was not added to the no-fly list until after he 
already crossed the Canadian border (due in part to concerns raised by 
the CDC about exposing sensitive information about a patient to DHS). 
Why didn't CBP Atlanta communicate Speaker's personal information up 
the chain to TSA?
    The TECS database is designed to allow for unique notes to be 
entered onto a passport. In other words, this notice is a unique 
message, and does not contain reference to a numeric warning code. An 
issue for DHS to consider is whether a standard medical text message 
(such as ``Code 42'' or ``Medical Incident Alert'') would be more 
effective than the specific message that the CBP officer saw in this 
case.

Wed, May 23
    Speaker received call from CDC while in Rome. He was told to cancel 
trip and return home. He was told he would be contacted by CDC the next 
day with travel information.\33\
    DHS identifies CDC physician David Kim as the individual who 
contacted Speaker in Rome. Dr. Kim was apparently working the Speaker 
case for Dr. Marvin Cetron of CDC's Division of Global Migration and 
Quarantine.\34\
    CDC told Speaker ``we have tools to keep you from flying into the 
U.S.''\35\
    On May 31, Speaker told The Atlanta Journal-Constitution that he 
was ``aware'' he was placed on a no-fly list, which is why he decided 
not to fly into a U.S. airport.\36\
    Dr. Kim told Speaker to turn himself into Italian health 
authorities the next morning and agree to go into isolation and 
treatment in that country for an indefinite period of time.\37\
    Speaker was told that hiring a private jet to fly back to the U.S. 
would have cost $100,000.\38\
    According to DHS officials, CDC offered Speaker a private plane. 
They would have charged him $50,000 for the flight.\39\
    Dr. Martin Cetron, Director for the DGMQ at the CDC, dispatched a 
former CDC employee working with Italy's health ministry to visit 
Speaker at his hotel and reiterate the message. By the time the former 
employee arrived at the hotel, Speaker was gone.\40\

    There is a controversy about why Speaker chose not to go to the 
Italian hospital. According to Speaker, he was afraid of the care he 
would receive. ``Both of us [Speaker and his wife] worried if I turned 
myself [in] the next day that's it. It's very real that I could have 
died there. . . . People told me if I was anywhere but Denver, I'll 
die.''\41\

    Speaker was not actually placed on the ``no-fly'' list until May 
24, after he already crossed the U.S. border from Canada. According to 
DHS officials, CDC suggested to Speaker that he was on the no-fly list 
(``we have ways of keeping you from the U.S.''). Was this proper use of 
protocol?
    DHS officials state that they did not receive a request from CDC 
regarding placing Speaker on the ``no-fly'' list until Thurs. May 24. 
Is this true?
    Was the CDC under the impression that DHS placed Speaker on the 
``no-fly'' list based on their conversation with CBP Atlanta on May 22? 
(Note: this is probably not the case, because CDC was in contact with 
Speaker on May 22 and probably did not consider him a flight risk until 
May 23.)
    Notification of foreign governments is an important issue to 
resolve. What policies and procedures are in place to notify foreign 
health authorities (like the World Health Organization) in situations 
such as this? When was the Italian government notified?
    Did anyone ever recommend or even think of using an air ambulance 
to transport Speaker back to the U.S. (as opposed to privately 
chartering an airplane that would have cost between $50--100,000)? Why 
not?

Thurs, May 24
    CDC contacted DHS Office of Health Affairs in ``early afternoon'' 
(around 1:00 PM) to request assistance in preventing Speaker from 
traveling via commercial air. According to DHS officials, CDC did not 
provide Speaker's name to DHS at this time.\42\
    CDC contacts World Health Organization (WHO) by phone to provide 
information on Speaker. CDC advised to provide details to 
[email protected] (the usual recipient of outbreak alerts). Dept. of 
Health and Human Services sends official notification to WHO that CDC 
has determined the event meets reporting criteria for a ``public health 
emergency of international concern'' as defined in the revised 
International Health Regulations.\43\
    Speaker returned to North America aboard Czech Air Flight 0104 from 
Prague to Montreal.\44\
    FOUO: Speaker landed at approximately 3:27 PM.\45\
    Speaker wore a mask on the flight.\46\
    FOUO: At 3:35 PM, CDC provided Speaker's name to DHS for inclusion 
on the ``no-fly'' list.\47\
    FOUO: At 3:46 PM, TSA informed TSA representatives in Europe and 
International Principal Security Inspectors worldwide to inform 
carriers, embassies, and host government authorities that Speaker 
should not board a commercial flight because he has a dangerous, 
contagious disease.\48\
    DHS was in process of putting Speaker's name on the ``no fly'' list 
when it learned he was already on a plane headed to Montreal.\49\
    Speaker rented a car with U.S. plates.\50\
    FOUO: 6:17.17 PM: Speaker and wife arrive at the Champlain, N.Y. 
port of entry. License plate reader incorrectly reads license plate a 
Pennsylvania plate.\51\
    FOUO: 6:17.27 PM: CBP officer manually corrects the plate as an 
Ohio plate, and receives a Customs Automated Operation System (CAOS) 
message to inspect the vehicle undercarriage.\52\
    FOUO: 6:17.28 PM: CBP officer scans wife's passport with the 
document reader, and receives a positive response. The TECS ``Lookout'' 
text message appears on the screen.\53\ The TECS message advises the 
officer to refer wife for secondary inspection. The Lookout states that 
wife was traveling with Speaker, who has XDR-TB.\54\
    FOUO: 6:17.55 PM: CBP officer clears the wife's hit without 
referral to secondary inspection.\55\
    FOUO: 6:18.34 PM: CBP officer enters Speaker's name on the name 
query line, presses ``enter,'' and receives a positive response. A TECS 
Lookout appears on the screen advising officer to refer Speaker for 
secondary inspection.\56\
    FOUO: 6:18.41 PM: Officer clears hit without referral to secondary 
inspection.\57\
    Speaker crosses the border into the U.S. at the Champlain, N.Y. 
border crossing.\58\N
    According to a May 30 article on CNN.com, Customs and Border 
Protection spokesman Kevin Corsaro said Speaker ``did not appear sick 
to border agents.'' \59\
    According to DHS spokesman Russ Knocke, ``there is some indication 
of deceitfulness on the part of the individual.'' \60\
    In a briefing with Committee staff, DHS officials stated that 
Speaker told CBP officers that ``he only wanted to cross the border for 
the day.'' \61\
    At 7:30 PM, TSA General Counsel gives approval for TSA 
Administrator Kip Hawley to place Speaker on the ``no-fly'' list. This 
was a point of contention for DHS for several hours (beginning at 3:30 
PM when they were informed of Speaker's name by CDC) until the TSA 
General Counsel persuasively argued that Hawley could use U.S. Code 49 
authority to place a ``non-terrorist'' on the ``no-fly'' list.\62\
    FOUO: Speaker's name appeared on a supplement to the ``no-fly'' 
list at 8:31 PM.\63\ (Canadian officials inform Committee staff that at 
approximately 8:00 PM, Speaker's name appeared on the Canadian ``no-
fly'' list.) \64\
    Speaker checked into a hotel in Albany, N.Y.\65\

    On May 31, Speaker told The Atlanta Journal-Constitution that he 
was ``aware'' he was placed on a no-fly list when he was in Rome, which 
is why he decided not to fly into a U.S. airport.\66\ However, Speaker 
was not placed on the no-fly list at that time.
    Speaker's name did not appear on the no-fly list until at least 2 
hours after his arrival into the U.S. Canadian officials tell Committee 
staff that the Canadian no-fly list is identical to the U.S. no-fly 
list. Therefore, any time that the U.S. list is updated, the Canadian 
list will reflect that update. Canadian officials state that Speaker's 
name appeared on their list at 8:00 PM. This, of course, was after he 
already crossed the border.\67\
    Speaker's name was entered onto the ``no-fly'' list. There are 
several lists that his name could have been entered into, including: 
the Terrorist Screening Database (TSDB), the TSA no-fly list, the TSA 
``selectee'' list, or the Interagency Border Inspection System 
(IBIS).\68\ In fact, there was an effort within DES to enter him onto 
the TSDB (though this would be inappropriate because he did not pose a 
``terrorist threat'').
    Though DHS officials claim that Speaker was deceptive, Speaker 
claims that he has cooperated completely with authorities.
    DHS (through the Atlanta CBP office) received information from CDC 
on May 22 about Speaker's identity and the fact that he posed a public 
health threat to the U.S. Why didn't DHS seek to place Speaker's name 
on the no-fly list at that time? What policies and procedures are in 
place to ensure that CBP officials in a field office are communicating 
this information to CBP HQ and to other agencies within DHS (like TSA)?
    Did the CBP agent interview Speaker prior to allowing him entry? 
CBP spokesman Corsaro's statement that Speaker did not ``appear to be 
sick'' implies that CBP was given latitude to detain Speaker.
    Why did the CBP agent manually enter Speaker's name into the 
``query line'' instead of swiping his passport?
    Does the National Treasury Employees Union (NTEU) agree with the 
facts that have been alleged by DHS regarding the actions of the CBP 
agent?
    DHS officials state that after receiving the request from CDC to 
place Speaker on a ``no-fly'' list, there was considerable confusion 
about what list he could be placed on. DHS officials tell Committee 
staff that they couldn't add Speaker to the ``no-fly'' list or the 
``selectee'' list because he wasn't a terrorist. Until 7:30 PM, 
officials were not sure that they had the authority to enter Speaker 
onto a list. Questions for DHS include (1) whether any ``non-
terrorist'' has ever been placed on the ``no-fly'' list and (2) why it 
took so long to determine the TSA Administrator's authorities under 
U.S.C. 49?
    What policies and procedures are in place to ensure that CBP agents 
have received adequate medical training? Do CBP agents have medical 
protective equipment?
    PDoes CBP have a medical detainment procedure? Are there isolated 
and secure areas that CBP agents could have taken Speaker?
    DHS spokesman Russ Knocke suggested that the failure by the CBP to 
detain the man was a result of not obtaining ``real-time'' passenger 
data for flights ending in Canada. This makes it ``very difficult for 
us to know who might be traveling there.'' \69\N Given the fact that 
Speaker's name wasn't entered into the no-fly list until 8:00 PM, the 
fact that DHS could not obtain real-time passenger data would not have 
made a difference in detaining Speaker.
    CBP said it has not changed its screening or security precautions 
as a result of the case.\70\

Fri, May 25
    National Targeting Center sends notification at 12:30 AM that 
Speaker was encountered at the Champlain, N.Y. port of entry but that 
he was not detained.\71\
    DHS notifies Dr. David Kim at 2:00 AM that Speaker entered the U.S. 
through the Canadian border, but he was not detained.\72\
    Dr. Gerberding asserts that the CDC ``made contact'' with Speaker 
as he was traveling between Albany and New York City.\73\
    Speaker drove himself voluntarily to an isolation hospital 
(Bellevue) in New York City for evaluation.\74\
    Speaker enters ``different door'' at Bellevue so as to limit 
interaction with other patients.\75\
    Speaker was admitted and served a provisional quarantine order that 
lasted 72 hours while he was being assessed.\76\
    Event is discussed at the morning WHO outbreak coordination 
meeting. Because of implication for European countries, WHO/HQ informs 
WHO/EURO.\77\
    Speaker most likely called the CDC as he was traveling from Albany 
to New York City.
    Why did the CDC send Speaker to New York City when he was a 
potential health risk? What safety procedures did they advise him to 
follow as he traveled from Albany to New York City? Why didn't CDC go 
to get him before he could possibly infect other people?

Mon, May 28
    CDC uses one of its planes to fly Speaker to Atlanta.\78\
    WHO/Stop TB receives further information about the status from CDC. 
WHO/ Stop TB contacts TB focal points in Italy and Stockholm, and 
provides advice to Canada TB health authorities on WHO's ``Guidelines 
for Air Travel and TB Control.''\79\
    If CDC used one of its planes to fly Speaker from NYC to Atlanta, 
why couldn't they have flown him from Europe? When can and does the CDC 
fly persons using its own travel assets or those of the Department of 
Health and Human Services?

Tues, May 29
    Dr. Julie Gerberding holds a press conference announcing that the 
CDC had taken the rare action of issuing a federal public health 
isolation order for Speaker.\80\
    CDC recommends that those passengers who were seated close to 
Speaker on the two trans-Atlantic flights notify their health officials 
in their respective states or countries, and that such persons should 
then be tested for TB.\81\
    CDC also recommended that other passengers be notified and offered 
the opportunity to be evaluated and tested, if desired.\82\
    Conference call between U.S., Canada, WHO/HQ, WHO/EURO, France, and 
Italy discussion of public health rationale for contact tracing.\83\
    How does an ``isolation order'' differ from a ``provisional 
quarantine order''?
    The CDC had a difficult time identifying passengers who sat next to 
the infected man, and relied on the media to spread the word about the 
flight. ``We are still trying to get not just the manifest and the name 
and the country of citizenry but actual locating information for those 
individuals. This takes time, longer than we like and longer than is 
necessary in an era where we have to track emerging pathogens across 
air flights, and we hope that system will be fixed and streamlined and 
improved in the future, but that takes time, which is why we're hoping 
that you will help us bring these folks forward so they could be 
evaluated.'' \84\
    What procedures exist for federal agencies to contact passengers?
    What international procedures are in place to notify CDC of the 
results of the testing?

Wed, May 30
    DHS spokesman Russ Knocke said investigators were looking into how 
Speaker and his wife entered the U.S. when all border crossings had 
been given his name and told to hold him if he appeared.\85\
    CDC asks DHS to provide passenger manifests.\86\
    The CDC elects to share publicly the names of the flights, and 
information about specific seats in order to have those persons self-
identify in order to receive very specific advice in terms of managing 
the risk.\87\
    The CDC begins contact tracing.\88\ Contract tracing is the method 
used to control endemic contagious disease A disease investigation 
begins when an individual is identified as having a communicable 
disease. An investigator interviews the patient, family members, 
physicians, nurses, and anyone else who may have knowledge of the 
primary patient's contacts, anyone who might have been exposed, and 
anyone who might have been the source of the disease. Then the contacts 
are screened to see if they have or have ever had the disease. The type 
of contact screened depends on the nature of the disease.\89\
    Conference call between U.S., Canada, WHO/HQ, WHO/EURO, PAHO, EC, 
ECDC, France, Italy, Greece, Czech Republic. Further discussions on 
details of the investigations.\90\

Thurs, May 31
    Speaker discharged from Atlanta Grady Memorial Hospital at 4:30 AM 
and transported to Denver by private plane.\91\
    Speaker instructed to wear a mask along with all who come into 
contact with him.\92\
    Speaker arrives at National Jewish Medical and Research Center in 
Denver at 7:45 AM (MST).\93\
    Authorities in the U.S. and several European countries are tracking 
down about 50 people who sat near Speaker on his Atlanta-to-Paris 
flight on May 12, and 30 people on his Prague-to-Montreal return May 
24. They will be offered testing to see if they are infected.\94\
    Speaker will go through a series of tests and be given two 
antibiotics, one oral and one intravenous.\95\
    CDC initiates a careful evaluation of Speaker's activities prior to 
his development of XDR TB in hopes of learning the source of 
exposure.\96\
    CDC establishes a webpage providing further information to airline 
travelers and other members of the public who are interested in this 
issue: http://www.cdc.gov/tb/xdrtb/.\97\
    Speaker is identified as a 31 year old lawyer from Atlanta.\98\
    News reports reveal that Speaker's father-in-law works for the 
Centers for Disease Control and Prevention in Atlanta. The father-in-
law, Robert C. Cooksey, is a microbiologist who has conducted research 
on tuberculosis for the National Center for Infectious Diseases.\99\
    The CBP agent who processed his entry on May 24 was placed on 
administrative duties while the investigation continuing.\100\
    CBP Internal Affairs begins interviewing the agent who processed 
Speaker's entry.\101\

Fri, June 1
    Homeland Security officials promise to examine systems for 
detaining sickened travelers, but they acknowledged ``there would 
always be holes in the system.'' \102\
    Dr. Julie Gerberding states that Speaker ``still does not appear to 
be highly infectious,'' and there is ``no indication that his 
infectiousness has changed in the past few months.'' \103\
    WHO/EURO informs WHO/HQ about non-EU passengers to be traced. WHO/
HQ contacts WHO/AFRO, WHO/EMRO, and PAHO to communicate names of 
passengers to be traced.\104\

Sat, June 2
    CDC said it has withdrawn the federal isolation order for Speaker 
because the order to detain him at the Denver hospital is enough to 
protect the public's health.\105\
    According to the CDC, officials have contacted 160 of the 292 US 
citizens who were on the same Atlanta-to-Paris flight as Speaker.\106\
    CDC says that the father-in-law of Speaker will be investigated to 
see how he was involved with the case.\107\

Mon, June 4
    Ted Speaker (Speaker's father) said he taped a meeting in which a 
doctor says three times that his son was not contagious though the 
doctors preferred that he not fly. The elder Speaker said he will 
release the tape at some point.\108\
    CBP announces policy updates to Committee staff: (1) supervisors 
will receive the same warnings that CBP agents receive on their 
screens; (2) agents will no longer be able to clear an ``exact match'' 
on identification (where a person's name, DOB, and passport number 
identically match a TECS warning). This will always be referred to 
secondary screening.

    \1\ Young, A. (2007, May 30). Atlantan quarantined with deadly TB 
strain; CDC issues rare isolation order; Air passengers warned. The 
Atlanta Journal-Constitution.
    \2\ Brown, D. (2007, May 31). Man With Rare TB Easily Eluded 
Safeguards. The Washington Post, p. A03. http://www.washingtonpost.com/
wp-dyn/content/article/2007/05/30/AR2007053001962.html
    \3\ Brown, D. (2007, May 31). Man With Rare TB Easily Eluded 
Safeguards. The Washington Post, p. A03. http://www.washingtonpost.com/
wp-dyn/content/article/2007/05/30/AR2007053001962.html
    \4\ Schwartz. J. (2007, June 2). Tangle of Conflicting Accounts in 
TB Patient's Odyssey. Retrieved June 4, 2007, from http://
travel.nytimes.com/2007/06/02/health/02tick.html
    \5\ (2007, May 30). Man knew he had TB before flying to Europe. 
Retrieved May 31, 2007, from http://www.cnn.com/2007/HEALTH/conditions/
05/30/tb.flight/index.html
    \6\ (2007, May 30). Man knew he had TB before flying to Europe. 
Retrieved May 31, 2007, from http://www.cnn.com/2007/HEALTH/conditions/
05/30/tb.flight/index.html
    \7\ (2007, May 30). Man knew he had TB before flying to Europe. 
Retrieved May 31, 2007, from http://www.cnn.com/2007/HEALTH/conditions/
05/30/tb.flight/index.html
    \8\ The Committee is currently attempting to acquire this letter. 
Young, A. (2007, May 30). Atlantan quarantined with deadly TB strain; 
CDC issues rare isolation order; Air passengers warned. The Atlanta 
Journal-Constitution.
    \9\ Brown, D. (2007, May 31). Man With Rare TB Easily Eluded 
Safeguards. The Washington Post, p. A03. http://www.washingtonpost.com/
wp-dyn/content/article/2007/05/30/AR2007053001962.html
    \10\ (2007, June 1). Exclusive: TB Patient Asks Forgiveness but 
Defends Travel. Retrieved June 1, 2007, from http://www.abcnews.go.com/
GMA/OnCall/story?id=3231184&page=1
    \11\ (2007, June 1). Exclusive: TB Patient Asks Forgiveness but 
Defends Travel. Retrieved June 1, 2007, from http://www.abcnews.go.com/
GMA/OnCall/story?id=3231184&page=1
    \12\ Young, A. (2007, May 30). Atlantan quarantined with deadly TB 
strain; CDC issues rare isolation order; Air passengers warned. The 
Atlanta Journal-Constitution.
    \13\ Schwartz. J. (2007, June 2). Tangle of Conflicting Accounts in 
TB Patient's Odyssey. Retrieved June 4, 2007, from http://
travel.nytimes.com/2007/06/02/health/02tick.html
    \14\ (2007, May 30). Man knew he had TB before flying to Europe. 
Retrieved May 31, 2007, from http://www.cnn.com/2007/HEALTH/conditions/
05/30/tb.flight/index.html
    \15\ Fact Sheet on Legal Authorities for Isolation/Quarantine, May 
3, 2005, available at http://www.cdc.gov/ncidod/sars/factsheetlegal.htm
    \16\ (2007, May 30). Man knew he had TB before flying to Europe. 
Retrieved May 31, 2007, from http://www.cnn.com/2007/HEALTH/conditions/
05/30/tb.flight/index.html
    \17\ (2007, May 30). Man knew he had TB before flying to Europe. 
Retrieved May 31, 2007, from http://www.cnn.com/2007/HEALTH/conditions/
05/30/tb.flight/index.html
    \18\ Stobbe, M. (2007, May 31). TB Patient Leaves Atlanta Hospital. 
Retrieved May 31, 2007 from http://breakingnews.nypost.com/dynamic/
stories/T/TUBERCULOSIS_INFECTION?SITE=NYNYP&SECTION=HOME
    \19\ Stobbe, M. (2007, May 31). TB Patient Leaves Atlanta Hospital. 
Retrieved May 31, 2007 from http://breakingnews.nypost.com/dynamic/
stories/T/TUBERCULOSIS_INFECTION?SITE=NYNYP&SECTION=HOME
    \20\ (2007, May 30). Man knew he had TB before flying to Europe. 
Retrieved May 31, 2007, from http://www.cnn.com/2007/HEALTH/conditions/
05/30/tb.flight/index.html
    \21\ Schwartz. J. (2007, June 2). Tangle of Conflicting Accounts in 
TB Patient's Odyssey. Retrieved June 4, 2007, from http://
travel.nytimes.com/2007/06/02/health/02tick.html
    \22\ (2007, May 30). Man knew he had TB before flying to Europe. 
Retrieved May 31, 2007, from http://www.cnn.com/2007/HEALTH/conditions/
05/30/tb.flight/index.html
    \23\ Stobbe, M. (2007, May 31). TB Patient Leaves Atlanta Hospital. 
Retrieved May 31, 2007 from http://breakingnews.nypost.com/dynamic/
stories/T/TUBERCULOSIS_INFECTION?SITE=NYNYP&SECTION=HOME
    \24\ Stobbe, M. (2007, May 31). TB Patient Leaves Atlanta Hospital. 
Retrieved May 31, 2007 from http://breakingnews.nypost.com/dynamic/
stories/T/TUBERCULOSIS_INFECTION?SITE=NYNYP&SECTION=HOME
    \25\ Department of Homeland Security Committee staff briefing with 
Dr. Jeffrey Runge, May 31, 2007.
    \26\ CDC Fact Sheet on Legal Authorities for Quarantine and 
Isolation, May 3, 2005, available at http://www.cdc.gov/ncidod/sars/
factsheetlegal.htm
    \27\ Department of Homeland Security Committee staff briefing with 
Department of Homeland Security officials (TSA, CMO, and CBP), June 4, 
2007.
    \28\ Department of Homeland Security Committee staff briefing with 
Department of Homeland Security officials (TSA, CMO, and CBP), June 4, 
2007.
    \29\ The Treasury Enforcement Communications System (TECS) is a 
legacy system that is at least 20 years old. Ordinarily, the system is 
used to track an individual who may pose a terrorist or smuggling 
threat to the U.S. The TECS system feeds into the Automated Targeting 
System (ATS), the Department?s computer system that scrutinizes a large 
volume of data related to a person crossing the U.S. border. Department 
of Homeland Security Committee staff briefing with Department of 
Homeland Security officials (TSA, CMO, and CBP), June 4, 2007.
    \30\ Department of Homeland Security Committee staff briefing with 
Department of Homeland Security officials (TSA, CMO, and CBP), June 4, 
2007.
    \31\ Department of Homeland Security Committee staff briefing with 
Department of Homeland Security officials (TSA, CMO, and CBP) June 4, 
2007.
    \32\ The Treasury Enforcement Communications System (TECS) is a 
legacy system that is at least 20 years old. Ordinarily, the system is 
used to track an individual who may pose a terrorist or smuggling 
threat to the U.S. The TECS system feeds into the Automated Targeting 
System (ATS), the Department's computer system that scrutinizes a large 
volume of data related to a person crossing the U.S. border. Department 
of Homeland Security Committee staff briefing with Department of 
Homeland Security officials (TSA, CMO, and CBP), June 4, 2007.
    \33\ Young, A. (2007, May 30) Atlantan quartantined with deadly TB 
strain; CDC issues rare isolation order; Air passengers warned. The 
Atlanta Journal-Constitution.
    \34\ Department of Homeland Security Committee staff briefing with 
Department of Homeland Security officials (TSA, CMO, and CBP) June 4, 
2007
    \35\ Department of Homeland Security Committee staff briefing with 
Department of Homeland Security officials (TSA, CMO, and CBP) June 4, 
2007
    \36\ (2007, May 31). TB patient's name released; Father-in-law 
works at CDC. Retrieved May 31, 2007, from http://www.cnn.com/2007/
HEALTH/conditions/05/31/tb.flight/index.html
    \37\ Young, A. (2007, May 30). Atlantan quarantined with deadly TB 
strain; CDC issues rare isolation order; Air passengers warned. The 
Atlanta Journal-Constitution.
    \38\ (2007, June 1). Exclusive: TB Patient Asks Forgiveness but 
Defends Travel. Retrieved June 1, 2007, from http://www.abcnews.go.com/
GMA/OnCall/story?id=3231184&page=1
    \39\ Department of Homeland Security Committee staff briefing with 
Dr. Jeffrey Runge, May 31, 2007.
    \40\ Brown, D. (2007, May 31). Man With Rare TB Easily Eluded 
Safeguards. The Washington Post, p. A03. http://www.washingtonpost.com/
wp-dyn/content/article/2007/05/30/AR2007053001962.html
    \41\ (2007, June 1). Exclusive: TB Patient Asks Forgiveness but 
Defends Travel. Retrieved June 1, 2007, from http://www.abcnews.go.com/
GMA/OnCall/story?id=3231184&page=1
    \42\ Department officials suggest that CDC was worried about 
releasing patient information. Department of Homeland Security 
Committee staff briefing with Department of Homeland Security officials 
(TSA, CMO, and CBP), June 4, 2007.
    \43\ Email from World Health Organization to Committee staff, June 
4, 2007, on file with Committee.
    \44\ Stobbe, M. (2007, May 30). Georgia traveler with tuberculosis 
is United States' first quarantine in decades. The Associated Press 
State & Local Wire.
    \45\ Department of Homeland Security Committee staff briefing with 
Department of Homeland Security officials (TSA, CMO, and CBP), June 4, 
2007. See Flight Itinerary of U.S. Traveler with Extensively 
Drug?Resistant Tuberculosis (XDR TB) (May 30, 2007) available at http:/
/www.cdc.gov/tb/XDRTB/caseflighthistory.htm
    \46\ Department of Homeland Security Committee staff briefing with 
Dr. Jeffrey Runge, May 31, 2007.
    \47\ Department of Homeland Security Committee staff briefing with 
Department of Homeland Security officials (TSA, CMO, and CBP), June 4, 
2007.
    \48\ Department of Homeland Security Committee staff briefing with 
Department of Homeland Security officials (TSA, CMO, and CBP), June 4, 
2007.
    \49\ Brown, D. (2007, May 31). Man With Rare TB Easily Eluded 
Safeguards. The Washington Post, p. A03. http://www.washingtonpost.com/
wp-dyn/content/article/2007/05/30/AR2007053001962.html
    \50\ Department of Homeland Security Committee staff briefing with 
Dr. Jeffrey Runge, May 31, 2007
    \51\ Department of Homeland Security Committee staff briefing with 
Department of Homeland Security officials (TSA, CMO, and CBP), June 4, 
2007.
    \52\ FOUO: The message displays on the bottom of the screen. CAOS 
is a computer application that allows port managers to schedule, run, 
record, and report on enforcement operations. Department of Homeland 
Security Committee staff briefing with Department of Homeland Security 
officials (TSA, CMO, and CBP), June 4, 2007.
    \53\ FOUO: The text note included instructions to ``place mask on 
subject, place in isolation, well ventilated room if possible.'' The 
note indicated that Speaker ?has multiple resistant TB and is a public 
health risk.'' Department of Homeland Security Committee staff briefing 
with Department of Homeland Security officials (TSA, CMO, and CBP), 
June 4, 2007.
    \54\ Department of Homeland Security Committee staff briefing with 
Department of Homeland Security officials (TSA, CMO, and CBP), June 4, 
2007.
    \55\ Department of Homeland Security Committee staff briefing with 
Department of Homeland Security officials (TSA, CMO, and CBP), June 4, 
2007.
    \56\ Department of Homeland Security Committee staff briefing with 
Department of Homeland Security officials (TSA, CMO, and CBP), June 4, 
2007.
    \57\ Department of Homeland Security Committee staff briefing with 
Department of Homeland Security officials (TSA, CMO, and CBP), June 4, 
2007.
    \58\ Stobbe, M. (2007, May 30). Georgia traveler with tuberculosis 
is United States' first quarantine in decades. The Associated Press 
State & Local Wire.
    \59\ (2007, May 30). Man knew he had TB before flying to Europe. 
Retrieved May 31, 2007, from http://www.cnn.com/2007/HEALTH/conditions/
05/30/tb.flight/index.html
    \60\ Brown, D. (2007, May 31). Man With Rare TB Easily Eluded 
Safeguards. The Washington Post, p. A03. http://www.washingtonpost.com/
wp-dyn/content/article/2007/05/30/AR2007053001962.html
    \61\ Department of Homeland Security Committee staff briefing with 
Dr. Jeffrey Runge, May 31, 2007.
    \63\ Only foreign airlines with a last point of departure to the 
U.S. are on the TSA ``no-fly'' distribution list. Department of 
Homeland Security Committee staff briefing with Department of Homeland 
Security officials (TSA, CMO, and CBP), June 4, 2007.
    \64\ Department of Homeland Security Committee staff briefing with 
Minister Roy Norton and First Secretary Bernard Li, Embassy of Canada, 
May 31, 2007.
    \65\ Department of Homeland Security Committee staff briefing with 
Dr. Jeffrey Runge, May 31, 2007.
    \66\ (2007, May 31). TB patient's name released; Father-in-law 
works at CDC. Retrieved Ma 31, 2007, from http://www.cnn.com/2007/
HEALTH/conditions/05/31/tb.flight/index.html
    \67\ Department of Homeland Security Committee staff briefing with 
Minister Roy Norton and First Secretary Bernard Li, Embassy of Canada, 
May 31, 2007.
    \69\ Brown, D. (2007, May 31). Man With Rare TB Easily Eluded 
Safeguards. The Washington Post, p. A03. http://www.washingtonpost.com/
wp-dyn/content/article/2007/05/30/AR2007053001962.html
    \70\ Brown, D. (2007, May 31). Man With Rare TB Easily Eluded 
Safeguards. The Washington Post, p. A03. http://www.washingtonpost.com/
wp-dyn/content/article/2007/05/30/AR2007053001962.html
    \71\ Department of Homeland Security Committee staff briefing with 
Department of Homeland Security officials (TSA, CMO, and CBP), June 4, 
2007.
    \73\ Center for Disease Control and Prevention. (May 30, 2007). 
Update on CDC Investigation Into People Potentially Exposed to Patient 
With Extensively Drug-Resistant TB. http://www.cdc.gov/od/oc/media/
transcripts/t070530.htm
    \74\ (2007, May 30). Man knew he had TB before flying to Europe. 
Retrieved May 31, 2007, from http://www.cnn.com/2007/HEALTH/conditions/
05/30/tb.flight/index.html
    \75\ Department of Homeland Security Committee staff briefing with 
Department of Homeland Security officials (TSA, CMO, and CBP), June 4, 
2007.
    \76\ (2007, May 30). Man knew he had TB before flying to Europe. 
Retrieved May 31, 2007, from http://www.cnn.com/2007/HEALTH/conditions/
05/30/tb.flight/index.html
    \77\ Email from World Health Organization to Committee staff, June 
4, 2007, on file with Committee.
    \78\ (2007, May 30). Man knew he had TB before flying to Europe. 
Retrieved May 31, 2007, from http://www.cnn.com/2007/HEALTH/conditions/
05/30/tb.flight/index.html
    \79\ Email from World Health Organization to Committee staff, June 
4, 2007, on file with Committee.
    \80\ Center for Disease Control and Prevention. (May 29, 2007). 
Public health investigation seeks people who may have been exposed to 
extensively drug resistant tuberculosis (XDR TB) infected person. 
http://www.cdc.gov/od/oc/media/transcripts/t070529.htm
    \81\ Center for Disease Control and Prevention. (May 29, 2007). 
Public health investigation seeks people who may have been exposed to 
extensively drug resistant tuberculosis (XDR TB) infected person. 
http://www.cdc.gov/od/oc/media/transcripts/t070529.htm
    \82\ Center for Disease Control and Prevention. (May 29, 2007). 
Public health investigation seeks people who may have been exposed to 
extensively drug resistant tuberculosis (XDR TB) infected person. 
http://www.cdc.gov/od/oc/media/transcripts/t070529.htm
    \83\ Email from World Health Organization to Committee staff, June 
4, 2007, on file with Committee.
    \84\ Center for Disease Control and Prevention. (May 30, 2007). 
Update on CDC Investigation Into People Potentially Exposed to Patient 
With Extensively Drug-Resistant TB. http://www.cdc.gov/od/oc/media/
transcripts/t070530.htm
    \85\ Brown, D. (2007, May 31). Man With Rare TB Easily Eluded 
Safeguards. The Washington Post, p. A03. http://www.washingtonpost.com/
wp-dyn/content/article/2007/05/30/AR2007053001962.html
    \86\ Department of Homeland Security Committee staff briefing with 
Department of Homeland Security officials (TSA, CMO, and CBP), June 4, 
2007.
    \87\ Center for Disease Control and Prevention. (May 30, 2007). 
Update on CDC Investigation Into People Potentially Exposed to Patient 
With Extensively Drug-Resistant TB. http://www.cdc.gov/od/oc/media/
transcripts/t070530.htm
    \88\ Center for Disease Control and Prevention. (May 30, 2007). 
Update on CDC Investigation Into People Potentially Exposed to Patient 
With Extensively Drug-Resistant TB. http://www.cdc.gov/od/oc/media/
transcripts/t070530.htm
    \89\ Louisiana State University, Medical and Public Health Law 
Site, available at http://biotech.law.lsu.edu/Books/lbb/x578.htm.
    \90\ Email from World Health Organization to Committee staff, June 
4, 2007, on file with Committee.
    \91\ (2007, May 31) Grady Memorial Hospital News Briefing 
[Television broadcast]. Atlanta, Georgia: CNN news.
    \92\ (2007, May 31) Grady Memorial Hospital News Briefing 
[Television broadcast]. Atlanta, Georgia: CNN news.
    \93\ Allstetter, W. (Speaker). (2007, May 31). CNN News Briefing 
from National Jewish Medical and Research Center [Television 
broadcast]. Denver, CO: CNN news
    \94\ Brown, D. (2007, May 31). Man With Rare TB Easily Eluded 
Safeguards. The Washington Post, p. A03. http://www.washingtonpost.com/
wp-dyn/content/article/2007/05/30/AR2007053001962.html
    \95\ Allstetter, W. (Speaker). (2007, May 31). CNN News Briefing 
from National Jewish Medical and Research Center[Television broadcast]. 
Denver, CO: CNN news
    \96\ CDC Capitol Hill Announcement, Update: Investigation of US 
Traveler with Extensively Drug Resistant Tuberculosis. May 31, 2007
    \97\ CDC Capitol Hill Announcement, Update: Investigation of US 
Traveler with Extensively Drug Resistant Tuberculosis. May 31, 2007
    \98\ CNN new development [Television broadcast], 2:00 pm May 31, 
2007
    \99\ (2007, May 31). TB patient's name released; Father-in-law 
works at CDC. Retrieved Ma 31, 2007, from http://www.cnn.com/2007/
HEALTH/conditions/05/31/tb.flight/index.html
    \100\ (2007, May 31). TB patient's name released; Father-in-law 
works at CDC. Retrieved Ma 31, 2007, from http://www.cnn.com/2007/
HEALTH/conditions/05/31/tb.flight/index.html
    \101\ Department of Homeland Security Committee staff briefing with 
Dr. Jeffrey Runge, May 31, 2007.
    \102\ Schwartz. J. (2007, June 2). Tangle of Conflicting Accounts 
in TB Patient's Odyssey. Retrieved June 4, 2007, from http://
travel.nytimes.com/2007/06/02/health/02tick.html
    \103\ (2007, June 2). Report: TB patient maintains he is married. 
Retrieved June4, 2007, from http://www.cnn.com/2007/HEALTH/conditions/
06/01/tb.flight/index.html
    \104\ Email from World Health Organization to Committee staff, June 
4, 2007, on file with Committee.
    \105\ (2007, June 4). TB patient's kin to be investigated. 
Retrieved June 4, 2007, from http://www.presstv.ir/
detail.aspx?id=11974§ionid=3510203
    \106\ (2007, June 4). TB patient's kin to be investigated. 
Retrieved June 4, 2007, from http://www.presstv.ir/
detail.aspx?id=11974§ionid=3510203
    \107\ (2007, June 4). TB patient's kin to be investigated. 
Retrieved June 4, 2007, from http://www.presstv.ir/
detail.aspx?id=11974§ionid=3510203
    \108\ McGhee, B. (2007, June 4). Parents of TB patient are ``in 
hell.'' Retrieved June 4, 2007 from http://www.chron.com/disp/
story.mpl/ap/health/4859300.html

    Chairman Thompson. Without objection, I would like to offer 
statements of Representative Engel of New York, the Association 
of American Flight Attendants, and the American Thoracic 
Association into the record.
    [The information follows:]

Prepared Statement of the Honorable Eliot L. Engel, a Representative in 
                  Congress from the State of New York

    Chairman Thompson and Ranking Member King, I wish to thank you for 
holding this important hearing today and for providing me the 
opportunity to submit testimony for the record. I am grateful for this 
opportunity and for your strong commitment to this important issue.
    Last week the threat of extensively drug-resistant tuberculosis, or 
XDR-TB, hit close to home. The world over, people's eyes continue to be 
fixed on a globetrotting Atlanta attorney who traveled throughout 
Europe and returned to Canada, where he rented a car and successfully 
traversed the US border-all while sick and potentially infectious with 
XDR-TB. XDR-TB is a deadly strain of tuberculosis so resistant to 
antibiotics that it can't be treated within international guidelines. 
Its emergence has rightly been called a global threat to public health. 
Dr. Mario Raviglione, the director of the Stop TB Department at the 
WHO, has called it the worst thing he's ever seen. Today's hearing 
focuses on the federal response to this threat, presented in the form 
of an airline and cross-border traveler. The committee notes this 
response was ``poorly coordinated.''
    While it is critical to have a well coordinated response to the 
risk presented by a single patient, some perspective is in order. This 
patient, who bypassed both airline security and U.S. Customs and Border 
Security agents, is merely one of an estimated 27,000 people who 
develop XDR-TB each year according to World Health Organization 
estimates. In addition to these, more than 400,000 people develop 
multi-drug resistant tuberculosis (MDR-TB), which is resistant to at 
least the two most effective TB drugs and is a precursor to XDR-TB. 
Tuberculosis is airborne so when one can access nearly any part of the 
globe in a day or two, there are sure to be more instances such as 
this. The risk is posed not so much by those who are diagnosed and 
identified but by those who are not. The federal response to XDR-TB 
must therefore address the problem at its root to ensure the proper 
control of tuberculosis by which the emergence of drug resistance is 
prevented in the first place. This approach not only reduces risk to 
the homeland, but it is cost effective as well: A study published in 
2005 in the New England Journal of Medicine found that to invest in TB 
control abroad both saves the US taxpayers money and reduces TB illness 
and death domestically versus attempting to screen the disease at our 
borders.
    It is critical to note that XDR-TB occurs nowhere in nature. It is 
completely manufactured, emerging when TB patients are not treated 
adequately and completely. It is a man-made problem caused by an array 
of factors including the misuse of antibiotics, inadequate funding for 
laboratory testing, inadequate access to needed drugs, and a dearth of 
investment in the research and development of new diagnostics, drugs 
and a vaccine. (The standard TB diagnostic test is over a century old, 
the newest TB drug came to market in the 1960s, and no effective 
vaccine exists.)
    As a result, XDR-TB has been confirmed on all six inhabited 
continents, is a growing epidemic in southern Africa, and was already 
reported to be here in the United States before the events of last 
week. Regular (non drug-resistant) TB is curable with drugs that cost 
just $16 dollars in most developing countries. Cases of drug-resistant 
TB, however, can cost literally hundreds of thousands of dollars to 
cure with treatment that is far more difficult for both patients and 
practitioners. In the 1990s, New York City alone spent over a billion 
dollars to address a few hundred cases of MDR-TB. We (the global 
community) have the power to prevent drug-resistant TB and the power to 
treat and control regular TB, and yet, we have not chosen to do so on 
the scale that is necessary. The World Bank has found TB control to be 
among the world's most cost-effective health interventions and yet, 
funding for bilateral TB control programs has flat-lined since 2005.
    Failing to improve our International TB control efforts will wield 
a devastating blow to our ability to manage what I believe is a 
mounting global health crisis. It is remarkable in this day and age, 
with treatment available, that TB is the biggest infectious killer of 
young women in the world. In fact, TB kills more women worldwide than 
all causes of maternal mortality. As you know, TB is also the biggest 
killer of people with AIDS worldwide. Someone in the world is newly 
infected with TB every second and TB accounts for more than one quarter 
of all preventable adult deaths in developing countries. The statistics 
are simply staggering.
    I strongly believe that the global community, with the U.S. in the 
lead, must do more to adequately address this disease by investing in 
quality TB control programs using the groundbreaking Global Plan to 
Stop TB as a guide. It is for that reason that I have introduced the 
bi-partisan Stop TB Now Act of 2007 with my colleagues Heather Wilson 
and Adam Smith which will set forth what we believe is the U.S. fair 
share towards achieving the goals of the Global Plan. The Stop TB Now 
Act will strengthen US leadership on international TB control by 
providing increased resources for the development of urgently needed 
new TB diagnostic and treatment tools to USAID and the CDC. My bill 
calls for a U.S. investment of $400 million for international tab 
control in FY08 and $550 million in FY09.
    I would like to thank the many global health groups that we have 
worked with on this legislation, who have also endorsed H.R. 1567: the 
RESULTS Educational fund, The American Thoracic Society and the Global 
Health Council.
    If we do not make bold--and wise--investments in international TB 
control, not only will we fail to save millions of lives and miss out 
on the many accompanying benefits of controlling this killer, but this 
disease will also become far more difficult and costly to treat. Make 
no mistake: XDR-TB raises the specter of a completely incurable form of 
this airborne disease. We cannot allow this to happen.???
    Moreover, we cannot allow the emergence of drug-resistant TB 
strains to undermine our fight against AIDS. The intersection between 
TB and HIV/AIDS is particularly chilling. People with HIV/AIDS have 
compromised immune systems, and therefore, TB and drug-resistant TB hit 
them especially hard. In 2004, more than 740,000 people who contracted 
TB were co-infected with HIV/AIDS. Globally, 90% of people living with 
AIDS die within 4 to 12 months of contracting TB if not treated.
    We must all be concerned that with drug-resistant TB spiraling out 
of control, especially in HIV/AIDS patients in Africa, the reductions 
in mortality rates from HIV/AIDS thanks to Anti-Retroviral treatment 
are now in severe jeopardy. In the first reported outbreak of XDR-TB, 
all 44 patients tested for HIV were positive. Some of them even 
acquired XDR-TB in a support group for AIDS patients receiving 
antiretroviral therapy. If we do not take urgent action now, progress 
made on the front lines of the fight against HIV/AIDS is in very 
serious danger of being undermined by drug-resistant TB. As Nelson 
Mandela said in 2004, ``We cannot win the battle against AIDS if we do 
not also fight TB.''
    The Stop TB Partnership's Global Plan to Stop TB projects that 
Africa will require $19.4 billion to strengthen and maintain country-
level TB control efforts through 2015. This represents nearly 44 
percent of the global total needed for countries to find and properly 
treat people with TB. While significant resources are being provided 
and will be provided by African governments themselves, the remaining 
funding gap for Africa stands at $11 billion over the next decade--with 
additional resources needed to scale up a response to drug-resistant 
TB. Yesterday the World Health Organization provided a briefing on its 
draft global response plan to XDR-TB. This plan should also be met with 
the full support it requires. XDR-TB is a wake-up call for the 
longstanding need to strengthen TB control and to build the necessary 
capacity in health services to respond to drug-resistant TB.
    Again, my bill, the Stop TB Now Act of 2007, seeks to authorize the 
funding level required from the U.S. in order to meet the goals of the 
Global Plan to Stop TB and therefore be able to address this TB problem 
globally. Chairman Thompson and Ranking Member King, I wish to 
respectfully ask for your co-sponsorship of this important measure. I 
urge the Committee members in attendance today to cosponsor H.R. 1567 
as well.
    Thank you again holding this important hearing. As your efforts 
today to improve the federal response to XDR-TB with testimony by 
experts from the Centers for Disease Control and Prevention, the 
Department of Homeland Security and U.S. Customs and Border Protection 
will certainly not go unnoticed. We will all learn from the information 
gathered today, and, more importantly, we must act on it.

                             For the Record

  Prepared Statement of Patricia A. Friend, International President, 
             Association of Flight Attendants-CWA, AFL-CIO

    Thank you, Chairman Thompson for holding this important hearing. My 
name is Patricia A. Friend and I am the International President of the 
Association of Flight Attendants--CWA (AFA-CWA), AFL-CIO. AFA-CWA 
represents over 55,000 flight attendants at 20 different airlines 
throughout the United States and is the world's largest flight 
attendant union. We would like to submit the following statement for 
the record. Flight attendants, as the first responders in the aircraft 
cabin and as airline safety professionals, are very concerned possible 
transmission of communicable diseases onboard passenger aircraft.
    Growing numbers of passengers are flying to and from regions of the 
world where tuberculosis (TB), avian flu, and other infectious 
communicable diseases are endemic. A 1998 report by the World Health 
Organization (WHO) estimated that ``[a]pproximately one third of the 
world's population is infected with Mycobacterium tuberculosis, and TB 
is the leading cause of death from a single infectious agent in adults 
worldwide.\1\ ''
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    \1\ Valway, S; Watson, J; Bisgard, C et al. (1998) ``Tuberculosis 
and air travel: guidance for prevention and control.'' WHO/TB/98.256
---------------------------------------------------------------------------
    Anecdotally, passengers and crew report an association between 
infectious disease transmission and air travel. Certainly, these 
reports are consistent with the close proximity of cabin occupants, low 
ventilation rates on aircraft, and contact with potentially 
contaminated surfaces; however, for commonplace infections it is often 
difficult to substantiate these claims because of the latency period 
between infection and symptoms, and the challenge of contacting 
passengers and crew after any given flight.
    The recently documented case of a passenger with multi-drug 
resistant TB flying unchecked on international flights is a wake up 
call about the risks of exposure to potentially lethal infectious 
diseases on commercial aircraft. This case reminds us that airlines 
need to be required to train their workers to better screen ill 
passengers before boarding, and to contain or at least minimize the 
spread of infection if such passengers are only identified in-flight. 
Airlines must also develop and implement action plans for notifying, 
testing, and treating individuals who may have been exposed and 
infected. Simple and proactive standards, as proposed below, will help 
to maintain the confidence of the flying public and will limit both the 
economic and human costs of infectious disease spread in the air.
    Last week's news of the passenger with TB is by no means the first 
such case; rather, there is a history of considerable interest in the 
risk of transmitting TB on aircraft. One of the more conclusive 
investigations was conducted by the US Centers for Disease Control and 
Prevention (CDC) and involved 802 (87%) of passengers and crew who had 
traveled on one of four flights with a person who had multi-drug 
resistant TB.\2\ The infectious passenger flew on two outbound flights 
and then, one month later by which time the patient's condition was 
reported to have worsened, on two return flights. On the first three 
flights, a total of 14 contacts had positive tuberculin skin prick 
tests, although of these, 13 had other risk factors for TB. However, on 
the last flight that lasted 8.75 hours, 15 contacts had positive 
tuberculin skin tests, and of these, six had no other risk factors for 
TB and were seated in the same cabin section as the index case, four 
within two rows of her. The observed pattern of infection within the 
cabin suggests the potential for ``drift'' of infected air between 
rows, and the absence of reported skin-test conversions in other cabin 
sections implies that bacteria were not transmitted through the 
aircraft's air recirculation system.
---------------------------------------------------------------------------
    \2\ Kenyon TA, Valway SE, Ihle WW, et al (1996) ``Transmission of 
multi drug-resistant Mycobacterium tuberculosis during a long airplane 
flight'', NEJM 334:933-938
---------------------------------------------------------------------------
    A less conclusive investigation into the risk of TB transmission on 
aircraft involved 225 (73%) passengers and crew on a 14-hour flight 
with one person who was highly infectious.\3\ Of these, 184 had 
positive tuberculin skin prick tests for TB, although only nine had 
skin conversions. Of those nine, the possibility of transmission from 
the index patient could not be ruled out in three cases, although all 
three were sitting between 15 and 23 rows from the index patient, not a 
compelling finding. The authors concluded that the risk of TB 
transmission on aircraft was no greater than those in other confined 
settings, noting that ``TB outbreaks often occur as a result of 
overcrowded conditions in poorly-ventilated facilities when there is 
prolonged close exposure to an infectious person.''
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    \3\ Wang PD (2000) ``Two-step tuberculin testing of passengers and 
crew on a commercial airplane'' Am J Infect Control 28:233-238
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    Finally, a documented investigation into a pilot with active TB who 
had flown with 48 other pilots over a six-month period found no risk of 
transmission.\4\ It is possible that this reduced risk is explained by 
the approximate 20-fold increase in the supply rate of outside air in 
the cockpit, compared to the economy section of the cabin.
---------------------------------------------------------------------------
    \4\ Parmet AJ (1999) ``Tuberculosis on the flight deck'' Aviat 
Space Environ Med 70:817-818
---------------------------------------------------------------------------
    TB is not the only disease at risk of being spread on commercial 
flights. To this end, there are documented reports of cases of SARS 
5,6,7&8 meningococcal disease,9 measles,10 
and colds/flu 11,12&13 associated with air travel.
---------------------------------------------------------------------------
    \5\ World Health Organization (4 April 2003) Weekly epidemiological 
record 78:97-120
    \6\ World Health Organization (7 May 2003) WHO update 49
    \7\ World Health Organization Communicable Disease Surveillance and 
Response (4 May 2003) Technical report on stability and resistance of 
SARS coronavirus
    \8\ World Health Organization (22 May 2003) WHO update 62
    \9\ CDC (15 June 2001) Morbidity and Mortality Weekly Report 
50:485-9
    \10\ CDC (9 Apr 2004) Morbidity and Mortality Weekly Report 53:1-2
    \11\ Whelan EA, Lawson CC, Grajewski B, et al (2003) ``Prevalence 
of respiratory symptoms among female flight attendants and teachers'' 
Occup Environ Med 62:929-934
    \12\ Nutik-Zitter J, Mazonson PD, Miller DP, et al (2002) 
``Aircraft cabin air recirculation and symptoms of the common cold'' 
JAMA 28:483-486
    \13\ Hocking MB and Foster HD (2002) ``Upper respiratory tract 
infections among airline passenger (Letter to the Editor)'' JAMA 
288:2972
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    In the media, high efficiency particulate (HEPA) filters have been 
billed as the cure-all for airborne transmission of TB and other 
infectious diseases. Currently, there is no minimum requirement to 
install or properly maintain HEPA filters on aircraft; however, some of 
the major US airlines report that they have done so. Assuming that HEPA 
filters are installed and maintained properly, they should be effective 
at removing the bulk of small particulate from the portion of air that 
is recirculated, including bacteria. Viruses are smaller than the pores 
of a HEPA filter, but if they travel in clusters or on big water 
droplets (e.g., generated by a sneeze or cough), then they should be 
trapped by a properly fitted HEPA filter.
    As front line first responders sharing the airplane cabin for up to 
18 hour periods in close proximity to passengers who may be carrying 
infectious diseases (including the recent case of multi-drug resistant 
TB), flight attendants are understandably concerned. Passengers at risk 
of contracting infectious disease have been described as those sitting 
within a few rows of an infectious person, but flight attendants, by 
definition, are within a single row of every person in their section 
during a food or beverage service, at a minimum. Also, ill passengers 
may congregate near the lavatories which are typically located next to 
a galley where flight attendants are stationed to work. Finally, and 
perhaps most importantly, flight attendants are the authority in the 
cabin during a flight and must make decisions about how to best 
minimize the spread of infectious disease, not only to themselves, but 
to other passengers. To this end, AFA-CWA offers the following 
recommendations:

        1. The first and most important line of defense is to prevent 
        infectious passengers from boarding in the first place. This 
        could be accomplished by the CDC expediting and expanding their 
        proposed rulemaking on infectious disease control.\14\ As 
        written, the proposed rule would expand the ability of public 
        health authorities to obtain data on passengers carrying 
        communicable infectious diseases which should allow for more 
        rapid notification and quarantine, as necessary. In adopting 
        the proposed rule, AFA-CWA recommends that the CDC require 
        airlines to provide appropriate initial and recurrent training 
        for all airline personnel who come in contact with passengers. 
        Such training should include, but not be limited to, methods 
        for workers to properly identify ill passengers pre-flight and 
        in-flight, explicit instructions on who has authority to 
        prevent ill passengers from boarding and on what basis, 
        measures that workers can apply to protect the health of other 
        airplane occupants if the ill passenger is not identified until 
        a flight is underway, and workers' rights and responsibilities 
        for notification, testing, and medical care after a potential 
        exposure.
---------------------------------------------------------------------------
    \14\ CDC (2005) Control of Communicable Diseases; Proposed Rule. 
Department of Health and Human Services. Federal Register, Vol 70(229)

        2. Airlines should be required to provide a TB test to all 
        prospective flight attendant hires to establish a baseline and 
        minimize the spread of infection in the cabin. If the test is 
        positive, then airlines should be required to provide a follow 
        up chest x-ray to determine if the disease is active or latent. 
        If the disease is latent, there is no reason to deny 
---------------------------------------------------------------------------
        employment.

        3. In the event of a confirmed case of an infectious passenger 
        or crewmember, the airline should be required to notify all 
        onboard crew and Cpassengers using language approved by the CDC 
        within 24 hours of the airline being informed, and must provide 
        testing, treatment, and medical leave as necessary to all 
        potentially affected airline personnel.

        4. To enable crewmembers to minimize the spread of infection 
        (or a bioterror threat) onboard if a suspected case is 
        identified during a flight, airlines must be required to 
        provide adequate stocks of personal protective equipment (e.g., 
        disposable gloves, surgical masks and N-95 respirators, CPR 
        masks with one-way valves, biohazard disposal bags, etc.) on 
        every aircraft in locations that are accessible to flight 
        attendants (i.e., not in the emergency medical kit, which can 
        only be accessed by licensed medical personnel).

        5. To reduce the risk of recirculating infectious agents in the 
        aircraft air supply system, Congress should require that all 
        recirculated air systems on commercial aircraft be fitted with 
        HEPA filters, and that airline operators install, operate, and 
        maintain these systems according to approved maintenance plans.
        In closing, we thank Congress for considering these comments 
        intended to protect the health of the traveling public and 
        crewmembers, to maintain consumer confidence, and to minimize 
        the economic impact posed by infectious disease transmission 
        during commercial flights.

                             For the Record

   Prepared Statement for the Record for the House Homeland Security 
Committee Hearing, The XDR Tuberculosis Incident: A Poorly Coordinated 
  Federal Response to an Incident with Homeland Security Implications.

On behalf of the undersigned organizations:
Aeras Global TB Vaccine Foundation
American Lung Association
American Public Health Association
American Thoracic Society
Infectious Diseases Society of America
    We would like to thank Chairman Thompson for holding this important 
hearing and we appreciate the opportunity to submit a statement for the 
record. The recent incident involving a patient with extensively drug 
resistant (XDR) tuberculosis (TB) in the U.S. demonstrates the ease 
with which this disease travels across borders and serves as a timely 
warning of the public health and homeland security challenges we face 
in controlling TB in all forms.

Introduction
    Tuberculosis (TB) is the second-leading infectious disease killer 
in the world, taking nearly 1.6 million lives per year. Currently, 
about a third of the world's population is infected with the TB 
bacterium.i The disease is predicted to kill millions more 
people in the next decade. TB is the leading global killer of women of 
reproductive age, ahead of HIV, heart disease and war and the leading 
killer of people with HIV/AIDS.
---------------------------------------------------------------------------
    i Tuberculosis. World Health Organization (WHO) 
Factsheet No. 104, March 2006.
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    The rise in HIV infection levels and the neglect of TB control 
programs have caused a global resurgence of TB. Drug-resistant strains 
of TB, including multi-drug resistant (MDR) TB and extensively drug-
resistant, (XDR)TB, have emerged and are spreading. While most TB 
prevalent today is a preventable and curable disease when international 
prevention and treatment guidelines are used, many parts of the world, 
such as Africa, are struggling to implement them, giving rise to more 
drug resistant TB, and, increasingly, XDR-TB.
    We support enactment of the Comprehensive TB Elimination Act, 
sponsored by Reps. Green (D-TX), Wilson (R-NM) and Baldwin (D-WI) and 
Sens. Brown (D-OH) and Hutchison (R-TX), and the Stop TB Now Act, 
sponsored by Reps. Engel (D-NY), Wilson (R-NM) and Smith (D-WA), and 
Sens. Boxer (D-CA) and Smith (R-OR), to provide full funding for TB 
control as recommended by the Institute of Medicine 2000 report, Ending 
Neglect: The Elimination of Tuberculosis in the U.S. To strengthen 
domestic TB control, including efforts to prevent the spread of XDR TB 
in the U.S., we recommend a funding level of $252. million in Fiscal 
Year 2008 for the program.

XDR-TB as a Global Health Crisis
    XDR-TB has been identified in all regions of the world, including 
the U.S. The strain is resistant to two main first-line drugs and to at 
least two of the six classes of second-line drugs. Because it is 
resistant to many of the drugs used to treat TB, XDR-TB treatment is 
severely limited and the strain has an extremely high fatality rate. In 
one of the latest outbreaks in South Africa from late 2005 until early 
2006, XDR TB killed 52 out of 53 infected patients.ii All of those who 
were tested were co-infected with HIV. The convergence of several 
factors threatens to result in XDR TB occurring on a much broader 
scale. The major factors include inadequate attention to and funding 
for basic TB control measures in high TB burden, resource-limited 
settings, which also have high HIV prevalence, and the lack of 
investment in new drugs, diagnostics and vaccines for TB.
---------------------------------------------------------------------------
    ii ``Virulent TB in South Africa May Imperil Millions.'' 
New York Times. 28 Jan. 2007. 21 Mar. 2007.

TB Has Not Been Controlled in the U.S.
    In the U.S., many people think tuberculosis (TB) is a disease of 
the past. This is untrue. Ten to 14 million Americans are infected with 
latent tuberculosis. TB occurs among foreign-born individuals nearly 
ten (according to the latest Centers for Disease Control and Prevention 
figures) times as frequently as among people born in the United States. 
Minorities are also disproportionately affected by TB. According to the 
CDC, although the overall rate of new TB cases is declining in the 
U.S., the annual rate of decrease in TB cases has slowed significantly, 
from about 7.3 percent (1993 to 2000) to 3.8 percent currently (2000--
2006).
    In the early 1990's New York city had a resurgence of TB that cost 
the city over $1 billion. The 2000 IOM report, found that the 
resurgence of TB in the U.S. between 1985 and 1992 was due, in large 
part, to funding reductions and concluded that, with proper funding, 
organization of prevention and control activities, and research and 
development of new tools, TB could be eliminated as a public health 
problem in the U.S.

Resources Needed to Address XDR-TB
    Currently, the extent of the global XDR TB burden remains unknown. 
Globally, supranational laboratory capacity must be built to enable 
drug susceptibility testing in all parts of the world. Immediate 
interventions require outbreak and cluster investigations to identify 
and interrupt the chains of transmission, and implementation of 
infection control precautions to protect healthcare workers, other 
patients, and their families. New rapid diagnostic tests must be 
deployed and promising new drugs against TB must be promptly evaluated 
for efficacy and safety, especially in those with virtually untreatable 
forms of XDR TB. Further investment must be made in developing new TB 
vaccines that will protect against all strains of TB, including those 
that are MDR and XDR.
    The current funding level of $136.4 million in FY07 for CDC's 
National Program for the Elimination of TB represents a 27% decrease 
over the past decade when adjusted for inflation. At the present 
funding level, CDC is ill-equipped to combat a significant outbreak of 
XDR-TB. The following specific resources are required to address the 
current unmet needs:
    (1) Build state and local public health laboratory capacity to 
assess the XDR burden in the U.S. All MDR patient samples must be 
routinely tested for second line drug susceptibility, and all isolates 
must be genotyped to recognize outbreak patterns.
    (2) Build supranational TB reference laboratory capacity for rapid 
surveys to evaluate susceptibility to first--and second-line anti-TB 
drugs and genotype isolates to guide planning for the global response.
    (3) Improve the domestic and global preparedness and outbreak 
response capacity, and options for effective treatment of affected 
persons. This includes providing travel and technical support for 
subject-matter experts to identify and investigate outbreaks; building 
capacity to institute infection control measures in affected areas--
with emphasis on healthcare settings where vulnerable HIV-infected 
persons congregate; and improving the use of anti-TB drugs and 
adherence measures that prevent the creation of drug resistance.
    (4) Accelerate field testing of new methods to screen for drug 
resistance and for real-time culture and drug-susceptibility testing of 
clinical isolates from TB patients.
    (5) Improve the capacity to conduct clinical research to evaluate 
the efficacy and safety of new promising compounds against drug-
resistant forms of tuberculosis; and develop new drugs to target 
resistant microbes that can be safely used in conjunction with 
antiretroviral therapy.

Need for New TB Tools
    New research on diagnostic and prevention/treatment tools and 
vaccines is urgently needed. The standard method of diagnosing TB was 
developed 100 years ago and fails to adequately detect TB in children 
and those co-infected with HIV/AIDS. Moreover, the newest class of 
drugs to treat TB is over 40 years old. The current TB vaccine, BCG, 
provides some protection against severe forms of TB in children, but is 
unreliable against pulmonary TB, which accounts for most of the 
worldwide disease burden. We support enactment of the Comprehensive TB 
Elimination Act, H.R. 1532, sponsored by Reps. Green (D-TX), Wilson (R-
NM) and Baldwin (D-WI) and Sens. Brown (D-OH) and Hutchison (R-TX), and 
the Stop TB Now act, sponsored by Reps. Engel (D-NY), Wilson (R-NM) and 
Smith (D-WA), which will both expand research efforts into new tools to 
combat TB. The bill includes authorization for research at the Centers 
for Disease Control and Prevention (CDC) and National Institutes of 
Health (NIH) into new TB drugs, diagnostics and vaccines, including the 
``Blueprint for Vaccine Development.'' as recommended by the Advisory 
Council for Elimination of Tuberculosis.

Global TB Control Efforts
    The World Health Organization declared TB a global health emergency 
in 1993. The Stop TB Partnership released the Global Plan to Stop 
Tuberculosis 2006-2015 at the World Economic Forum in January 2006. If 
all elements of the plan are implemented, an estimated 14 million lives 
will be saved between 2006 and 2015. The components of the plan and 
corresponding implementation strategies are as follows:
    1. Pursue high-quality directly-observed treatment strategy (DOTS) 
expansion and enhancement through:
        (a) Political commitment with increased and sustained financing
        (b) Case detection through quality-assured bacteriology
        (c) Standardized treatment, using internationally recommended 
        drug regimens and quality-assured drugs with appropriate 
        supervision and patient support
        (d) Monitoring and evaluation system, and impact measurement

    2. Address TB/HIV, MDR-TB and other challenges
        (a) Implement collaborative TB/HIV activities
        (b) Prevent and control MDR-TB
        (c) Address prisoners, refugees and other high-risk groups and 
        situations

    3. Contribute to health system strengthening
        (a) Actively participate in efforts to improve system-wide 
        policy, human resources, financing, management, service 
        delivery, and information systems.
        (b) Share innovations that strengthen systems, including the 
        Practical Approach to Lung Health (PAL)
        (c) Adopt innovations from other fields

    4. Engage all care providers
        (a) Public-public and public-private mix (PPM) approaches
        (b) Implement the International Standards for Tuberculosis Care 
        (ISTC)
    5. Empower people with TB, and communities
        (a) Advocacy, communication, and social mobilization
        (b) Community participation in TB care
        (c) Implement the Patient's Charter for Tuberculosis Care

    6. Enable and promote research
        (a) Program-based operational research
        (b) Research to develop new diagnostics, drugs and vaccines
Conclusion
    The best way to prevent the future development of drug-resistant 
strains of tuberculosis is through establishing and supporting 
effective tuberculosis control programs in the U.S. and globally. As we 
provide resources to respond specifically to the XDR TB emergency, we 
must keep in mind the ongoing need for consistent support of global TB 
control programs through the U.S. Agency for International Development 
(USAID) and the Centers for Disease Control and Prevention (CDC).
    To strengthen domestic TB control, including efforts to prevent the 
spread of XDR TB in the U.S., we recommend a funding level of $252 
million in Fiscal Year 2008 for the program and enactment of the 
Comprehensive TB Elimination Act, H.R.1532, sponsored by Reps. Green 
(D-TX), Wilson (R-NM) and Baldwin (D-WI) and Sens. Brown (D-OH) and 
Hutchison (R-TX).
    To combat TB globally, we support enactment of the Stop TB Now Act, 
sponsored by Reps. Engel (D-NY), Wilson (R-NM) and Smith (D-WA), and an 
appropriation of $300 million for the Global Fund to Fight AIDS, TB and 
Malaria in Fiscal Year 2008. Enactment of the Stop TB Now Act and the 
Comprehensive TB Elimination Act will provides researchers and public 
health officials the tools needed to help eliminate TB in the U.S. and 
around the world.
    We appreciate the opportunity to submit this statement for the 
record.

    Chairman Thompson. The Chair now recognizes the Ranking 
Member of the full committee, the gentleman from New York, Mr. 
King for an opening statement.
    Mr. King. Thank you, Mr. Chairman. Thank you for yielding. 
I certainly support the holding of this hearing today because 
it does raise very substantive and very profound questions as 
to exactly how our defenses are in order; how they are not in 
order; how this individual Mr. Speaker was able to take two 
transatlantic flights, visit five countries, and make his way 
across the Canadian border into the United States.
    It is especially significant, going beyond this one 
individual, in that we do know we could well be faced with a 
terrorist attack by use of infectious diseases. So this has 
very serious implications for the United States, something that 
has to be addressed, why there was not better communication 
between the CDC and the various entities in homeland security, 
and what the protocols will be to prevent this in the future.
    I would say, though, since the Chairman mentioned incidents 
beyond this particular case in his critique of the Department 
of Homeland Security, we did see this last weekend in New York 
where the JFK plot was stopped. I was very involved in dealing 
with the FBI and the NYPD in New York, and they specifically 
stated the enormous contributions they received from the 
Department of Homeland Security, especially Customs and Border 
Protection, ICE, TSA, air marshals. All of that was involved in 
taking down of that case.
    Also, the other reality is we have gone 69 months since 
September 11th without being attacked, so I think we have to 
keep all of this in perspective.
    Having said that, none of that diminishes from the issue 
that we face here today is why this individual was basically 
allowed to traverse the globe, especially since it was thought 
that he had a very serious strain of TB. Whether he does or 
not, I guess, is an unanswered question. The reality is at 
least faced with the hypothetical case, the government did not 
do the job we were supposed to do.
    So I am very interested and looking forward to the 
testimony today to see what went wrong and how we protect it 
for the future. But in doing that I think we should keep in 
perspective what has been achieved and also give credit where 
credit is due, and certainly the taking down of the JFK plot in 
which DHS was very much involved deserves to be on the record 
if we are going to go beyond this specific case.
    With that I yield back the balance of my time.
    Chairman Thompson. Other members of the committee are 
reminded under committee rules, opening statements may be 
submitted for the record.
    Chairman Thompson. In addition, Dr. Gerberding is 
testifying over at the Senate, and we expect very shortly that 
she will come and join our panel of witnesses.
    I welcome our panel of witnesses: Dr. Jeffrey Runge, the 
Assistant Secretary For Health Affairs and Chief Medical 
Officer at the Department of Homeland Security. Dr. Runge is an 
emergency physician and former emergency medical technician, 
and prior to DHS he was the Administrator of the National 
Highway Traffic Safety Administration.
    Our second witness is Mr. Ralph Basham, Commissioner of 
Customs and Border Protection at the Department of Homeland 
Security. Mr. Basham previously served as the Director of U.S. 
Secret Service and Director of the Federal Law Enforcement 
Training Center.
    Mr. Ahern, you are just the backup for Mr. Basham.
    Thank you very much. Without objection, the witnesses' full 
statements will be inserted into the record. I now ask each 
witness to summarize his statement for 5 minutes, beginning 
with Dr. Runge.

 STATEMENT OF JEFFREY RUNGE, CHIEF MEDICAL OFFICER, DEPARTMENT 
                      OF HOMELAND SECURITY

    Dr. Runge. Thank you, Mr. Chairman.
    Chairman Thompson, Ranking Member King, members of the 
committee, thank you for the chance to share with you some of 
the policy, procedures and processes that we have in place with 
our Federal partners to enhance our Nation's biodefense at the 
borders. We take the role of this committee very, very 
seriously, and I appreciate the candidness with which I have 
been able to share information with your staff and the report 
that we have, Mr. Chairman.
    DHS is aware that the committee is acutely interested in 
the details and implications of our interactions with our 
Federal partners in dealing with a person with an infectious 
disease crossing our borders. We appreciate the opportunity to 
address this case with you and the actions that we have taken 
since that time to improve our biodefense posture and to 
respond to your questions. It is extremely important to note 
that due to the diligence and the diligent actions of the CDC 
and its divisions, this subject no longer poses a threat to our 
public's health. We are happy to play a part in assisting Dr. 
Gerberding and her team in discharging their duties to protect 
America's health, which we do over 200 times in a year, in 
addition to working with them in extensive joint planning for 
pandemic influenza and other threats to our Nation.
    When this individual chose to travel overseas against 
medical advice, and CDC became aware of the potential for 
disease spread, CDC reached out to activate processes that we 
already have in place through agreements and procedures among 
our agency's various components. Within a very short time of 
the CDC's request, DHS components were able to put into effect 
procedures at the U.S. points of entry and with 250 or so 
airlines that share information with DHS.
    The system worked as intended. Although we have identified 
several processes that we have to improve upon, the problem for 
DHS was not in the system. As my written testimony said, Mr. 
Chairman, there appears to have been a single point of human 
failure in this case, which Commissioner Basham, Assistant 
Commissioner Ahern can address.
    This committee has also expressed its concern which we at 
the Department share about the implications of this incident 
for biodefense at our Nation's borders. We share the genuine 
concern over the fact that our borders are not impervious to 
infectious diseases in spite of the best efforts of CDC and DHS 
and its components.
    Short of Draconian and economically damaging health-
screening techniques being routinely implemented at each port 
of entry, for the millions of people crossing the border there 
will always be opportunities for people who are ill to cross 
our borders undetected.
    Having said that, our citizens have every right to expect 
that when we know of a person who poses a risk, we should be 
able to enforce CDC's isolation and quarantine authority at the 
border. For other illnesses that can readily be detected 
because of fever or other outward signs, it is reasonable to 
expect us to meet that challenge with tools and training and 
partnerships with State and local authorities. But for those 
that cannot be readily detected with available tools and 
training, we want the committee to appreciate the formidable 
challenge that that presents both to those who enforce the law 
at the border and those who are responsible for isolation and 
quarantine.
    The great majority of our 326 ports of entry are manned by 
law enforcement officials from CBP who have received no 
advanced medical training, although each does receive training 
in various diseases both for recognition and for self-
protection.
    Mr. Chairman, you and your staff have made it clear to me 
that you expect our Office of Health Affairs to assist CBP and 
the other components in discharging their health-related 
responsibilities, and we intend to do so as we grow and man up.
    Mr. Chairman, this concludes my opening statement, and I 
would ask that the Department's written statement be submitted 
entirely for the record.
    Chairman Thompson. Thank you very much. Thank you for your 
testimony.
    [The statement joint statement of Dr. Runge, Mr. Ahern, and 
Mr. Basham follows:]

Joint Prepared Statement of Dr. Jeffrey Runge and Jayson P. Ahern, and 
                            W, Ralph Basham

Introduction
    Thank you Mr. Chairman for the opportunity to share with the 
Committee some of the policy, procedures and processes we have in place 
with our Federal partners for the Nation's biodefense across our 
borders.
    DHS is aware that the Committee is acutely interested in the 
details and implications of the recent interactions with a patient 
infected with extensively drug resistant tuberculosis (XDR-TB). We 
appreciate the opportunity to address this case with you and the 
actions we have taken to improve our biodefense posture. While this 
case is indeed interesting, it is extremely important to note that it 
poses no ongoing threat to public health in the United States. This 
case involves one patient who was diagnosed with tuberculosis during a 
medical examination by his personal physician and was subsequently 
identified by public health authorities as a potential transmission 
risk after the diagnosis of MDR-TB, and later the XDR-TB was confirmed.
    The story took a rare and unusual turn when the individual chose to 
travel overseas after the subsequent diagnosis, thus activating the 
processes to present an isolation order to the individual upon his 
reentry into the United States. The system created to effect such an 
isolation order involves the Department of Health and Human Services 
(HHS), (including its Centers for Disease Control and Prevention (CDC)) 
acting under the authority of the Public Health Service Act and the 
Department of Homeland Security (DHS). The system functioned properly 
in this case. However, there appears to have been a single point of 
failure in this case--human error by an individual who may have failed 
to follow appropriate procedures. DHS continues to investigate this 
issue. While the investigation is pending, DHS has ensured that the 
individual is not carrying out inspection duties at the border.
    The fact that a failure occurred underscores the need to implement 
additional failsafe mechanisms. U.S. Customs and Border Protection 
(CBP) has already made changes to its procedures designed to prevent 
this particular failure from occurring again. This was indeed a lesson 
learned and not simply a lesson observed.
    The Committee has also expressed its concern, which the Department 
shares, about the implications of this incident for biodefense at our 
Nation's borders. We share the genuine concern over the fact that our 
borders are not impervious to infectious diseases, in spite of the best 
efforts of the CDC and DHS and its components. Unless draconian health 
screening techniques are routinely implemented at each port of entry as 
a standard operating procedure for the millions of people crossing the 
border, there will always be opportunities for people who are ill to 
cross our borders undetected. The land border environment presents 
additional challenges because individuals claiming U.S. and Canadian 
citizenship are not always required to present passports that validate 
identity and citizenship. The Department is committed to addressing 
this security gap through implementation of the Western Hemisphere 
Travel Initiative (WHTI). Ultimately, the WHTI will provide technical 
enablers and controls to mitigate volume issues and ensure that high 
risk travelers are better identified at our ports of entry. WHTI 
implementation will enhance the screening process by increasing the 
number of travelers that can be efficiently queried at the time of 
entry through the ports of entry based on better documentation, 
identity and citizenship.
    Currently, however, CBP officers are only able to query 
approximately 50 percent of land border crossers by requesting 
documents with machine readable zones (as noted previously, because 
individuals claiming U.S. and Canadian citizenship are not yet required 
to present documents denoting identity and citizenship) or by flat-
fingering the query. In addition, the great majority of our 327 ports 
of entry are manned by law enforcement officials from CBP who have 
received no advanced medical training. CBP officers do have procedures 
to follow when a U.S. citizen or non-U.S. citizen appears to be ill and 
in need of medical attention at the border, and each is trained in 
those procedures. These procedures involve consulting medical 
personnel. Federal medical resources at the borders come from the CDC's 
Division of Global Migration and Quarantine (DGMQ), which provides that 
service at approximately 20 ports of entry. Even though steps were 
taken to fortify ports of entry with medical staff, even fully staffed 
quarantine stations are not in a position to perform routine health 
screening on all passengers crossing the border as a standard operating 
procedure. It is important to stress that individuals will not 
necessarily exhibit symptoms of illness and that CBP officer must make 
their best assessment within a limited period of time.

The Incident in Question
    On May 22, 2007, CBP Port of Atlanta received information from the 
CDC regarding an individual, who traveled to Europe on May 12, 2007, 
noting that he is a carrier of a drug resistant form of tuberculosis.
    A shift muster, a daily briefing for shift employees on significant 
policy and operational matters, was distributed and briefed to CBP 
Officers at all locations.
    On May 24, 2007, at 1818 hours, the individual arrived at the land 
border crossing at the Champlain, NY port of entry in a rental vehicle, 
accompanied by his wife.
    More detailed information can be provided in a classified briefing. 
However, as a result of this incident, CBP initiated a systems 
enhancement (effective June 5, 2007) that will help ensure that 
officers will follow appropriate procedures when processing persons of 
interest seeking to enter the United States. This systems change will 
allow CBP to better account for and control all referred persons of 
interest for secondary inspection. It will also require that such 
persons undergo additional questioning and examination to determine 
whether they may be cleared or whether other appropriate action is 
warranted. The Department's long-term solution remains a WHTI enabled 
screening procedure that tackles the inherent problem of increasingly 
high traffic volume with improved query capabilities.

Information Sharing_U.S. and Canada
    In December 2001, former Secretary of Homeland Security Tom Ridge, 
then serving as Director of the White House Office of Homeland 
Security, signed a Smart Border Declaration with the Canadian Deputy 
Prime Minister. The Declaration set forth a 30-point action plan 
designed to enhance the security of the United States and Canadian 
shared border while continuing to facilitate the flow of legitimate 
travelers and cargo. This action plan resulted in initiatives to share 
information between the United States and Canada related to air travel, 
including Advanced Passenger Information/Passenger Name Record (API/
PNR) Risk Assessments. An essential goal of the API/PNR Risk Assessment 
Initiative is the concentration of inspection resources on high-risk 
travelers while facilitating the movement of legitimate members of the 
general traveling population. A risk assessment process evaluates 
passengers arriving into the United States or Canada.

Current Health Screening Procedures at Ports of Entry and information 
Sharing
    Among CDC, CBP, and other DHS Components As part of CDC's authority 
to prevent the introduction, transmission, and spread of communicable 
diseases into the United States, its possessions, and territories, CDC 
is authorized to isolate and/or quarantine arriving persons reasonably 
believed to be infected with or exposed to specified quarantinable 
diseases and to detain carriers and cargo infected with a communicable 
disease. DHS has agreed to assist CDC in the execution and enforcement 
of these authorities, primarily in the enforcement of CDC-issued 
quarantine orders, and through collaboration with other Federal, State, 
and local law enforcement entities.
    HHS and DHS executed a Memorandum of Understanding in October, 2005 
that details the roles and responsibilities of each Department and 
agency to mitigate the entry of infectious diseases at the Nation's 
borders. (within HHS this memorandum implemented through the CDC.) 
Since the CDC's DGMQ cannot possibly cover every port of entry, 
successful screening depends on CBP officers having access to simple, 
usable tools and protocols to identify travelers who may be infected 
with a quarantinable disease. By the same token, CBP has law 
enforcement powers to aid CDC in carrying out its authorities and has 
access to data that CDC needs to perform its public health duties.
    HHS will consult with DHS to define steps necessary to obtain 
information expeditiously when either agency believes there is a public 
health emergency. The Departments agreed to assist one another in 
informing the traveling public of potential disease threats, including 
assisting in the distribution and dissemination of CDC Travel Notices 
or Health Alert Notices if necessary and as resources permit.
    DHS has agreed that its personnel will assist with surveillance for 
quarantinable or serious communicable diseases of public health 
significance among persons arriving in the United States from foreign 
countries, with the understanding that DHS personnel may not have 
medical training and therefore are not expected to physically examine 
or diagnose illness among arriving travelers. Surveillance by DHS 
personnel would generally consist of the recognition and reporting of 
overt visible signs of illness or information about possible illness 
provided to them in the course of their routine interactions with 
arriving passengers, and does not include eliciting a medical history 
or performance of a medical examination. In situations where a 
significant outbreak of a quarantinable disease is detected abroad, CDC 
may request that DHS personnel assist with active surveillance, using a 
number of methods to assess the risk that individual passengers, 
arriving from affected countries or regions, are carrying a 
quarantinable disease. CDC will ensure that a quarantine officer or 
designated official with public health training will be available to 
assist in the evaluation of individuals identified through active 
surveillance.
    CDC has statutory authority to require reporting of ill travelers, 
conduct certain public health inspections of carriers and cargo, and 
impose certain entry requirements for carriers and cargo that may pose 
a communicable disease threat. DHS will aid CDC in the enforcement of 
its statutory authority regarding quarantine rules and regulations 
pursuant to operational guidelines to be developed by mutual agreement 
of the parties. Such guidelines will include emergency measures to be 
taken when a carrier or vessel is determined, after leaving a foreign 
port, to be carrying a passenger or passengers with a quarantinable or 
serious communicable disease.

Passengers with Potential Public Health Threats and the Commercial 
Airlines
    Under the Aviation and Transportation Security Act, the 
Transportation Security Administration (TSA) has broad authority to 
assess and address threats to transportation and passenger security. 
Under this authority, TSA can direct airlines to deny boarding to an 
individual identified by the CDC as a threat; this includes individuals 
identified by the CDC as a public health threat. Based on the request 
from CDC/HHS, the Assistant Secretary of Homeland Security at TSA may 
determine that the presence of such an individual aboard a commercial 
passenger airline flight poses a threat not only to that flight but to 
the entire transportation system, should the disease spread to other 
passengers, flights and flight crews, and other modes of transportation 
used by those individuals.
    TSA has a number of options where a person who poses a public 
health threat may attempt to use the commercial airline system. In the 
case of last week's incident, as soon as CDC recognized that the 
individual may have been attempting to fly on a commercial airliner to 
enter the United States against their CDC advice, TSA directly 
contacted the Transportation Security Administration Representatives 
(TSARs) in Europe and International Principal Security Inspectors 
(IPSIs) world-wide to inform carriers, embassies, and host government 
authorities that the infected individual should not board a commercial 
flight. TSA also chose to use the existing infrastructure of its watch 
list system. Given the imminent travel of this infected individual, 
using the existing process was deemed the most expeditious way to alert 
the airlines to prevent the individual from boarding. At no time, 
however, was the infected individual identified as a terrorist. TSA has 
other means at its disposal to communicate threats to airlines 
immediately and direct them to implement specific security measures, 
such as the issuance of a Security Directive.
    The fact that the introduction or spread of a communicable disease 
through the transportation system is not necessarily a threat involving 
criminal violence or other unlawful interference with transportation 
does not preclude TSA from exercising its authority to address such a 
threat. The security of the transportation system involves protection 
of the system from any threat that may disrupt transportation or 
endanger the safety of individuals in transportation. In the case of 
biological threats to the transportation system and its passengers, 
such as the introduction of a communicable disease, it may be 
impossible to determine whether the source of the threat is intentional 
human action, human failure, or a natural occurrence. TSA's authority 
is not limited to dealing only with threats of intentional terrorist 
acts against the transportation system. TSA is charged with assessing 
all threats to transportation and executing such actions that may be 
appropriate to address those threats.
Conclusion
    In summary, let me restate that DHS will proactively exploit the 
lessons learned from this incident to strengthen our homeland defenses 
and response to infected air travelers. We also look forward to 
streamlining collaboration with HHS/CDC, the Department of State, and 
State and local public health authorities to jointly combat the growth 
of global infectious disease threats, including pandemic influenza. DHS 
apparently had a single point of failure, but that has been corrected 
and has resulted in structural improvements to border security thanks 
to decisive action by CBP leadership.
    We are encouraged that the U.S.-E.U. information sharing of 
Passenger Name Records for public health purposes contributed to CDC's 
efforts to contact travelers who may be at risk for disease 
transmission. We look forward to strengthening U.S.-Canadian 
cooperation and communication on API/PNR and have already reached out 
to continue negotiations. The TSA acted quickly to provide assistance 
to CDC in this case, and has already begun to explore expeditious ways 
of communicating ``pop-up'' threats to commercial air carriers. 
Finally, my office, the Office of Health Affairs, leads the ongoing 
efforts to fulfill the Department's responsibilities for Biodefense, 
including enhanced biosurveillance, and emergency preparedness and 
response, in close coordination with our Federal partners.
    Thank you for the opportunity to present the Department of Homeland 
Security's testimony today. My colleagues and I are available to 
respond to your questions.

    Chairman Thompson. I now recognize Mr. Ralph Basham to 
summarize his statement for 5 minutes.

STATEMENT OF W. RALPH BASHAM, COMMISSIONER, CUSTOMS AND BORDER 
          PROTECTION, DEPARTMENT OF HOMELAND SECURITY

    Mr. Basham. Thank you, Mr. Chairman, ranking Member King 
and distinguished members of the committee. I am here before 
you today to discuss the role of U.S. Customs and Border 
Protection and the Federal Government's efforts in late May to 
track down a U.S. citizen now identified in the media as Andrew 
Speaker who was traveling with his wife internationally while 
he was infected with a rare strain of tuberculosis.
    Joining me here today, as you stated, is Assistant 
Commissioner for Office Field Operations Jay Ahern, who has the 
responsibility over all of our ports of entry. Together we hope 
to provide you with what happened when a CBP officer 
encountered the traveler and his wife crossing the land border 
with Canada at the Port of Champlain, New York, and allowed 
them to enter the United States contrary to CBP instructions. 
We will also update you on our resulting follow-up actions.
    Let me state at the outset to this committee and the 
American people CBP had an opportunity to detain Mr. Speaker at 
the border, and we missed. That missed opportunity is 
inexcusable, and it appears at this stage to be largely the 
result of a CBP officer failing to follow procedures and 
instructions. That failure is felt collectively by all of CBP's 
leadership and all of the frontline employees whose good work 
and reputation are tarnished by his actions.
    There is no criticism that can be leveled today or in 
coming weeks by outsiders harsher than the blame and 
frustration we have already turned upon ourselves since the 
discovery of Mr. Speaker's reentry into the United States.
    The failure to detain this traveler unfortunately 
overshadows and negates a lot of good work done in this 
particular case by CBP employees both before and after the 
encounter in Champlain.
    The work of other employees began in Atlanta on May 22nd 
when CDC brought the information to local CBP officials before 
the May 24th encounter. On the 22nd, a nationwide alert was 
placed in our electronic system that gave us the necessary 
information to intercept the traveler. Despite not knowing how 
or where he would attempt to enter, we continued our effort 
looking for Mr. Speaker's travel into the United States in the 
event he chose an alternate time, date and method of travel.
    When it was determined by our National Targeting Center 
that the traveler had entered, we alerted the CDC within hours 
of the entry. Our efforts continued last week with CBP 
employees using our tools and information to identify Mr. 
Speaker's travel pattern and track down other passengers from 
his flight potentially at risk for tuberculosis from exposure 
to him.
    This also overshadows all the good work of CBP officers on 
a daily basis. Just to put this incident in context, on that 
day of May 24th, at the port of Champlain, New York, we 
processed entry of 1,296 passenger vehicles, 1,378 commercial 
trucks, and responded to numerous alerts that were properly 
referred for secondary inspection. Nationwide on average, on an 
average day, CBP processes 1.1 million passengers and 
pedestrians, almost 71,000 trucks, rail and sea containers, 
over 240,000 incoming international air passengers, 327,000 
incoming privately owned vehicles, and 85,300 shipments of 
goods. What should have been a textbook success story to 
demonstrate how our systems work effectively was overshadowed 
by the failure to stop this one traveler.
    There is no excuse or acceptable explanation to offer for 
failing to stop this individual at the border. I do not believe 
that it can be explained by any lack of tools or training. The 
actions of the individual officer and supervisors in Champlain 
are being fully investigated, and appropriate action will be 
taken. It is understood by all employees in CBP that we are 
responsible for our actions. Because there is a required 
administrative process, we may not be able to say as much today 
as I would like, especially in an open hearing, with respect to 
action that may be taken against the individual officer; 
however, I cannot offer any defense for the individual actions 
that lead to the failure to interdict and detain this 
individual upon entry into the United States. To my mind those 
actions appear to be indefensible, and in a closed briefing we 
would be happy to show you and the Members more detail on what 
took place in those critical few moments in Champlain.
    We have taken some immediate steps to implement 
enhancements to our information technology systems and 
protocols at our ports of entry to further reduce the 
possibility that an officer on primary inspection could ignore 
or clear a public health alert in the same manner again. We can 
discuss these matters in further detail during questioning.
    I would say a word in defense of the human element on the 
front line of America's borders and in all law enforcements 
that has been critically questioned during the past 2 weeks. 
While the human element can be a weakness, it also is a source 
of our greatest strength. A great many of the threats we 
intercept on a daily basis at our ports of entry are caught not 
because of known alerts or a watch list already in a computer, 
but due to the training and experience of our frontline 
officers in dealing with the unknown. The unknown threat is 
still our greatest vulnerability.
    We were presented with such a threat in the Millennium 
bomber, who was intercepted at the border with a car trunk 
containing explosives on his way to blow up a terminal at LAX 
in 1999. This is an example of an alert customs inspector who 
acted not because the traveler was a known threat or on a watch 
list or alert but because the inspector relied upon her 
training, experience and intuition to determine that something 
just wasn't right on that entry.
    It is important that despite this most recent failure we 
not lose sight of the value of the human element in 
inspectional work nor overreact in trying to turn our officers 
into robots devoid of the ability to exercise the appropriate 
judgment and discretion.
    Those who signed up to protect the homeland understand that 
we are expected to take the right action every single time. 
When we hit the mark, there will be precious little news 
because it was just doing our job; and when we slip, even once, 
it makes headlines. We accept that standard of 100 percent 
success, that standard of 100 percent success without 
complaint, because the mission is so important.
    Mr. Chairman, I have spent my 37 years in law enforcement. 
I am no stranger to the concept of being judged by the 
unforgiving standard of 100 percent success, the concept that 
everyone must unfailingly perform the duties and 
responsibilities of his or her position in order to meet that 
standard and the consequences of failure. In my previous job as 
Director of the Secret Service, what kept me up at night was 
knowing that no matter how elaborate the protection scheme we 
could design, no matter how much technology was available or 
how many redundancies we could build in, at the end of the day 
a single agent or uniformed officer's failure to take the 
proper and expected action at a key moment could literally cost 
the life of the President of the United States.
    Since becoming Commissioner of U.S. Customs and Border 
Protection, I have emphasized the theme of integrity, and I 
preach its importance to our field employees many times by 
explaining that CBP is like a chain which is only as strong as 
its weakest link, and that the neglect and failure of even a 
single employee intentionally or otherwise can undermine the 
efforts of all.
    Our review thus far indicates that this is exactly what 
happened in this case. Again, I can offer no defense for what 
happened that day in the Champlain port of entry, and I will 
not offer any hollow promises today that human failings will 
never again occur among the 44,000 employees charged with the 
critical and complex mission of securing our Nation's borders. 
Similarly, I cannot guarantee that CBP will hit 100 percent 
success 100 percent of the time.
    But this incident has reinvigorated our focus on the 
mission of protecting American people, causing us to reexamine 
how we perform that mission and reinforce in a way words cannot 
the critical importance of every single employee in doing their 
duty.
    Thank you, Mr. Chairman. I would be happy to take your 
questions.
    Chairman Thompson. Thank you very much, Mr. Basham, for 
your testimony.
    Chairman Thompson. I would like to remind the Members that 
Dr. Gerberding is expected momentarily, and at what point she 
comes, we will ask unanimous consent to have her testimony from 
CDC.
    In the interim we will start with the questioning of our 
witnesses. I will allow myself 5 minutes to start.
    In my testimony I mentioned about a memorandum of 
understanding between DHS and CDC. We now have that as of a few 
minutes ago, and we will share that with other Members as 
quickly as possible.
    What I would like to go through, Mr. Basham, if I can, is 
whether or not you think the Atlanta CBP office provided real-
time action once it was notified of this situation.
    Mr. Basham. Mr. Chairman, as was stated, I believe you have 
the timeline, on the 22nd when CDC came to CBP Atlanta office 
and explained the situation with regard to Mr. Speaker and 
basically was inquiring as to whether or not we could track Mr. 
Speaker's travel, and explained that Mr. Speaker had, in fact, 
left the country, at that time our office in Atlanta decided to 
put an alert in our system and to try to make--if he tried to 
reenter the United States, that we would have that information 
so that we would be able to intercept or interdict him when he 
came in.
    At that point in time, it was understood by the Atlanta 
office that we had an individual who was compliant and was 
following the instructions of CDC. We were not told at that 
time the danger of or the lack of danger of this individual and 
his travel. So when we put that alert in the system, which 
alerted all of our ports of entry, we felt confident that if 
Mr. Speaker tried to reenter the country, we would be able to 
intercept him.
    Chairman Thompson. At what point were you provided 
information that Mr. Speaker was potentially dangerous?
    Mr. Basham. When he actually did reenter the United States.
    Chairman Thompson. You just said at the point that the 
Atlanta office was notified that he was a danger, and I am just 
trying to follow up, at what point did someone tell you that he 
was potentially a danger?
    Dr. Runge. Maybe I can put a fine point on that, Mr. 
Chairman. CDC came to CBP because of its concern that he was, 
in fact, an infectious disease risk, but at that time they had 
been in conversations with him and did not know him to be a 
flight risk.
    CBP has reservation information through their system and 
expected him back on a certain day, and they really had no 
reason to believe that he would try to evade the situation if 
he reentered the United States.
    Mr. Basham. I would say, Mr. Chairman, that we were told 
that day that he had XDR tuberculosis. That was entered into 
the alert. When we placed the alert in the system on the 22nd, 
the instruction, very clear instruction, was that anyone who 
encountered this individual was to refer that individual for 
secondary inspection, to put a mask on that individual, to 
isolate that individual, and to ventilate that individual, and 
to notify the CDC, Dr. Kim I believe was the name.
    So those instructions went in on the 22nd, and I am not 
sure exactly what the time was.

STATEMENT OF JAYSON P. AHERN, ASSISTANT COMMISSIONER, OFFICE OF 
      FIELD OPERATIONS, CUSTOMS AND BORDER PROTECTION, DHS

    Mr. Ahern. The alert went in on the 22nd at 11:30 after we 
were contacted by the CDC. It should be noted that Mr. Speaker 
departed the country on May 12th. At that time CDC, because of 
the close working relationship with our port officials in the 
Port of Atlanta, they did come and talk about the situation, 
and we did make a determination it was best to put within our 
border system of lookouts a Treasury enforcement communication 
system, not to be confused with watch listing or no-fly 
listing. Our border lookout system was executed for the 
individual coming back in the country through Atlanta, JFK or 
LAX, or, as he ultimately did, in Champlain, New York. So it is 
a nationwide system that was executed at Atlanta locally.
    At that point in time, that is then flagged for it that 
individual is encountered coming back into that country. 
Further we started to conduct sweeps daily to see if the 
individual's flight reservation through our automated targeting 
system to target people through the air venue reflected there 
was a return flight coming to the United State to Atlanta on 
June 5th. That continued to show through our twice-daily 
reservation checks and showed no alternative or deviation from 
that original record at that point in time, nor for the next 2 
days when he actually arrived at the land border crossing.
    Chairman Thompson. So, in essence, you had no knowledge as 
to his travels until he got to the border crossing.
    Mr. Ahern. That is correct. The reservation that was 
existing in the system through the passenger name record that 
we use for targeting individuals of potential travel concern, 
as we have talked about before in some of the hearings, and for 
other settings, this is a system we use to see what return 
travel or any deviations from the travel.
    Without going into the methods and means of it, we would be 
happy to in a closed setting, it gives us the ability to see on 
that reservation if it is modified or whether individuals are 
linked to that particular system. However, it won't go further.
    My point is that the individual did not modify or change 
that particular reservation. That remained in the system, and a 
new reservation was executed to show that within Europe and 
ultimately the Canada flight.
    Chairman Thompson. I guess the question is with the new 
reservation, our system is not designed to pick up a new 
reservation?
    Mr. Ahern. That is correct. That is certainly something--as 
we continue to look through our agreements with the European 
Union and other national, international parties, we need to 
take a look at our global sharing--I think it is a critical 
point that we need to have greater visibility--and to the 
transportation patterns so that we can target and better 
secure.
    Chairman Thompson. Now, is CBP doing this or TSA?
    Mr. Ahern. At this particular point in time, this is CBP 
looking at the reservation. We certainly do, through our 
National Targeting Center, have many different Federal agencies 
here in northern Virginia. TSA and the Federal air marshals are 
part of that process.
    Chairman Thompson. So is the protocol for the regional 
office to work it or push it to headquarters and let 
headquarters make the decision?
    Mr. Ahern. I think clearly as far as what we need to do is 
when we have a piece of tactical information like this, that 
for an agency we have a relationship with, my sense is in my 31 
years of experience we need to get that lookout in the system. 
I think as we go forward, and Dr. Runge may want to talk 
further about this, is we need to bring a lot of it up to the 
national level and certainly having some information with our 
National Operations Center to make sure we have the overarching 
DHS umbrella with all components fully engaged at early onset. 
Those oftentimes are hard to predict when you have a case that 
happens with great routine for different types of lookouts on a 
regular basis throughout the country. We need to put a better 
process in place, at the same time having a measure put in 
place immediately.
    Chairman Thompson. Thank you.
    I yield 5 minutes to the Ranking Member from New York Mr. 
King.
    Mr. King. Thank you, Mr. Chairman.
    Commissioner Basham, as I understand it from the Chairman's 
questioning, CDC came to CBP on May 22nd, but TSA was not 
notified until May 24th. Should there be better coordination 
among the CDC, CBP and TSA, especially since the CBP and TSA 
are under the same roof?
    Mr. Basham. I would clearly--in hindsight, Mr. King, we 
could have done a better job of coordination, but looking at it 
through the lens of that office on that day, at that point in 
time, as I said before, the expectation was that this 
individual was going to return to the United States on a flight 
on June 5th. I believe it was an Air France flight. And we had 
already begun to put in a plan where we would coordinate our 
efforts with TSA, with ICE, and with CDC upon Mr. Speaker's 
arrival back into the United States.
    So on that day there was no reason to expect that this was 
not going to be anything other than this individual either 
coming back on a commercial flight or a flight that was going 
to be arranged, a charter flight that could be arranged by CDC. 
So it was a local issue at that point in time, sir, and in 
retrospect, in the events as they played out, we could have 
probably done a better job in the communication.
    Dr. Runge. Congressman King, can I add? You are absolutely 
correct, there should have been better coordination. But I want 
to put in a caveat to that, and that is that there are 
literally a couple hundred of these lookouts that CDC 
communicates with CBP that really don't rise to a certain 
threshold. We do rely on the judgment of the field officers in 
whatever agency to decide when something needs to get bumped 
upstairs. That will probably change as a result of this.
    There is no question that when an interagency interaction 
takes place, that it should take place through the National 
Operations Center. We have had some very productive 
conversations about that over the last week or so and have 
reached that agreement. In fact, when we were notified, 
frankly, 2 days later when CDC learned that he was not as 
compliant as they thought he would be, we immediately convened 
a conference call with the Transportation Security Operations 
Center, the National Operations Center, the CDC's operation 
center to discuss the issue, and that, in fact, lead to TSA's 
involvement and his addition to a no-fly situation. So you are 
absolutely correct that going forward we will do that.
    Mr. King. Rather than, leaving Monday-morning 
quarterbacking aside, from a lessons-learned perspective, if we 
are talking about someone who has such a virulent disease, and 
since September 11th we have been taught to think outside the 
box, rather than assume he is going to come back the way he is 
scheduled to, does it make sense, especially in a case like 
this, talking about a deadly disease, we assume the worst and 
that we send out an APB and put everyone on notice, especially 
when TSA and CBP are under the same roof?
    Let me ask you, Dr. Runge, obviously you are new in your 
position, but when I look at the testimony here from CDC where 
it says that perhaps one in three people in the world at least 
had a latent exposure to tuberculosis, which I guess runs into 
the billions, I am trying to do some fast math in my head, and 
we are dealing with millions and millions of people coming into 
our country every year by airplanes and other means, certainly 
by plane. Do you think more should be put in place?
    I know they have to get TB tests, but I think you have a 
year after your test before you have to take another one coming 
into the country. Again, trying to anticipate something in the 
future, do you feel apart from any terrorist connotations at 
all, do we have enough protections and should be more 
coordination between you and the CDC?
    Dr. Runge. That is a great question, sir. The CDC and we do 
coordinate, in fact, very well, particularly at the action 
officer level, and we will do better at communicating more at 
the senior level.
    The issue of the ubiquitousness of TB is quite interesting, 
and it does speak to the fact that the transmissibility is 
relatively low in casual contact, and, in fact, it is minimal, 
I would say, and that people who come into casual contact with 
people who have TB really have nothing to worry about. It is 
being in a closed space like an Army barracks, or college dorm 
or shelter, or a multiple-family situation in which people are 
living in very close contact in which we see the risk is 
raised.
    The literature says that flights of less than 8 hours are 
really not of a concern, but those that are more than 8 hours 
in the proximity of someone, people should--they have an 
increased risk of contracting the disease.
    So the other thing I should point out is that we don't 
decide, DHS does not decide for itself, who we quarantine and 
isolate. We are the law enforcement agent for the CDC's 
authorities, and we take cues from them. That is an important 
distinction. And they are really the experts with respect to 
disease transmission, and we will take their advice.
    Mr. King. Thank you very much. Yield back, Mr. Chairman.
    Chairman Thompson. Thank you very much, Mr. Chairman.
    I now yield 5 minutes to the gentlelady from the Virgin 
Islands Mrs. Christensen.
    Mrs. Christensen. Thank you, Mr. Chairman. Thank you for 
holding this hearing, and I also want to thank the Chairman, 
Chairman Langevin, for his leadership on this issue.
    Mr. Chairman and colleagues, this is not just about one man 
or one family with someone who has active TB. This is whether 
we as a country almost 6 years after 9/11 are prepared to deal 
with the potential biologic threat or an agent of bioterrorism 
that is introduced into our country or another country in this 
world.
    We have appropriated over $5 billion for Bioshield, over $6 
billion for avian flu that may or may not come anytime soon. At 
the same time, despite the call from many of us, we have 
virtually ignored the simple public health measures that would 
be the first line of defense no matter what the agent is.
    Also in the prior two Congresses, we basically ignored the 
fast cures legislation which would have directed research to 
speed up identification processes and the development of new 
vaccines and countermeasures for agents we may or may not have 
seen before. And I have only held off reintroducing this 
legislation from assurances under Secretary Jay Cohen that such 
research was being given priority already. I would recommend 
the committee take a look at whether that is occurring and to 
what extent.
    We are very lucky that it seems as though this gentleman is 
not contagious, and so far as we know, it has just been one 
person. So today I am hoping we get some answers that will 
restore the faith of the American people that they will be 
protected against diseases introduced to harm them, and 
assurance that the needed investment will be made in a strong, 
well-staffed, well-trained, informed public health system once 
again.
    So my first question, I guess, and I am looking forward to 
having Dr. Gerberding here because I have more questions for 
her, is what is in the 2008 budget for hospitals and public 
health departments? Do you know offhand? It has never been 
adequate.
    Dr. Runge. Your questions are always very insightful on 
these issues, and I haven't got an answer for that. That would 
be more appropriate for Dr. Gerberding or perhaps someone else 
from HHS.
    Mrs. Christensen. Well, Mr. Basham, our prior information 
had said that the name of Mr. Speaker went on the list, the no-
fly list, which I assume means more than just a no-fly list; it 
includes all of the lists that would come up at a border; that 
it was on the 24th of May that it went on the list. You are 
saying it was on the 22nd?
    Mr. Basham. Mr. Speaker's name went into our alert system, 
which, the Commissioner pointed out earlier, is not the no-fly 
list, nor the watch list. It is a Treasury enforcement 
communication system that goes out to all of our ports of 
entry, and it alerts our officers on individuals and gives the 
name, date of birth. And that went out in--I believe he said it 
was 11 a.m. on the 22nd.
    On the 23rd a notification went out that--when we 
discovered that he was traveling with his to-be wife Ms. 
Cooksey, a notification went out on the 23rd through the same 
system to be on the lookout for Ms. Cooksey in the event she 
tried to reenter the U.S.
    Mrs. Christensen. Mr. Basham, you gave a lot of statistics 
about what had been processed at the Canadian-U.S. border and 
what is processed every day. Were you in any way suggesting 
that you are understaffed at those borders?
    Mr. Basham. No, I am not suggesting that we are 
understaffed, particularly in this situation. All of the 
information, all of the training that was necessary--this 
individual was an 18-year veteran, and, as I said, there is no 
excuse on that individual allowing that person into the country 
and not referring that person to secondary.
    This situation has nothing to do with staffing. It is a 
clear and blatant disregard, in my opinion, of an individual 
that just decided to make a decision contrary to the 
instructions that was given to him.
    Mrs. Christensen. Thank you, Mr. Chairman.
    Chairman Thompson. Thank you very much.
    We now yield the gentleman from Indiana Mr. Souder for 5 
minutes.
    Mr. Souder. Thank you, Mr. Chairman.
    I first feel compelled to put on the record that while many 
of the agents are the same, the fact is Diana Dean and her 
colleagues at Port Angeles were Customs employees. This 
happened before the creation of the Department of Homeland 
Security that they caught the Millennium bomber. The Department 
has been restructured, and many of us have had concerns. While 
many of the people are the same, they are not structured the 
same.
    Dr. Runge said no advanced medical training and that we 
need more medical training. This was not a question of medical 
training. I mean, it is place mask on subject, place in 
isolation, well-ventilated room if possible. Subject has 
multiple resistant TB, public health risk, contact the public 
health service, and the name of the contact, and then the phone 
numbers to contact.
    As you said, it is a clear violation. This isn't a medical 
knowledge question, this is a question of we have trouble 
catching anybody. If we actually catch them, will we keep them? 
And sometimes I wonder if the Department of Homeland Security, 
rather than right now the top people running around arguing for 
amnesty, they ought to be paying attention to the Department 
itself in securing the border. What you have done in the middle 
of the immigration debate is undermine the American confidence 
that you have control of the border.
    The fact is that TB, just taking that, this isn't unknown. 
I visited a detention center in Florence, Arizona. We have a 
set-aside there at the detention center for people with TB. 
There is a clinic there. We are watching TB on a regular case 
basis.
    Mr. Basham, you said this is a singular failure to enforce. 
Now, before this incident, my understanding is your agency 
showed a tape to my staff and the other staff here on the 
Border Subcommittee that showed agents sitting and waving 
people across the border. And tapes exist, as I know from going 
to the border crossings, and I presume does a tape exist in 
this case as well of this agent?
    Mr. Basham. Yes.
    Mr. Souder. Are you aware of this other tape shown that 
this was not--the other cases weren't a TB case, but not an 
isolated incident. Are you aware of the existence of that tape?
    Mr. Basham. I am not.
    Mr. Ahern. Congressman, the tape that you are referring to 
is something we use as an internal training tape going back to 
last summer. It isolated some areas we needed to improve upon 
with our performance. It needs to be put in its proper context, 
and I believe that was why it was shown to the staff in an off-
line setting.
    We do have a tape of this particular circumstance as well, 
and it was not an instance of anybody waving anyone through. 
There was well over a minute and a half the individual spent 
with the individuals coming across the border. The lookout was 
in the system clearly, and it was a failure to act.
    Mr. Souder. Just like the other people on the tape were a 
failure to act. Can you use the tape to fire individuals not 
only in this case, but in other places where you have this 
tape, you have people waving people through? We have this 
problem, as you know, and we have worked many years in 
narcotics with even agents paid off, that lookouts watch to see 
favorable agents, some who may occasionally be lazy, some who 
may be bought off. We have that problem in the United States, 
not the same problem Mexico has. This isn't impugning the 
character. They are frustrated with lazy or bought-off people 
who are undermining the whole agency.
    The question is can you use the tape to fire an individual 
if you catch them?
    Mr. Ahern. Certainly in the internal investigations work, 
which I won't be able to comment on in this particular 
circumstance, all the evidence will be reviewed in the final 
administrative proceeding of the individual, and it certainly 
could be a critical piece of evidence in that process.
    Mr. Souder. So it is not banned from being used as part of 
a case to dismiss someone.
    Mr. Ahern. I wouldn't know why it would be.
    Mr. Souder. There was a 6-1/2-hour gap until the National 
Targeting Center identified the individual. Could you explain a 
little bit how this works? This person was supposed to go to 
secondary, then the name, if it is a match of a license plate, 
got kicked. Does this mean we will always have like 6-1/2 hours 
until we get tipped off that somebody is headed to an airport 
or has a bomb in their car if the agent, in fact, fails? I 
mean, we are going to have people fail, and your job is to try 
to keep it minimal.
    Mr. Basham. In this particular situation, as we discussed 
earlier, that individual's name--the individual's name went 
into the system on the 22nd and 23rd. The information that we 
had up until the 24th was that the individual, Mr. Speaker and 
Ms. Cooksey, were going to be arriving back in the United 
States on June 5th.
    Mr. Souder. That is not my question. At 6:18:41 the officer 
cleared it without referral, and then at 12:45 a.m., the 
National Targeting Center picked it up.
    Mr. Basham. That is because what the Assistant Commissioner 
was talking about earlier, they instituted sweeps of the system 
beginning on the 22nd to determine whether or not this 
individual chose to reenter the United States at other time or 
another place or in another method. So these sweeps were going 
on about twice a day.
    When they did the sweep at 12:32 in the morning, that is 
when they discovered that Mr. Speaker had entered the country.
    Mr. Souder. So there is not an instantaneous or even within 
an hour that if somebody comes through on a terrorist watch 
list, the agent misses him, it gets into the system, there is 
not a thing that pops up that says we missed this guy, gets on 
it. Twice-a-day sweep is what you are telling me.
    Mr. Basham. Let me have Mr. Ahern address this.
    Mr. Ahern. To put it in perspective, what the National 
Targeting Center was doing was the automated targeting system, 
which has been discussed before this committee before, and it 
is a critical piece of use of systems for us, we were sweeping 
against the airline reservation to find out if there had been 
any modifications to it. ATS being such a valuable system, it 
also pulls in border crossing history as well.
    At that point in time the National Targeting Center, when 
they were doing the ATS sweep, found there had been an entry at 
the Champlain port 6:18 p.m., and this was at 0032 the 
following morning, so there was about a 6-hour difference 
certainly.
    But one of the features we are putting in at the port is 
the ability or the inability for the record to be missed in the 
future. There will not be an ability for the officer to clear 
that record. We are building some additional redundancies that 
we would happy to talk about in further off-line settings 
because they are law-enforcement-sensitive. Please be assured 
we are looking at adding additional measures so we can't have a 
single failure.
    Chairman Thompson. Thank you very much. The gentleman's 
time has now expired.
    Now recognize the gentlelady from California for 5 minutes, 
Ms. Harman.
    Ms. Harman. Thank you, Mr. Chairman. I apologize to you and 
other colleagues and our witnesses for stepping out. 
Unfortunately I had a direct conflict with another committee. 
But I was here to hear your opening statement and to talk to 
the witnesses in advance.
    First let me say that I find it very disappointing that the 
CDC has not yet shown up here. My understanding is that Dr. 
Gerberding was going to be out of town, but her deputy 
accepted, and now it turns out both she and her deputy are 
testifying in the Senate. I think we deserve equal time, and 
one of them should be here now. That empty chair is a visible 
reminder of the fact that CDC has a lot of work to do here. So 
I am very disappointed.
    My impression from talking to the witnesses in advance and 
from the reading that I have done on this matter is that a lot 
of blame is being put on this particular CBP agent who didn't 
do his job well enough, although he was an 18-year veteran. I 
would just like to suggest that the blame game is not a good 
way to handle this, and I did mention that to the witnesses.
    I think we had a meltdown here; not that everything went 
wrong, but that a lot of things went wrong, and this could have 
been much more serious, because had this fellow had a real--and 
he could have--communicable disease--his form of TB apparently 
wasn't communicated to anyone or hasn't been yet, but had it 
been, or had it been smallpox or something else, we could have 
right this minute a national--major national emergency both in 
health terms and economic terms. So I think that the potential 
here is very serious.
    My question to these witnesses is if your sister or your 
wife or your mother had been seated next to Mr. Speaker on this 
airplane going to Europe or his airplane returning to Canada, 
what would you say to them? Would that affect your view?
    Dr. Runge. Congresswoman Harman, it is important to 
understand that in this particular case, the individual left 
the country before anyone knew about it. I would say to my 
family member sitting next to that person, it is unfortunate 
that this person chose to be irresponsible not to comply with 
clear instructions from his doctor.
    Moreover, let me point out that the treatment of TB across 
this country is really based on a relationship between 
physicians and patients and an area of trust. People can 
abscond with an infectious disease any time. So it is 
unfortunate that he was not more forcefully kept from flying in 
the first instance.
    Ms. Harman. I know that is what you feel, but let me just 
take this a step further. Your sister or your mother or 
whomever comes down with some very drug-resistant disease, 
having been seated next to someone who somehow fell through the 
cracks of our system. And you are in the hospital with this 
person who may have a life-threatening disease, and you are 
going to say, gee, sorry, sometimes these things happen, or 
would you say something else?
    Let me just ask the other two witnesses. Would you feel 
differently about it if it personally affected one of your 
close family members?
    Mr. Basham. Well, I certainly would try as best I could to 
explain what happened, and why it happened and that the failure 
for us to stop this individual from traveling is inexcusable.
    Ms. Harman. Thank you.
    Mr. Basham. I can't make an excuse for that. I can't make 
an excuse for us not interdicting this individual when he came 
back into the United States. Obviously this has told us that we 
have got a lot of work to do here. We have got a lot of 
communication that we need to improve upon, as Dr. Runge has 
mentioned before. We are engaged with the CDC. We are engaged 
with the Canadian government now to talk about how we can 
better improve the territorial boundaries of North America. 
This has resulted, in my opinion, in an awakening that we need 
to do a better job. And I am not going to sit here and say that 
the system worked because we know that we can improve upon the 
system. It may have worked the way it was designed at the time. 
But now we recognized it was not good enough, and we are 
working very hard to ensure that that communication that Dr. 
Runge talked about is not at the local level. It does go to the 
national level, that we do put a national response to 
something--an event like this in the future.
    Ms. Harman. Mr. Chairman, my time has expired, but if the 
last witness has an answer I would hope you would accommodate 
that.
    Mr. Ahern. I would be happy to. First, let me answer the 
first question you posed, which is how I would feel. I would 
certainly make sure that if it was a family member of mine that 
they not overreact to something that could or could not be a 
health risk. I would want them to follow the appropriate 
medical care to determine accurately if there is a concern. But 
to your question how would I personally feel, I feel very 
personally concerned with the performance of our frontlines 
people and how this agency performed. I am the responsible 
person for this organization, for our ports of entry. We did 
not execute well enough. So I feel very personally concerned 
with how we performed.
    Ms. Harman. Thank you. Thank you, Mr. Chairman. I 
appreciate that last answer very much.
    Chairman Thompson. Thank you very much. And I would like to 
comment on Ms. Harman's reference to Dr. Gerberding. If in fact 
she is held over at the Senate, we will in all probability 
recess the hearing and reschedule it in as fast a time as 
possible so that the committee can get the benefit of the CDC's 
testimony as we look at this overall issue.
    I would like to recognize the gentlelady from Florida for 5 
minutes, Ms. Brown-Waite.
    Ms. Brown-Waite. Thank you, Mr. Chairman, and I certainly 
thank our panel for being here. It is very easy to do Monday 
morning quarterbacking. And when I first heard about this 
story, I remembered that when I was very young my father had 
TB. He was in a sanitarium at that time. We took TB very 
seriously. And for this to happen I think indicates that the 
American public still should not feel that safe with our 
current system. I have a couple questions about the person who 
actually pressed the clear button. And, you know, when I come 
to a red light or a stop sign, I wish I had that clear button. 
Or when the officer, you know, stops me if I am going a little 
too fast, I wish I had had a little button I could press that 
says, it is OK. Her speeding was acceptable. How close to the 
end of the employee's shift did this happen? And what is the 
average workweek for those officers who are screening the 
incoming passengers?
    Mr. Basham. The actual contact occurred--I believe it was 
at 6:18 in the evening. And it is my understanding the 
individual was on the 4:00 to midnight shift. So this was early 
in this individual's shift. And so any indication that this may 
have been fatigue-driven, and it is my understanding that it is 
not an inordinate workweek. They are not working 80 hours a 
week. They are working a normal 4:00 to 12:00 shift, generally 
speaking, unless there is a need for coming in on a day off. So 
6:18 and 2 hours into a shift.
    Ms. Brown-Waite. I appreciate that information. But you 
still didn't answer my question as to how much overtime this 
person had before that day.
    Mr. Ahern. We haven't looked at the entire workweek 
schedule of how many hours he had actually worked in that 
entire week, whether it was overtime or just his regular 40-
hour shift. We certainly would provide the detail after the 
hearing. It is a question for the record. We would be happy to 
answer if you would like that.
    Ms. Brown-Waite. OK. And for probably Dr. Runge, how 
effective is the no-fly list at stemming international spread 
of disease when only airlines that have the U.S. as the final 
point of arrival participate in that?
    Mr. Runge. It is my understanding--
    Ms. Brown-Waite. Would you turn on your microphone, please?
    Mr. Runge. It is my understanding that--well, in fact when 
we discussed this with the chief of intelligence for TSA--and 
he has been around quite a long time--we could not remember 
another case that someone who has been put onto what they have 
as an adjunct to the no-fly list for health reasons. So we have 
no history in this regard. This was in fact a novel case. 
Speaking hypothetically, the fact that information is shared 
only with those airlines that do have connection into the 
United States, it varies among airlines. Some airlines actually 
put it into their entire system so that if there is only one 
flight into the U.S., that they receive the information, it 
goes into their entire record. Others only control the certain 
flight that goes into the U.S. So it is variable.
    Ms. Brown-Waite. I appreciate that answer. One final 
question and probably, Dr. Runge, it would be addressed to you 
but if anyone else wants to jump in, please feel free to. The 
revised international health regulations which were actually 
adopted in 2005 will not be enacted I understand until some 
time next week. They actually strengthen the authority of the 
World Health Organization and the national public health 
authorities in providing for more coordinated international 
responses to infectious disease outbreaks, including the 
detection and control of for example TB in this case. Can you 
tell me if these revised regulations would have changed what 
occurred in this case? And could they possibly have altered the 
course of events?
    Mr. Runge. I do not believe that if they had been enacted 
sooner it would have in any way changed this course of events. 
The responsible party for the notification of the W.H.O. is the 
Department of Health and Human Services. They are through their 
operation center here in Washington. It is my understanding 
that they did in fact report this case under the IHR even 
though the--sorry--the international health regulations have 
not gone into effect yet.
    Ms. Brown-Waite. And they are going to go into effect next 
week, that is correct?
    Mr. Runge. I thought it was June 15. I saw another 
reference that is July 15. But we will nail that down. We have 
a task group at DHS that is in my office that is pulling people 
from CBP and TSA and Policy to look at how we are going to 
implement our responsibilities under the IHR and that that 
process is ongoing.
    Ms. Brown-Waite. And let me just also comment that I 
believe that the new procedures of having a supervisor also 
review whether or not someone should come into the country if 
they are on the watchlist is an excellent one. And I am sorry 
that it took this situation for the Department to set that up. 
But certainly you were quick to act, and we appreciate that.
    Mr. Runge. Thank you.
    Ms. Brown-Waite. Thank you. And I yield back my time, Mr. 
Chairman.
    Chairman Thompson. Thank you very much.
    Dr. Runge, one of the questions that continues to haunt 
this whole issue is why TSA waited so long in its deliberation 
as to whether or not they could or could not do it. Can you 
share with the committee any knowledge you have of that 
deliberation?
    Mr. Runge. Yes, Mr. Chairman. The Acting Deputy 
Administrator for TSA actually made the decision within about 2 
hours after we received the name from the CDC. There were some 
issues--because the person is not a terrorist, there were some 
issues as to how he could be entered physically on the list. 
And there was a conference of lawyers taking place from the 
Department of Justice and the Department of Homeland Security 
and TSA, and possibly others, to make sure that the authorities 
that the Department has--and TSA knew that it had to enter 
someone on the no-fly list even though they were not a 
terrorist--were in fact able to be followed. And so I believe 
we received the name from the CDC around 3:30 in the afternoon 
and by 5:30 the Deputy Administrator had made the decision. At 
7:30 or so the electrons began to flow out from the Office of 
Intelligence to all of the airlines and all of the points of 
information sharing that TSA has.
    Chairman Thompson. Thank you very much. And I think you 
referenced 2 hours. But if we look at the timeline I think it 
is 4 hours before an ultimate decision was reached in this 
entire process by TSA.
    Mr. Runge. TSA actually reached the decision within 2 
hours. It took the confab of lawyers from the other departments 
a while to become comfortable with that, and in fact he was 
added at about 7:30. So that is where the 4 hours--
    Chairman Thompson. Another 2 hours.
    Mr. Runge. Right.
    Chairman Thompson. All right. OK. And I will yield to the 
gentleman from Pennsylvania, Mr. Carney, for 5 minutes.
    Mr. Carney. Thank you, Mr. Chairman. I would like to thank 
the panel for attending. I wish Dr. Gerberding was here, but we 
will proceed as we can. Please forgive my ignorance on this 
one, Mr. Basham, but what was the border guard's explanation 
for this incident?
    Mr. Basham. Without trying to get into the specifics of 
what this individual's reaction may have been, I can just say 
that he apparently made the determination that the information 
that he read was inaccurate, was not accurate, and that he 
looked at the individual and decided the individual didn't look 
sick.
    Mr. Carney. Did the individual--did Mr. Speaker say, hey, I 
am not sick, this is wrong?
    Mr. Basham. It was never--the question was never raised as 
far as we know, Jay, with Mr. Speaker. And in fact it is to my 
understanding Mr. Speaker said we are on a mini vacation up in 
Canada and we are returning to the United States from Canada.
    Mr. Carney. Mr. Ahern?
    Mr. Ahern. I would add at this point there has been a very 
active internal investigation. There have been sworn affidavits 
taken. The individual is afforded a certain amount of privacy 
in that process. And we need to let the process unfold. 
Unfortunately, I don't think we can get into a lot of the 
details of what was said in that encounter. I know it has been 
reviewed by internal affairs, by senior management, it has gone 
before a discipline review board and appropriate action will be 
followed up on. I think we cannot discuss further, certainly in 
this forum, the particular details of what was actually the 
conversation or primer.
    Mr. Carney. I look forward to reading the report when it is 
available to us.
    You know, it seems that we pick up lessons learned in this 
sort of thing after an event. Now, we don't have lessons 
learned or the plans in place to anticipate these things. How 
often does the CDC and DHS and TSA actually train for these 
kinds of things, hold training exercises?
    Mr. Runge. It is interesting that you raise the question, 
Congressman Carney. We actually are engaged deeply in a 
planning process right now on border management during the 
pandemic. So we have put together a multi-agency team, actually 
including the Association of State and Territorial Health 
Officials, the Association of City and County Health Officials 
and others we know are going to have to help in this instance 
to decide on roles and responsibilities in managing these 
border issues during a pandemic. Now, I have to say, even that 
effort would not have contemplated this particular instance. 
However, this is what--a lesson learned, I guarantee you this 
is a lesson learned, not just a lesson observed. We have taken 
steps to make sure that the information does not simply reside 
at the local field office level but gets up to where it can be 
coordinated across the agencies.
    Mr. Carney. So in other words, you haven't trained on this 
yet?
    Mr. Runge. That--well.
    Mr. Carney. Say, for example, we get a suicide biological 
bomber instead of a C4 dynamite bomber. We haven't trained to 
that sort of thing at all?
    Mr. Runge. A procedure would be put in place in that 
instance where if the individual is known, yes. There is ample 
training on that issue, and the American public deserves to 
have that person intercepted. You know, again, with that sort 
of information, if it is a person who we don't know who it is 
and when they are coming and so forth, then the intelligence 
community works with the Customs and Border Protection and CIA 
and FBI, and so forth, to try to set up a risk-based algorithm 
to deal with a situation like that. But yes, that is absolutely 
trained.
    Mr. Carney. Have there been training exercises prior to 
this event for something similar to this?
    Mr. Ahern. We need to do more training. We need to do some 
more exercise clearly. And I think we have got that process, as 
Dr. Runge outlined. But I think one of the important things I 
would suggest for your consideration is these individuals knew 
each other, the CDC official and the CBP official in Atlanta. 
They are actually collocated in the office suite. They were 
able to walk in because of their interaction, not only in this 
exercise but on a daily basis to be able to know that we do 
have a situation for border lookouts that could be used to go 
ahead and identify concerns and also to look for flight 
reservations. We have that through our MOU within DHS and HHS. 
That is an ongoing process. Certainly as we now take a look at 
this after the fact, we need to take a look at doing more 
planning and more exercising, more preparation work for these 
types of things. I think certainly we do. Those would be much 
more applicable in a broader national event. This is a good 
opportunity for us to go back and learn.
    Mr. Runge. With your particular concern about TSA, the fact 
that it took us a while to make sure that everybody was legally 
OK speaks to the fact that no, we had not rehearsed this.
    Mr. Carney. Right. That was my point exactly. Thank you, 
Dr. Runge. I yield back, sir.
    Chairman Thompson. Thank you very much. We yield 5 minutes 
to the gentleman from Connecticut, Mr. Shays.
    Mr. Shays. Thank you. Dr. Runge, your comment, the person 
was not a terrorist. Would it be inaccurate for me to say that 
he was a potential walking biological weapon?
    Mr. Runge. I would not characterize him that way.
    Mr. Shays. Why not?
    Mr. Runge. Well, if we speak to this person directly, you 
know, TB is transmissible. We don't worry about it on flights 
that are less than 8 hours. We don't worry about it with casual 
contact. I think that would be a little hyperbole.
    Mr. Shays. So then why did you have a warning? Place mask 
in on subject. Place in isolation or ventilation room if 
possible. Subject has multiple resistant TB, public health risk 
and so on.
    Mr. Runge. Yes. That is the prudent medical action to take 
with anyone who is identified as having active TB.
    Mr. Shays. So this is all hype that was generated by the 
press?
    Mr. Runge. I do think that ordinarily this type of case 
would have and most likely is on a more--these cases are dealt 
with without CNN, without Fox News, without the involvement of 
the networks every day.
    Mr. Shays. I don't understand your comment. They are dealt 
without--what is your point?
    Mr. Runge. Well, the point is that the way this would 
ordinarily play out is that the individual is identified. If 
there are people who are at risk of transmission, the CDC--
epidemiological intelligence officers go through a very 
specific format.
    Mr. Shays. --think this was a contagious.
    Mr. Runge. No, sir. Let me finish, please. They go through 
a very specific set of protocols in order to find the contacts 
by phone by next of kin. They do epidemiological tracing. TB 
takes months to play out. So contact tracing here was not an 
emergency. So I don't want to respond to your characterization 
of hype, but I believe that this could have been done in fact 
without it being in the press.
    Mr. Shays. I don't understand that for the life of me. So 
we shouldn't have notified folks in Europe because this man was 
not a threat? Was he a threat or wasn't he a threat?
    Mr. Runge. We believe that he was an infectious disease 
threat to those on the flight who were sitting within a few 
rows.
    Mr. Shays. I just have to tell you, if I was on that flight 
and I heard your response, I would be absolutely outraged. I 
have a lot of--if I could have made the comment in the opening 
statement, I would have said congratulations, DHS. There were 
three or four bombings in Thailand by Muslim terrorists. We 
don't have any around. You guys are doing a good job. But you 
have a few weaknesses. So I was in the mindset when it came to 
this hearing to say, you know, you guys deserve to be 
congratulated. When I hear your response now, I am thinking 
there is a huge disconnect. And maybe it is my problem or maybe 
it is DHS's problem. The bottom line is, if I was on that 
plane, if my daughter was on that plane, if my wife was on that 
plane, frankly, I would find it outrageous that he was on the 
plane. And I would find it outrageous that somehow even this--
you know 2 hours there and another 2 hours, I mean it is like--
it is like there is--we are talking like this, and I am pretty 
unhappy that the Centers for Disease Control isn't here. It 
would have been helpful because what I am trying to understand 
is, is this a contagious disease and should this person have 
gone over to Europe? The answer should be no, correct?
    Mr. Runge. That is correct.
    Mr. Shays. Why? Because he was potentially carrying a 
contagious disease. Now I don't care, frankly, if it is a 
terrorist carrying the contagious disease or a citizen who 
doesn't give a darn about anybody else. I would treat them 
frankly the same way because the result could be the same way. 
Tell me what is wrong with my logic.
    Mr. Runge. Actually with that part of your logic absolutely 
nothing. In fact to characterize it that way is perfectly fine. 
In fact, local health authorities have the authority to stop 
someone from traveling. They have the authority to in fact 
confine someone.
    Mr. Shays. Why did he go to Canada instead of fly right 
into the United States?
    Mr. Runge. That is not an appropriate question for me, sir.
    Mr. Shays. Well, he did go to Connecticut. That is--I mean 
he did go to Canada, correct?
    Mr. Runge. Yes. We assume--
    Mr. Shays. And the place that he wanted to get to was the 
United States.
    Mr. Runge. Yes. We assume it was for the purpose of 
evasion.
    Mr. Shays. Absolutely. And so he made it--and so I 
congratulate DHS on the ability to stop people flying into the 
United States. So that is a plus, not a negative. The guy 
thought he had to go to Canada. Now, that raises a heck of a 
lot of concerns. But he knew that what he was doing was wrong. 
He knew that he was carrying a potentially contagious disease, 
and frankly the way I look at it was he was a walking 
biological weapon. And I would like our people to think that 
way when we have citizens who are willing to endanger others. 
That is the way I would like them to think.
    Thank you.
    Chairman Thompson. Thank you very much. We yield 5 minutes 
to the gentleman from North Carolina, Mr. Etheridge.
    Mr. Etheridge. Thank you, Mr. Chairman. And I would like to 
associate myself with the comments of my colleagues and 
especially the gentleman from Connecticut. Let me follow that 
line of questioning a little further because the Washington 
Post has characterized Mr. Speaker's actions and the Federal 
response as a bizarre cat-and-mouse game. I am inclined to be a 
little bit more concerned than that, I guess, and a bit more 
critical because we now know he was a known carrier of an 
extensive drug resistant tuberculosis. He leaves the United 
States. He travels across to Europe. It is now apparent that he 
intentionally or it appears that he intentionally meant to 
evade. You said earlier that we couldn't track if he changed 
from one airline to another and made a change. And I do hope 
that is being corrected or has already been corrected. Because 
if I make a reservation on an airline to travel from point A to 
point B and I change my reservation, they know it, the airlines 
know it. My question is why don't we know it and why can can't 
we deal with it?
    second, the efforts to put him on a no-fly list and an 
actual border alert that apparently a person at the border 
ignored the information. It is reported in the press--and I 
would like to hear your response on this because this really is 
your area of jurisdiction. He said he didn't look sick. The 
last time I checked, that is not the job of a border agent. 
They are not medical officers. If you get an order you are 
supposed to follow it out.
    So my question is this, because he either didn't know what 
he was supposed to do or he wasn't following the protocol that 
you are supposed to provide or we hadn't given him the 
information. So the CDC and the TSA and the CBP determined what 
your statutory capacity of doing in the public health, had we 
looked at, what we are going to do in the future. We can't 
correct what has already happened. I recognize that. My 
question is, have we dealt with the problem so that we won't 
have that kind of problem in the future? And second, how are 
emergency response plans being modified in response to what you 
have learned from this incident? Because as Mr. Shays said, 
this person could very well have been a walking biological 
problem. If he got through in this situation my grave concern 
is, the response and the responsibility we have, I fly a lot, 
as do many of my colleagues and people across this country. Now 
they check me when I go to the airport to see if I am carrying 
a nail file, if I am carrying a bit too much gel--I flew last 
week. They took my hair spray and my hair gel and my 
toothpaste. Somebody needs to make sure when I got on that 
plane that the people are safe and that is our problem. So I 
would like to hear your comment on that, please.
    Mr. Basham. If I could just address your first point on 
knowing whether Mr. Speaker changed airline reservations.
    Mr. Etheridge. Yes, sir.
    Mr. Basham. That was the very purpose for the sweep that 
the National Targeting Center was conducting on a daily basis 
to determine whether or not Mr. Speaker did not intend to come 
back on June 5 on the Air France flight but that if he changed 
his reservation, the sweeps we were doing would have picked up 
that information and so we could have notified the proper 
ports. So that system now--in terms of foreign carriers.
    Mr. Etheridge. You are just sweeping for him coming 
directly to the States?
    Mr. Basham. Let me ask Jay to answer that.
    Mr. Ahern. The current reservations were for flights 
destined to the United States or any modifications from that 
existing record. If the individual completely books an entirely 
different record with another airline that is not destined for 
the United States, we are blind to that and that is not looked 
at.
    Mr. Etheridge. Is that being looked at to be fixed?
    Mr. Ahern. We are looking at that. We have a got lot of 
negotiations going on with the European Union.
    Mr. Etheridge. Do you have a timeline for that?
    Mr. Ahern. It is going to take very intensive negotiations, 
legal issues, sovereignty issues, and we have to take a look at 
privacy concerns as well.
    Mr. Etheridge. And the safety of passengers on those.
    Mr. Basham. I will comment, Mr. Congressman, in fact that 
we are working as we speak with our Canadian counterparts, and 
the Secretary or the DHS is going to be discussing this issue 
with them in--I think this month or on a trip up there on this 
issue of trying to secure the territorial borders of North 
America. So it is--
    Mr. Etheridge. North and south.
    Mr. Basham. Yes. Yes.
    On your second point, fixing it. I believe Dr. Runge did 
mention earlier in his comments that working with DHS and the 
HHS--and I will let you expand upon that. Now in terms of your 
CBP, we have instituted after this event processes that are now 
in place that would not permit an officer at the port of entry 
to clear an individual who is a name match. That has to go, 
automatically has to go to a secondary for further inspection. 
And then in terms of their emergency response, I am going to 
let Dr. Runge address that.
    Mr. Runge. Congressman, so I understand, the question is 
about how the interaction takes place at the border between 
health authorities and CBP?
    Mr. Etheridge. Yes, sir.
    Mr. Runge. There are around 18 or 19 quarantine stations 
that exist at the busiest ports of entry that are manned in 
fact by CDC quarantine officers from the Division of Global 
Migration and Quarantine, and they are on call for CBP officers 
who see someone who does not look right and there have been, 
you know, hundreds of referrals in that situation. For those 
ports of entry where there are not CDC officers stationed, 
there are memoranda of agreements with local public health and 
local health authorities that if a CBP officer doesn't like the 
way someone looks or if he has a rash that looks like smallpox, 
if he is bleeding from his eyes in the case of a hemorrhagic 
fever they will refer them to secondary, put them in isolation 
and adhere to those protocols of calling public health, and 
emergency responders are a part of that as well.
    Mr. Etheridge. Mr. Chairman, my time has expired. I hope 
someone will follow up on the question as it relates to that 
protocol though for the person who has a known record and still 
gets through.
    Mr. Runge. We will be happy to discuss that with you.
    Chairman Thompson. Thank you very much. I would yield for 
the sake of the question to the gentlelady from California, Ms. 
Harman.
    Ms. Harman. I thank you for that, Mr. Chairman. As you 
know, I chair our Intelligence Subcommittee and I heard the 
exchange between you and Dr. Runge and I don't think our record 
is clear without asking one more question here. You were asking 
him whether TSA made an effort to include Mr. Speaker's name on 
the terrorist screening database, and I think the response was 
that you spoke to Charlie Allen--not mentioned by name--the 
head of the intelligence.
    Mr. Runge. This was TSA intelligence.
    Ms. Harman. OK. So it was TSA intelligence, so it wasn't 
Charlie Allen. You spoke to TSA intelligence and this was a 
first-time problem but my question--and I think it needs to be 
answered for the record--is if you did put his name on the 
terrorist screening database, was this an appropriate use of 
that database?
    Mr. Runge. Congresswoman Harman, we will get back to you on 
the specifics of that. We should let TSA answer the specifics 
of the question. But I can tell you that--since Secretary 
Hawley has been very careful to say this was an adjunct to the 
no-fly list. So there is not a requirement that he has to be on 
the terrorist screening database, but that in fact the TSA 
Administrator has the authority to add someone to the no-fly 
list for other reasons. But he would prefer to characterize it 
as an adjunct to the no-fly list. If the counselor behind me is 
nodding, I am very happy.
    Ms. Harman. I think we should get that question carefully 
answered for our record, Mr. Chairman, because it does matter 
how this is done. All of us wanted this guy to be stopped. But 
what tools are used is very relevant. Thank you, Mr. Chairman, 
for taking my question out of order.
    Chairman Thompson. And I assure you we will make sure the 
Department has an opportunity to respond. We will now recognize 
the gentleman from Florida, Mr. Bilirakis, for 5 minutes.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it 
very much. Mr. Basham, again can you tell us what the status of 
the officer is currently?
    Mr. Basham. As Mr. Ahern stated a few moments ago, that 
officer is currently on administrative leave and we are in the 
process of doing a thorough investigation of the actions of 
that day by all parties. And at this time I am afraid I can't 
state exactly what his current status is.
    Mr. Bilirakis. OK. You mention in your testimony that this 
situation underscores the need to implement additional fail-
safe mechanisms. Elaborate on that, if you will, please.
    Mr. Basham. I am going to ask Mr. Ahern if he will address 
that.
    Mr. Ahern. I think one of the things we talked about with 
many of your staffs on Monday this week, we talked about some 
of the fixes that were going in place. In this open setting 
here I am frankly not comfortable with talking about some of 
the law enforcement system enhancements and redundancies we 
will be taking to our systems and have been made effective 
midnight Monday evening. We would be happy to go into great 
detail and show those to you and show you the screens as they 
existed on this particular account, show you the video that 
occurred. But in this setting I am frankly not comfortable 
talking about the specific fixes to the law enforcement 
databases that we have. I regret that.
    Mr. Bilirakis. It is my understanding that a text message 
appeared on the CBP officer's computer screen but no alarm 
sounded. Alarms apparently only sound when a person is armed or 
considered dangerous. Isn't one man with an infectious 
potentially as dangerous as one man with a gun, shouldn't there 
have been a real alarm instead of a text advisory?
    Mr. Basham. I think the question of the degree of threat 
with respect to disease or with a weapon, the alarm on a person 
who is armed and considered dangerous is for safety purposes 
for the officer that is at--it is to notify the people 
basically and secondary that they need to respond. That doesn't 
mean the person is going to use the weapon. But the idea there 
is the safety of the officer and the people that may be there.
    In terms of whether the gun is more--is less a danger than 
an individual with an infectious disease, Dr. Runge, I guess I 
am going to have to ask you to comment on that.
    Mr. Runge. I am not sure. We don't have any data on the 
relative danger of somebody who is armed and dangerous versus 
somebody with tuberculosis. that is a really tough question to 
answer. I would say that the danger to the officers is clearly 
more imminent by somebody who has a gun than somebody who has 
an infectious disease almost no matter how infectious it is. 
And that would be a call for CBP management. Certainly we would 
be happy to weigh in with scientific data on relative risk, and 
we will play however they want to but that is an administrative 
call.
    Mr. Ahern. If I might add to that a little more from the 
operator's perspective, certainly we need to make sure as well 
over 400 million people come into this country every year, over 
300 of which come across our land borders from Canada and 
Mexico. What we need to make sure is that we are assessing risk 
appropriately and engaging appropriately. I would submit that 
as we go forward with our system change, we need to be very 
thoughtful in how we deploy those changes so that we don't have 
complete chaos with unnecessarily alarming people for the 
immediacy of executing a threat which I would submit to you 
that a weapon would versus certainly the deadly aspect of 
someone having an infectious disease could have that certain 
end game but the immediacy of engaging and having officer 
safety, public safety in that immediate area, I believe we need 
to assess those risks on a different tiered basis. Some of 
those thoughtful things are in place. We are going to enhance 
those even further with some of the changes we would be happy 
to talk further with you.
    Mr. Bilirakis. Thank you, Mr. Chairman. It is my hope that 
the Department will be more proactive instead of reactive based 
on this occurrence in the future.
    Thank you.
    Chairman Thompson. Thank you very much. One thing I want to 
make sure we get on the record is the system before this issue 
we are discussing today occurred, is it that when an individual 
who was put on the screen, that that notice would only hit on 
that screen and there was no backup?
    Mr. Basham. Are you asking the alert, whether it was only 
on that screen?
    Chairman Thompson. The alert.
    Mr. Basham. When that individual's name matched the name 
that was on the alert, that notification also goes on a screen 
in secondary. And then it is the determination of that 
frontline officer as to what action they are going to take with 
respect to that individual. So it appears on the primary 
screen, but it also is--there is a message at the bottom and, 
Jay, maybe you can explain it in more detail. But there is a 
message at the bottom of the screen in secondary saying there 
had been a name match at that particular point.
    Chairman Thompson. Mr. Ahern?
    Mr. Ahern. The Commissioner explained it very accurately 
and those are some of the additional enhancements that we will 
be bringing to the system as we go forward that will explain in 
great detail.
    Chairman Thompson. The question going to--maybe it is not 
an alarm. But if there is already a secondary backup to this 
system, was it not timely enough to still catch this individual 
at the border? Is that not the reason for a secondary 
notification?
    Mr. Ahern. Enhancements need to be made on that front and 
those are some of the fixes that we are putting in place, sir.
    Chairman Thompson. Well, can you tell me--that secondary, 
are you looking at that secondary employee too?
    Mr. Ahern. We are looking at the totality of all the 
circumstances, all the facts and all the individuals.
    Chairman Thompson. OK. Well, let me be a little more 
specific. The guard is on administrative leave for whatever 
reason pending an investigation. We now have testimony that 
there was a backup to the system, a secondary notification. 
Now, are we looking at the individual--is that individual who 
was responsible for viewing secondary notifications, is that 
person on administrative leave?
    Mr. Ahern. We are looking completely at the entire set of 
facts as one individual that is on administrative leave at this 
point as we continue to do our internal investigation.
    Chairman Thompson. You know, I am--
    Mr. Basham. The answer to your question, Mr. Chairman, is 
that person--no one else other than Mr.--the officer at primary 
is on administrative leave at this point.
    Chairman Thompson. But there are other individuals who 
should have been notified simultaneously of that hit?
    Mr. Basham. That is exactly what Mr. Ahern is referring to, 
as we are looking at all of the actions on that day and who 
failed to perform or who did perform and how they performed.
    Chairman Thompson. Well, and back to some other comments 
about the blame game. You know, we put a lot of things on this 
one guard at the border. But now it appears that there are some 
other people along the way on this one particular instance that 
should be in the same boat. And what I would--at some point 
either in a classified briefing or what have you, would like to 
follow up on Mr. Bilirakis' line of questioning because he kind 
of previewed my inquiry based on that.
    I now yield 5 minutes to the gentleman from Colorado, Mr. 
Perlmutter.
    Mr. Perlmutter. Thank you, Mr. Chairman. And I guess after 
listening to this testimony and reading your remarks, reading 
the timeline, I mean the good news here, this was a comedy of 
errors and not a tragedy of errors. I mean, this is about as 
close to a real-life test, and it really was a test as 
anything. You know, but what it illustrates is a number of 
vulnerabilities in our system. Here is a couple, understandably 
scared by their potentially dangerous situation. In fact, Mr. 
Speaker's remarks to the press, I guess, people told me if I 
was anywhere but Denver I will die. So they are going to try to 
find a way to get him--or he is going to try and his wife is 
going to try to find a way to get him to Denver, some fashion 
or another. And here is a couple, you know, without--they are 
sort of on the innocent side of the continuum as opposed to 
somebody who wants to come into our country and intentionally 
do us harm through a medical kind of device or you know an 
illness or a gun or something like that. And I mean this just 
shows some very serious problems. I mean we have been picking 
on you two from, you know, the border guard, the CBP. You know 
quite frankly I think the medical side of this. I am angrier at 
the medical side, and I am generally a pretty charitable guy.
    I am going to ask a couple questions. Very happy that we 
busted the JFK kind of a system. But you know there are spy 
novels out there that talk about people coming across with an 
Ebola type of a virus or somebody being infected, you know, and 
that is how they are going to do our country harm. We had an 
opportunity to save other countries, you know, a lot of 
aggravation by keeping Mr. Speaker in our country and sending 
him to Denver and then we had the opportunity to keep him out 
of the country, and we failed on both counts. This is a 
rhetorical question, and I appreciate Dr. Runge's comments 
about hyperbole in the rhetoric. But in this instance we 
really--this is bad news. This is, you know, in the War on 
Terror, we are asking our homeland security community to play 
ball in the big leagues, and this was T-ball and we still 
struck out. We couldn't communicate with our friends in Greece, 
Italy or Canada in a timely fashion. So, you know, what does 
this incident say about our efforts in the broader war on 
terror? And I guess, Mr.Basham, I am going to turn it to you 
first and then I would like to hear from the doctors on this.
    Mr. Basham. Mr. Congressman, let me just say that in the 
war on terror, and without getting into detail in this 
particular forum, a whole different set of protocols and 
processes are in place and would have been in place. So to 
compare this particular incident with our ability to deal with 
a terrorist I think perhaps is not a fair way of looking at 
this incident.
    Mr. Perlmutter. And let me tell you why I put it in that 
frame. Recently in Colorado the TSA has a red team. OK. And 
their red team goes in and it is designed to test the system, 
to see where we are vulnerable or where we are not, where we 
have solid defense. And really it is about a con game. Who can 
get through the human element, you know, who can say, geez, I 
am, you know, I am Andrew Speaker. I am a lawyer from Atlanta. 
I am just a regular guy. I am not sick. You know, and you get a 
contact with him and then you have a contact with his wife and 
both of them somehow talk their way through that. That is how 
the red team works when it tries to get through our airport 
systems. And so I don't want people to have to be robots. You 
know, and I want them to be able to use their discretion and 
their talents. But here, you know, something really went awry 
down at CDC. The father-in-law is involved with CDC, there are 
comments from CDC sort of slowly winding their way. I mean we 
had--there were like 10 places to stop this guy, and every one 
of them failed. So it is not the war on terror but, boy, it is 
a good test of the system and we didn't do a very good job and 
you have admitted that.
    I would like to talk to Dr. Runge and Dr. Gerberding to see 
what your reaction is.
    Mr. Runge. If I could make one point, Congressman 
Perlmutter, and that is you bring up the information of systems 
that need to be in place so that these sorts of human errors or 
human faults can't enter in and torch the rest of the system. 
And this is a good chance to talk about information sharing 
with our partners. Secretary Chertoff was in Europe last week 
discussing the issue of sharing passenger name records. I think 
we share a goal to do more efficient connections between the 
Advanced Passenger Information System with Canada. Certainly 
you know if you say here's the reaction, here's an ideal world, 
certainly if they had access to the records that CBP put forth, 
the person would have been interdicted in Montreal and wouldn't 
have had an opportunity to come across the Lake Champlain 
border.
    I want to associate myself with your comments. Yes, we need 
better systems in place and yes, we need better international 
cooperation with our partners, and that is well known by our 
leaders.
    Chairman Thompson. Thank you very much. Before Dr. 
Gerberding has an opportunity to answer, I would like to ask 
unanimous consent to have her written testimony entered into 
the record for the committee's benefit. Thank you. Dr. 
Gerberding, welcome.
    [The statement of Dr. Gerberding follows:]

           Prepared Statement of Julie L. Gerberding, MD, MPH

    Good morning, I am Dr. Julie Gerberding, Director of the Centers 
for Disease Control and Prevention within the Department of Health and 
Human Services (HHS). Chairman Thompson, Ranking Member King, and other 
distinguished Members of the Committee, it is my pleasure to be here to 
discuss with you HHS/CDC's ongoing investigation of a U.S. traveler 
recently diagnosed with extensively drug resistant tuberculosis.
    Before I begin to describe the specifics of this investigation, I 
wanted to briefly provide some background information on tuberculosis 
(TB) and the drug-resistance of TB.

Definition:
    Tuberculosis is an airborne infectious disease that is spread from 
person to person, usually through coughing, sneezing, speaking, or 
singing. In the late 19th and early 20th centuries, until the 
introduction of streptomycin in the 1940's, TB was one of the leading 
causes of death in the United States. Currently, the World Health 
Organization (WHO) reports that one in three people in the world are 
infected with dormant or latent TB. TB is a slow growing bacterium that 
often takes weeks to culture. Only when the bacteria become active do 
people become ill with TB. Bacteria become active as a result of 
anything that reduces the person's immunity, such as HIV, advancing 
age, or some medical conditions. TB bacteria can also become active in 
individuals that are not immunocompromised. Currently, TB that is not 
resistant to drugs can be treated with a six to nine month course of 
``first-line drugs' (the most effective), including isoniazid and 
rifampin; this treatment cures over 95 percent of patients. However, 
since people in many resource-poor countries lack access to appropriate 
treatment, nearly nine million people in the world develop TB disease 
each year and about 1.6 million die.
    TB that is resistant to at least isoniazid and rifampin is called 
multidrug-resistant (MDR) TB. MDR TB requires treatment for 18-24 
``second-line drugs'' that are much less effective, often poorly 
tolerated by the patient, and far more costly. The cure rate is 70-80 
percent under optimal conditions, but is usually closer to 50 percent. 
Many countries with a high TB burden find it impossible to treat MDR TB 
patients because of the cost of second-line drugs, and the more 
sophisticated laboratory services to diagnose resistance to drugs, and 
more intensive programmatic support required to administer the drugs. 
Extensively drug-resistant TB (XDR TB) is a subset of MDR TB caused by 
strains of bacteria that are resistant to the most effective first--and 
second-line drugs. Reported mortality rates among persons with XDR TB 
are extremely high. Among non-immunocompromised persons, reports 
indicate that less than 30 percent of patients can be cured, and more 
than half of those with XDR TB die within five years of diagnosis. 
Among immunocompromised persons, illness is more severe, and mortality 
rates are even higher and death occurs within a shorter time.
    The risk of transmitting any type of TB can depend on several 
factors, including the extent of disease in the patient with TB, the 
duration of exposure, and ventilation. Both regular TB and drug-
resistant TB bacilli become aerosolized when a person with TB disease 
of the lungs or throat coughs, sneezes, speaks, or sings. These bacilli 
can float in the air for several hours, depending on the environment. 
Persons who breathe air containing these TB bacilli are at risk for 
becoming infected.

Scope of the Problem:
    In response to anecdotal reports from physicians who were finding 
cases of TB that were unresponsive to the first-line and second-line TB 
drugs, in 2005 HHS/CDC and WHO jointly conducted a survey, with support 
from the U.S. Agency for International Development, which examined 
about 18,000 patient specimens tested during 2000 to 2004 by 
Supranational Reference Laboratories. Researchers examined the drug-
resistant isolates, and found that 10 percent of the MDR TB isolates 
actually met the definition for XDR TB. XDR TB was identified in 17 
countries from all regions of the world, most frequently in the former 
Soviet Union and other Asian countries. However because many countries 
do not routinely test all isolates for resistance to second line drugs, 
the precise global incidence of XDR TB remains uncertain. Because of 
the ease with which drug resistance can occur (due to the use of 
second-line drugs in suboptimal conditions, changes in program focus 
away from TB case management, interruptions in drug availability 
because of supply management/resource availability/patient drug 
noncompliance, high HIV prevalence), XDR TB could be much more 
widespread than this survey shows. The ability of the disease to 
develop resistance to treatments and to travel easily across borders 
makes worldwide TB control efforts critical.

TB and the Threat to the United States:
    Between 1993 and 2006 in the United States, there were 49 cases of 
XDR TB reported to HHS/CDC. By comparison, 13,767 TB cases (a rate of 
4.6 cases per 100,000 persons) were reported in the United States in 
2006 (the most recent year of aggregate annual reporting). The 2006 TB 
rate was the lowest recorded since national reporting began in 1953. 
While the total number of MDR and XDR TB cases is relatively small, 
their impact on U.S. TB control programs can be significant in terms of 
human capital and financial resources. One patient with MDR or XDR TB 
requires a minimum of 18-24 months of treatment. Recently collected 
data show that in-patient costs alone can average $500,000 per case.
    XDR TB continues to be widely distributed geographically abroad and 
is cause for public health concern in the United States, though the 
overall domestic risk of XDR TB currently appears to be relatively low. 
However, due to the ease with which TB can spread, and given its 
significant health consequences, XDR TB will continue to pose a serious 
risk to the U.S., as long as it exists anywhere.

TB Prevention and Control: Public Health Partnerships in Action
    Generally, TB is a condition that is detected and treated by 
medical care practitioners. As with other infectious diseases, state, 
local, and territorial health departments serve important functions to 
support and augment the medical care system. These ``front line'' 
public health agencies are in direct contact with medical care 
providers and patients, providing important TB control services such as 
laboratory support, surveillance, contact tracing, and patient 
counseling. These agencies also generally possess legal authority to 
isolate or quarantine patients in those rare instances where 
traditional doctor-patient relationships or other means have failed to 
protect the community.

    At the Federal level, HHS/CDC serves several critical roles in 
controlling TB. First, HHS/CDC provides leadership and scientific 
support for TB control efforts, both nationally and internationally, 
including our global efforts to eliminate TB and stem the emergence of 
XDR TB as a health threat. Secondly, HHS/CDC provides approximately 
$100 million annually in support to State, local, and territorial 
health departments for TB control efforts. Third, State and local 
public health departments routinely test samples of respiratory 
secretions from patients in order to diagnose tuberculosis and for some 
state laboratories, including Georgia, HHS/CDC routinely conducts 
second line drug susceptibility testing. HHS/CDC receives isolates from 
approximately 20 state laboratories each year as part of those 
laboratories' regular referral process. Each year HHS/CDC conducts drug 
susceptibility tests for approximately 1,000 samples. Fourth, HHS/CDC 
has the capacity to assist state or local authorities with its 
scientific resources. HHS/CDC may also use its federal legal 
authorities to prevent the introduction, transmission, and spread of 
communicable diseases from foreign countries into the United States or 
between U.S. states. As I will describe, HHS/CDC's involvement in the 
recent case spanned all of these roles.

The Current XDR TB Investigation: Locate, Isolate, Transport, 
Investigate
    The following narrative is based on information assembled and 
reviewed in time for this testimony. The ongoing HHS/CDC investigation 
involves a U.S. citizen with potentially infectious XDR TB who traveled 
to and from Europe on commercial flights. In late March, the patient 
was diagnosed with TB by his doctor. Once diagnosed, Fulton County 
Health Officials became involved in managing the potential public 
health risk to others.
    On May 10th, the Fulton County Health Department became aware that 
the patient's TB strain was resistant to the first-line of antibiotic 
treatments. This same day, the county health department met with the 
patient and his family to inform them of the diagnosis of MDR TB. Our 
understanding, from conversations with the county health officials, is 
that they orally advised the patient to forego his planned travel 
abroad. On the evening of May 10th, the Georgia Health Department 
emailed HHS/CDC's Atlanta Quarantine Station and reported that they 
were aware of an MDR TB patient (patient was not identified) that may 
intend to travel in three weeks. HHS/CDC exchanged emails with the 
Georgia Health Department with options to prevent travel including 
written notification under local authority. In the days following this 
meeting, Fulton County Health Officials attempted to serve the patient 
with written notice advising that the patient not travel, but the 
patient could not be located at either his residence or business.
    It should be noted that normally when a patient has tuberculosis, 
he or she voluntarily complies with recommended treatment and 
recommendations to ensure that they don't put themselves in situations 
where they could potentially expose others to a serious health threat. 
Public health practitioners have a high success record using voluntary 
means of information and advice. In fact, the vast majority of TB 
patients comply with treatment recommendations, including remaining in 
isolation units in hospitals or in isolation at home until 
infectiousness has resolved without the need to invoke state or local 
legal authorities. It is extremely rare that Federal quarantine or 
isolation authority is required to manage domestic TB cases.
    On May 18th after the patient left the United States, HHS/CDC's 
Division of Global Migration and Quarantine was notified that the 
patient traveled internationally against medical advice and his 
whereabouts were unknown. At this point, HHS/CDC's public health 
mission focused on locating the patient, isolating him, ensuring safe 
transportation and contact tracing. Between May 18th through the 22nd, 
HHS/CDC worked with Fulton County health department, Georgia State 
Department of Health, commercial airlines and the patient's family to 
locate him. In addition, on May 22nd, HHS/CDC laboratories determined 
that the patient had the rarer and deadlier subtype of XDR TB.
    On May 22nd, HHS/CDC quarantine officials requested that the 
Customs and Border Protection (CBP) Atlanta office arrange to have the 
patient detained upon re-entry to the US. On both May 22nd and 23rd, 
HHS/CDC spoke with the patient in Rome, Italy and informed him of his 
XDR TB diagnosis; explained the severity of the disease; instructed him 
to terminate all travel and to cease use of commercial air carriers; 
and initiated conversations about the need for isolation, treatment, 
and travel alternatives. Despite assurances from the patient that he 
would not travel, it was discovered, on May 24th, that the patient had 
checked out of his hotel.
    With the patient's exact location and intention to travel unknown, 
HHS/CDC contacted the Transportation Security Administration (TSA) on 
May 24th and requested them to exercise their authority to prevent the 
patient from boarding a commercial aircraft and thereby mitigating the 
risk of transmitting the disease on another long-distance commercial 
flight destined for the U.S. On May 25th, HHS/CDC learned from CBP that 
the patient had traveled via commercial airliner from the Czech 
Republic to Canada and subsequently reentered the U.S. the previous 
evening. HHS/CDC then notified the Public Health Agency of Canada and 
requested they initiate efforts to get the passenger manifest of the 
patient's inbound flight to North America. HHS/CDC called WHO in Geneva 
on May 24th and the HHS Secretary's Operations Center, the designated 
Focal Point for the United States under the revised International 
Health Regulations (2005), officially notified the WHO Secretariat of 
the case on May 25, even though the Regulations do not come into force 
for the United States until July 17, 2007.
    On May 25th, after repeated prior attempts, HHS/CDC officials made 
contact with the patient on his cell phone and directed him to report 
immediately to the Bellevue Hospital in New York City where he would be 
served a quarantine order for isolation and be evaluated. He followed 
this direction, and at Bellevue was served a Federal order of 
provisional isolation and medical examination authorizing medical 
evaluation and respiratory isolation for 72 hours for extensively-drug 
resistant tuberculosis (XDR TB). The patient was later safely 
transported to Grady Hospital in Atlanta, Georgia via HHS/CDC aircraft 
and was issued a Federal order that mandated continued isolation on 
arrival in Atlanta, GA. As part of this process, the patient was 
advised that he could request an administrative hearing to review the 
order but he did not request such a hearing. On May 31st, he was safely 
transported by private airplane to National Jewish Medical Center in 
Denver, Colorado accompanied by his wife and a CDC quarantine officer. 
On June 2nd, HHS/CDC rescinded the Federal quarantine order for 
isolation because Denver health officials assumed public health 
responsibility for this patient. The patient is currently under the 
quarantine authority of Denver County.
    HHS/CDC is currently investigating the source of the patient's XDR 
TB. HHS/CDC is conducting an epidemiological investigation to look back 
at the patient's activities prior to his diagnosis in hopes of learning 
the source of the exposure. The patient has a history of travel to 
numerous locations outside of the United States. Sequences of DNA from 
the patient's TB strain do not match any currently on file in HHS/CDC's 
TB fingerprinting library. HHS/CDC is making efforts to compare it with 
TB fingerprinting libraries in other countries.

HHS/CDC Recommendations for Passengers:
    Though the risk of transmission to the other passengers on the 
flights the patient took is low, it is not zero. In accordance with the 
WHO TB and Airline Travel Guidelines, and to ensure appropriate follow-
up and care for persons who may have been exposed to XDR TB, HHS/CDC 
has recommended that passengers aboard the two transatlantic flights 
longer than 8 hours in duration who were seated in the same row as the 
patient, those seated in the two rows ahead and the two rows behind, 
and cabin crew members working in the same cabin should be evaluated 
for TB infection. This includes initial evaluation and testing with re-
evaluation 8-10 weeks later. Because undiagnosed, latent TB exists in 
the general population, it is reasonable to expect that some of the 
passengers will test positive because of a previous exposure to TB, and 
not because of exposure on the flight in question. While we believe 
that passengers seated outside the immediate vicinity of the patient 
are at extremely low risk of contracting XDR TB, given the serious 
consequences and limited treatment options of XDR TB, we are notifying 
all U.S. residents and citizens on these flights and encouraging these 
individuals to seek TB testing and evaluation.
    HHS/CDC is taking the lead in contact tracing of the U.S. citizens 
on these flights and is coordinating with other countries for the 
contact tracing of their citizens. As of June 5th, HHS/CDC has had 
direct contact with 245 of the approximately 276 US citizens and 
residents on Air France 385. Of the 26 high priority passengers, seated 
in the same row, two rows in front or two rows behind the patient, HHS/
CDC has spoken directly with 24 of these individuals.

Isolation and Quarantine, An HHS-DHS Partnership:
    To contain the spread of a contagious illness, public health 
authorities rely on many strategies. Two of these strategies are 
isolation and quarantine. Both aim to control exposure to infected or 
potentially infected persons, and both may be undertaken voluntarily or 
compelled by public health authorities. The two strategies differ in 
that isolation generally applies to persons who are known or suspected 
to have a communicable disease, and quarantine generally applies to 
those who have been exposed to a communicable disease but who may or 
may not become ill. Isolation is a standard procedure used in hospitals 
today for patients with tuberculosis (TB), and in most cases isolation 
is voluntary; however, many levels of government (Federal, state, and 
local) have basic authority to compel isolation of infected people to 
protect the public. State and local governments have primary 
responsibility for isolation and quarantine within their borders and 
conduct these activities in accordance with their respective laws and 
policies.
    The Department of Health and Human Services has authority under 
section 361 of the Public Health Service Act to prevent the 
introduction, transmission, and spread of communicable diseases from 
foreign countries into the United States and between states. HHS/CDC, 
through its Division of Global Migration and Quarantine, is authorized 
to detain, medically examine, or conditionally release persons 
suspected of carrying certain specified communicable diseases. The 
communicable diseases for which Federal isolation and quarantine are 
authorized are established by Presidential order and currently include 
infectious TB, cholera, diphtheria, plague, smallpox, yellow fever, 
viral hemorrhagic fevers, severe acute respiratory syndrome (SARS), and 
influenza with pandemic potential.
    HHS/CDC relies primarily upon DHS for the enforcement of isolation 
and quarantine orders at the borders, but may also rely on other 
federal law enforcement agencies and state and local law enforcement. 
By statute, our DHS partners at the borders--Customs and Border 
Protection (CBP) and Coast Guard officers--aid in the enforcement of 
rules and regulations relating to quarantine and isolation. Violation 
of Federal regulations regarding quarantine and isolation constitute a 
criminal misdemeanor, punishable by fine and/or imprisonment. Federal 
public health authority includes the authority to release persons from 
quarantine or isolation on the condition that they comply with medical 
monitoring and surveillance.
    HHS/CDC maintains a close partnership with DHS and its agencies. 
DHS and HHS signed a memorandum of understanding (MOU) in 2005 that 
establishes specific cooperation mechanisms as part of a broad 
framework for cooperation to enhance the Nation's preparedness against 
the introduction, transmission, and spread of quarantinable and serious 
communicable diseases from foreign countries into the States, 
territories, and possessions of the United States. DHS has charged the 
Homeland Security Institute with facilitating the implementation of the 
MOU and HHS/CDC's Division of Global Migration and Quarantine is 
collaborating in this effort. Concurrently, HHS/CDC has conducted table 
top exercises at ports of entry in cooperation with DHS' component 
agencies and state and local partners to develop and refine 
communicable disease response plans.
    The partnership between CBP and HHS/CDC is particularly vital, as 
CBP officers act as HHS/CDC's ``eyes and ears'' on the ground. In 
addition to assisting with the enforcement of Federal quarantine and 
isolation, HHS/CDC helps to train CBP officers to identify and respond 
to travelers, animals, and cargo that may pose an infectious disease 
threat. CBP also assists quarantine officials with the distribution of 
health risk communication materials for the traveling public, such as 
notices that alert travelers of possible exposure to communicable 
disease threats abroad and offer guidance on steps they can take to 
protect themselves.

Next Steps, What More Can Be Done:
    With the support of Congress and the President, and in accordance 
with the recommendations of the Institute of Medicine (IOM), HHS/CDC is 
investing in building a Quarantine and Migration Health System that 
meets the needs of the 21st Century. HHS/CDC is enhancing the numbers 
and competencies of staff, training, physical space, and utilization of 
technology to meet the Quarantine System's evolving, expanding role. 
This has included the creation of additional quarantine stations at 
airports and other major ports of entry into the United States. HHS/CDC 
has expanded this critical public health infrastructure to 20 stations 
and is focusing on fully staffing these stations.
    By continuing to expand the capacity of the U.S. Quarantine and 
Migration Health System through science, partnership, and preparedness, 
HHS/CDC will be better equipped to play an active role in worldwide 
biosurveillance, to coordinate nationwide response to global microbial 
threats of public health significance and to protect the U.S. public 
from communicable disease threats. The President has requested an 
additional $10 million dollars in FY 2008 to support the further 
enhancement and expansion of the Quarantine and Migration Health 
System.
    In addition, HHS/CDC has been working to update interstate and 
foreign quarantine regulations [42 CFR Parts 70 & 71] to codify 
procedures that more completely reflect the 21st century implementation 
of disease containment measures such as isolation and quarantine, and 
that strengthen the nation's public health security at ports of entry. 
On November 30, 2005, HHS/CDC published a notice of proposed rulemaking 
(NPRM) to update the interstate and foreign quarantine regulations [42 
CFR Parts 70 & 71]. Once adopted, these changes will represent the 
first significant changes to these regulations in 25 years.
    Key provisions proposed include: more explicit due process 
protections for written orders and an administrative review hearing; 
expanded reporting of ill passengers on board air carriers; and 
requirements that will facilitate the timely transmittal of passenger 
and crew contact information to HHS/CDC to ensure quick notification of 
exposure to communicable disease threats. These procedures are expected 
to expedite and improve HHS/CDC operations by allowing immediate 
medical follow-up of potentially infected passengers and their 
contacts. HHS/CDC received over 500 pages of comments from 
approximately 50 organizations and individuals regarding the proposed 
rule. HHS/CDC is currently addressing issues raised during the public 
comment periods, including working with DHS to most efficiently share 
contact information, and developing a draft final rule.
    To control TB, HHS/CDC and its partners must continue to apply 
fundamental principles including: (1) State and local TB programs must 
be adequately prepared to identify and treat TB patients so that 
further drug resistant cases can be prevented; (2) TB training and 
consultation must be widely available so that private health care 
providers recognize and promptly report tuberculosis to the public 
health system; (3) State and local public health laboratories must be 
able to efficiently perform and interpret drug susceptibility and 
genotyping results in TB specimens; and (4) CDC and local health 
authorities must work collaboratively to ensure that isolation and 
quarantine authorities are properly and timely exercised in appropriate 
cases.
    The prospects for development of new TB drugs also are promising 
and those efforts must continue. There are at least 4 new anti-TB 
compounds entering human trials while others are in advanced 
preclinical testing. These new compounds represent new drug classes 
that may offer promise for treating resistant cases.

Conclusion:
    We have begun a careful review of our protocols and capabilities. 
First and foremost, we are reminded that infectious diseases are not a 
thing of the past, and that we need to continually adapt our prevention 
and response capabilities in an era of increasing threat and 
globalization. We are reminded that almost all infectious disease cases 
are effectively handled within our existing systems of care by 
patients, clinicians and local public health authorities, and that it 
is important to continue to reinforce and augment these existing roles 
and relationships. Our public health protection network assisted us in 
responding to this event in a more timely and coordinated manner. 
Public health officials continue a long tradition of working together 
on every level to identify, contain and mitigate the spread of 
communicable diseases in US communities and abroad.
    The case also reminds us that there are a number of existing 
channels that we can leverage more effectively in the future. Through 
the Global Health Security Action Group--a group of senior policy 
officials, top scientists, and media experts from the ministries of 
health of G-7 nations, Mexico, the World Health Organization and the 
European Commission--we can quickly convene relevant public health 
officials via phone and video conferences to convey information on 
cases like this to our key allies in a more timely and effective way.
    In an age of global air travel, infectious diseases can, and do, 
cross geographic borders every day. People can be infected with a 
disease and have few visible indications, people can vary in terms of 
how infectious they are, it is often not possible to rapidly test and 
confirm whether a person has an infectious disease, and people's health 
status can change quickly and unpredictably. We will never be in a 
position where we can guarantee that infectious people will not cross 
borders, but we will work to ensure that the measures available are as 
effective as possible. And so too this case reinforces the need to 
advance our efforts to modernize our Quarantine and Migration Health 
System and update Federal quarantine regulations; improve our 
information technology and communications capabilities; and define and 
exercise our capabilities and relationships with international, 
Federal, state, and local partners so that we are prepared to deal with 
situations that pose a threat to public health. We believe the lessons 
learned from this case will improve HHS/CDC's ability to protect the 
nation's health in our ever-changing global environment.

    Dr. Gerberding. Thank you, sir. And I apologize to the 
committee for not being able to be here at the beginning. It 
was hard to be in two places at the same time. And I thought we 
could work it out timewise, but it was not successful. There 
were some delays on the Senate side. So I am very sorry and I 
would be happy to meet with any of you at some other time if 
that would be helpful to clear up what I don't have time to 
address today.
    You asked the question, I think, about what does this mean, 
what does this mean in terms of our overall ability to keep the 
bad guys out of the country--
    Mr. Perlmutter. Or let our bad guys go to another country 
and do some damage to them.
    Dr. Gerberding. I understand what you are saying. One thing 
that I would like to point out is that there is a difference 
between a terrorist and an infectious person. Our medical 
approach is to generally give the patient the benefit of the 
doubt. And in the time that I have been the CDC Director, 
72,000 people with tuberculosis have been diagnosed in this 
country and I have never had to file a Federal order. We have 
been able generally to work with patients, get them to do the 
right thing to protect our people. Sometimes they have to be 
put in an isolation order or quarantine order at the local 
level.
    But we have never had a situation like this where we had a 
patient who had compelling reasons to go against medical 
advice. We made decisions based on the theory that the patient 
would cooperate. That was in retrospect a wrong matrix for 
making decisions in this case, and if we had to do it all over 
again knowing what we know now, we would have acted much 
earlier. Actually, had we initiated the notifications earlier, 
in this example it wouldn't have made any difference based on 
what the current capacity is to exercise the watch and the no-
fly capabilities. But nevertheless we were not expecting the 
patient to make the decisions that he made. And that is a very 
sad lesson for all of us to learn at CDC.
    Mr. Perlmutter. OK. Thank you, Mr. Chair.
    Chairman Thompson. Thank you very much. We now recognize 
the gentleman from California for 5 minutes, Mr. Lungren.
    Mr. Lungren. Thank you very much Mr. Chairman. Sixty-three 
years ago is a rather important day, may have changed our 
lives. It was D-Day. My dad was waiting as medical officer to 
go off to Normandy. The day before President Eisenhower wrote 
this note:
    Our landings in the Cherbourg-Havre area have failed to 
gain a satisfactory foothold and I have withdrawn the troops. 
My decision to attack at this time and place was based on the 
best information available. The troops, the airmen and the Navy 
did all that bravery and devotion to duty could do. If any 
blame or fault attaches to the attempt, it is mine alone.
    He wrote that in case we failed so that he would take all 
the blame. And the difference between that generation and our 
generation unfortunately is the difference between taking 
responsibility and accountability and blaming someone else. Mr. 
Speaker is the person who bears the initial responsibility for 
here and I would have to disagree with you, Doctor, to say he 
had compelling reasons not to follow advice. He had self-
absorbed reasons. He wanted to have his wedding in Europe. His 
first response as reported in the press is I am an intelligent, 
well-educated person. Well, evidently intelligence and good 
education doesn't give you common sense or concern for other 
individuals.
    Now I have heard us say that this is different than terror, 
and I understand it is different than terror. But we have been 
told that he has multiple drug resistant TB. Now either that 
means something or it doesn't. Are we to think that multiple 
drug resistant TB is not a serious concern? And that multiple 
drug resistant as a string of adjectives to describe TB doesn't 
mean that it is something that ought to be taken seriously? I 
think not. And my concern is this, we have lauded the 
Department for the great work done by the customs officer on 
the border of the United States with Canada a few years ago to 
stop a terrorist from coming in who wanted to blow up LAX. That 
was great work by an officer right there on the line. She used 
her intelligence, she used her background, she used her 
decision making to stop a threat to the United States.
    In this case, based on what I have seen, if the facts are 
as they appear to be, we had someone who failed that test. Now 
there ought to be different treatment between someone who saves 
us from an attack and someone for whatever reason ignores a 
statement that says that basically you are supposed to 
immediately put this person secondary. You are supposed to 
immediately use protective gear. You are not to let the person 
in.
    Now I don't know about you, and I understand I am a lawyer. 
I plead guilty, and we have to worry about the rights and we 
can't say too much, and by God we don't want to punish someone 
too much. I mean, we are lucky that this person is not 
communicable right now or at least we don't think he is. Or if 
you are satisfied that he isn't, then why are we having these 
people tested who were on the airplane with him?
    I remember TB as a serious thing. I had a guy in my high 
school had spent something like 3-1/2 months in the hospital 
when we were in high school. It is serious stuff. So all I can 
say is if the facts are what they are I would hope you would 
consider firing this person and the other people involved 
because this is much with the FBI about the national security 
letters. I have asked the President and I have asked the FBI, 
has anybody been disciplined for the errors that were made in 
the NSL? And I hear this, we are looking at it. What message 
does that send to the employees other than to say we are going 
to make sure we follow every single thing, not going to let 
their names be known, can't talk about it here. We will let you 
know in a confidential briefing but we have to make sure that 
everybody is protected here.
    What about the public? What about the public? All I want to 
know is I want a statement from you, are you going to take 
action with respect to the people involved? And will there be 
action, completed action with respect to their employment, 
whatever that means under the system you are allowed to 
operate.
    Mr. Basham. The answer is yes.
    Mr. Lungren. And when?
    Mr. Basham. We are in the process now of conducting a 
thorough review of what happened. The individual that you are 
speaking of is currently--his weapon has been taken away.
    Mr. Lungren. Let me ask you, you say you are looking at it. 
Let me ask you, if someone gets an alert or whatever you call 
it on the--that came up that tells him to stop the person, do 
secondary search, what authority does that person have to 
ignore that? Because he or she says, oh, he looked pretty good 
to me. What authority do they have to ignore that?
    Mr. Basham. He doesn't have the authority to ignore it. He 
chose to ignore it. His instructions were very clear. You have 
in front of you what he should do. He did not do it.
    Mr. Lungren. I mean, it is not a question of not 
understanding the language. It is fairly clear. It is 
straightforward, tells you what to do.
    Mr. Basham. I have got 12 grandchildren, Mr. Congressman. I 
don't know of any one of them that would not have known what to 
do in that situation.
    Mr. Lungren. I am sorry to get emotional about this. But 
some of us have been defending you guys for a long time, 
thinking you are doing great work in other areas. We see great 
work done by somebody up in Vancouver to stop a terrorist 
attack, and then we see this. And frankly I do not see the 
sense of urgency about taking this and resolving this and 
making it clear to the public that we have resolved. But let's 
remember first and foremost, the person who is responsible for 
this is Mr. Speaker, who decided on his own to ignore because 
he wanted to have a wedding in Europe. And then took evasive 
action because somehow somebody told him he might be on the no-
fly list and snuck back into the United States and, had it not 
been for an inerrant or an errant action by one of your 
employees, would not have gotten here. And this guy wants 
sympathy. This guy shouldn't get sympathy.
    Frankly, I hope there is some laws that we can use against 
him. I am sorry, but some of the responses you had to Mr. Shays 
to suggest that this is not that big a deal really upset me. 
This is a big deal. We are lucky, we are lucky that for some 
reason at this stage he is not communicating this disease to 
others.
    So hopefully this is like the test that none of us wanted 
to have, but we have and it shows what we have got to do and it 
means we have to do a lot.
    Thank you very much, Mr. Chairman.
    Chairman Thompson. Thank you very much. We now yield 5 
minutes to the gentleman from Rhode Island, Mr. Langevin.
    Mr. Langevin. Thank you, Mr. Chairman. Thank you, Mr. 
Chairman. I think Mr. Lungren and Mr. Perlmutter and others of 
my colleagues have expressed all of our frustrations about this 
issue. It is truly a catastrophic failure, in my opinion, that 
has taken place because this issue has as much to do with 
preventing a terrorist from entering the country as it does 
with the effect that it has on our public health system in 
protecting us against a public health threat. And this has done 
irreparable damage as far as I and many others are concerned.
    I have so many questions I almost don't know where to begin 
but I want to start--because I want to get to Dr. Gerberding--I 
want to start though with Mr. Basham, Mr. Ahern. With respect 
to training and how we prevent this type of thing from 
happening again--first of all, how frequently do border agents 
get these text messages on their systems, first of all? And the 
second question is, with respect to training, how often do 
agents get refresher training? I mean this is clearly not a 
situation where you can just train someone once and then be 
left to their own devices--and Mr. Basham, you would know this 
in your previous role as Director of the Secret Service. The 
Secret Service is a great model because they always have to be 
on, they always have to be fresh. They go through frequent 
training. They are on for a certain period of weeks and they go 
through training again to make sure that they are sharp always. 
So I would like you to relate that to this experience and how 
our CBP agents kept fresh and how much retraining do they do?
    Mr. Basham. In this particular instance, the officer that 
we are speaking of, I believe has had training, passenger 
training on a yearly basis that instructs them on how to deal 
with these sorts of situations. I believe that is the case. In 
terms of--let me just say, as the Director of the Secret 
Service, as I said, I understand the significance of what one 
individual, the impact that they can have with respect to what 
the Secret Service's mission is. I have been in this position 
for a year, one year now, and I am just going to say this. CBP 
agents and officers take a back seat to no one when it comes to 
the dedication and commitment to getting this job done. That is 
the unfortunate piece of this issue, is that this one 
individual has tainted that in my mind. They know what their 
responsibility is, and that is about protecting America against 
all threats. And the training that they receive is intended for 
them to be prepared to deal with all threats, including this 
threat.
    Mr. Langevin. So there is built in training and retraining 
throughout their time in the service?
    Mr. Ahern. Yes. Thank you, Congressman.
    Certainly my experience is 31 years, I started on the 
border with Mexico back in the 1970's. One of the most 
fundamental responsibilities the primary office has is using 
the lookout system. That is very clear; that is a very 
fundamental core part of the function, of what occurs.
    As the commissioner stated, certainly what we do on an 
annual refreshing basis is to provide training for--not to be 
medical professionals or to actually aid them in making 
diagnoses--it is more for personal safety, and also be able to 
deal with isolating the individual--on blood-borne pathogens 
and TB on an annual basis, as well as training on an influenza 
pandemic. We have been doing that on an annual basis for 
several years now. This is a core function of what goes on.
    Obviously, I am not sure that this is a training issue or 
retraining requirement. I think there is a failure to act here 
that we will deal with very swiftly internally.
    Mr. Langevin. How frequently do border agents get these 
types of text messages, by the way?
    Mr. Ahern. As the commissioner stated in his opening 
statement, I believe it was in the 40-number range for this 
particular port, Champlain, which is a moderate-sized location.
    We see significant numbers of alerts throughout the country 
on a daily basis, well into the thousands. So this is not an 
unfamiliar or occasional occurrence that occurs; this is a 
fundamental core value.
    Mr. Langevin. Thank you.
    Dr. Gerberding, I know my time is running out, but first of 
all, I think this incident highlights the Federal Government is 
not fully prepared to respond when individuals have highly 
contagious communicable diseases. I want to turn my attention 
to the quarantine issue. We need increased coordination I 
believe among Federal agencies such as CDC and DHS, as well as 
the ability to isolate and/or quarantine these people, 
especially when they are uncooperative.
    My question is, I understand the President can issue an 
executive order for quarantine and isolation on very specific 
diseases, but to Dr. Gerberding, Dr. Runge, please describe 
what other procedures are occurring for the Federal Government 
to issue an isolation order or provisional quarantine order.
    Also, what is the role of DHS and the CDC when these orders 
are issued?
    Dr. Gerberding. I think I can answer that in a fairly 
straightforward way.
    The primary responsibility for isolation of sick people or 
quarantine of exposed people lies with the local or State 
jurisdiction. They have the legal authority and the 
accountability for doing that, and from time to time they 
exercise that authority.
    When a State needs help and asks for help, when there is an 
issue of interstate movement or risk of importation, we can 
exercise our Federal authorities on top of whatever State 
authorities exist; and that is exactly what happened in this 
case. I exercised my authority as the CDC Director to issue a 
Federal order of isolation to this patient as soon as his feet 
touched the soil in the U.S. Obviously, I can't execute or make 
that order when he is not here in my jurisdiction.
    The one question that we have about this authority is that 
it does not specifically address exportation. Our quarantine 
laws were designed to keep people out, and in this case, the 
threat was from someone leaving and exposing others in our 
global network at risk.
    We believe we may be able to use our existing authorities, 
but we need a legal clarification that it was permissible for 
me to issue a Federal order at the onset.
    Mr. Langevin. I hope we will get that clarification.
    Dr. Gerberding. Absolutely. We have already requested and 
are working on--that was actually something in play before this 
event even took place.
    Mr. Langevin. I know my time has expired, Mr. Chairman.
    Do you have an MOU with other public health counterparts 
around the world so that if you issue that kind of order, even 
though it is not in your jurisdiction, you can communicate that 
with your counterparts in foreign countries that they could 
then use their discretion to exercise that?
    Dr. Gerberding. Our country is a member of the World Health 
Assembly. The World Health Organization has developed 
international health regulations that will ironically go into 
effect June of this year, but we have been respecting those 
health regulations and they do have provisions for 
intergovernmental cooperation in these situations.
    The truth is, having just developed these guidelines and 
getting 193 member countries to agree to them is the first 
step. Now they have to be operationalized, they have to be 
exercised.
    I think what we have just been through in the last 2 weeks 
is a great case study of how we are going to have to create the 
procedures and the processes to take these guidelines and turn 
them into something that actually works for all member 
countries.
    But there is a World Health Organization process and it 
will get a lot better shortly as we step to the plate and try 
to address these details.
    Mr. Langevin. Clearly, it can't happen soon enough.
    Dr. Gerberding. I couldn't agree with you more, sir. We 
really came up against a good idea. But how do you execute this 
and what are the relationships?
    I want to quickly also say, CDC has a memorandum of 
understanding with the Customs and Border Patrol, as well as an 
HHS memorandum of understanding with Homeland Security for our 
interagency collaboration. It is the Coast Guard and the CBP 
officers who have the responsibility for enforcing the order 
that CDC makes. So when we needed law enforcement support for a 
quarantine order, we turn to Homeland Security to provide that 
law enforcement arm. CDC is not a law enforcement agency.
    We worked very hard to work on this agreement to train and 
work together to execute that effectively.
    Mr. Langevin. I thank the Chair for his indulgence. Thank 
you, Chairman.
    Chairman Thompson. Thank you. I now recognize the gentleman 
from Texas, Mr. Green, for 5 minutes.
    Mr. Green. Thank you, Mr. Chairman. I thank the ranking 
member as well. These are important hearings, and I thank the 
witnesses for your testimony. This is not going to be a 
``gotcha'' session, hopefully, as it relates to me, but I do 
want you to understand that, in my opinion, Mr. Speaker is a 
wake-up call. He really is.
    We have to do some introspection, we have to ask ourselves 
some very tough questions. If we treat Mr. Speaker as an 
aberration, we will probably fail our Nation. We cannot allow 
this to be treated as a one-time occurrence. My suspicion is 
that you will not, but I think that has to be said.
    Mr. Speaker obviously wanted to have his wedding cake and 
eat it too, and that is very unfortunate because he put a lot 
of people at risk in so doing. And it is unfortunate that we 
cannot have empirical data to support a comment that was made 
by the doctor because, Doctor, I am not sure that this is an 
occurrence that is a one-time occurrence because we have no way 
of knowing how many people have been told by their physicians, 
do not travel, who have actually traveled. I don't know that 
empirical data is available to substantiate the notion that 
this is a one-time occurrence.
    You indicated that in all of your years this is the first 
time you have had to file for a certain type of order. However, 
there are other circumstances that may not have come to your 
attention, and I think the question has to be posed: Is trust 
enough?
    Is trust enough in the world that we live in today? Is 
trust between the physician and the patient enough to protect 
the broader society from a person who may have a deadly 
communicable disease? Is trust enough?
    Doctor, I ask if you would please respond as quickly as 
possible.
    Dr. Gerberding. Sir, trust is not enough. It is absolutely, 
unequivocally not enough.
    Mr. Green. If trust is not enough, Doctor--excuse me for 
interceding, but my time is short and I have other questions. 
If trust is not enough, then the question becomes, what system 
do we put in place to prevent the person who is informed that 
you have a communicable disease, what system goes into place, 
into action such that that person cannot travel 
internationally? First question. I have some local concerns as 
well, but internationally what do we do?
    Dr. Gerberding. There are quarantine authorities and 
isolation authorities, as I mentioned. A local health officer 
can place a patient in voluntary isolation, meaning here is 
what we recommend, or require isolation.
    Mr. Green. Is that authority discretionary?
    Dr. Gerberding. It is determined by the local health 
authorities' assessment of the risk.
    Mr. Green. It is done on a case-by-case basis?
    Dr. Gerberding. Absolutely.
    Mr. Green. It is discretionary.
    Do we need to modify the system such that some of the 
discretion is extracted, such that we can be assured that a 
person who has a communicable, deadly disease is not boarding 
international flights?
    Dr. Gerberding. Mr. Green, I wish I could say that there 
was a way to accomplish what you are proposing, but people can 
leave and come into our country with communicable diseases by 
bypassing the system if they are asymptomatic. It is impossible 
for border agents to be able to detect every symptomatic 
person.
    Mr. Green. Let's talk about the person who is known to have 
a deadly communicable disease. Let's talk about that person for 
this paradigm. How do we stop that person?
    Dr. Gerberding. Our borders have never been hermetically 
sealed.
    Mr. Green. Let's not get to the border. Let's talk about 
the trust between the doctor and the patient, because that is 
the genesis of the problem, the trust factor.
    Are we in a society where we can continue to allow people 
to be trusted who have communicable diseases of this magnitude?
    Dr. Gerberding. Seventy-two thousand times in the last 5 
years we have been able to trust the patient, minus a handful 
of people that did not cooperate and needed to be isolated. We 
have to balance--
    Mr. Green. Wouldn't that be 72,000 that we know of?
    Dr. Gerberding. I thought that is what you were asking me.
    Mr. Green. There are many other circumstances that we don't 
know of.
    Let me move on quickly and say this. The Border Patrol 
agent failed us, but we also failed him. We failed him because 
somehow we have given him this stereotype of what a sick person 
looks like. And my suspicion is that if this person had 
different characteristics, we may have had a different outcome. 
That is my suspicion. My suspicion is that Mr. Speaker chose to 
go to Canada because he had his beliefs about the type of 
reception he would get making his way across a certain border 
point as opposed to another point.
    So we failed him. He may take the heat, he may be the fall 
guy, but there is a failure in a system that promotes the 
notion that people who are sick probably look a certain way and 
probably have certain characteristics.
    Mr. Chairman, I thank you. I have gone beyond the time and 
I yield back.
    Chairman Thompson. Thank you very much, Mr. Green.
    We now yield to the gentlelady from Texas for 5 minutes, 
Ms. Jackson Lee.
    Ms. Jackson Lee. Thank you very much, Mr. Chairman. Let me 
add my appreciation to you and your staff for the prompt, 
efficient and quick way that we have been able to address this 
question.
    I believe this committee takes the life-or-death issues 
that we have to address very seriously. And I would like to 
join the chairman in including TSA in this debate, in this 
oversight, in possibly some forum, whether it be a briefing or 
hearing; because as I am looking at the timeline, we are seeing 
that they are obviously intertwined into this. I say that as I 
pose questions.
    Let me welcome Dr. Gerberding and others here and let me 
take my line of questioning to simply say that it is tragic to 
say, but we have been given a gift. The gift is that we were 
able to survive what would have been a catastrophic event that 
could have generated thousands upon thousands of deaths.
    The thing that frightens me and gives me great pause is 
that all of us have defended the representation or the 
question, are we safer today than we were before 9/11. These 
kinds of mishaps say to the American people that we are not, 
and it disturbs me; but more importantly it gives me pause and 
it gives me a great sense of failure that we who have this 
responsibility have failed the people who invest in us, who 
have confidence in us, and it goes across the board.
    So I am looking for answers that would suggest that we do 
more celebration of the success stories and less of the mea 
culpa.
    This seems to be one that was avoidable. These are not 
circumstances that we were unfamiliar with. We had the 
coordinates in place, we had the agencies in place.
    Now all we hear is, we might need new laws, we weren't 
connected, we didn't give the right information, we didn't know 
who to give it to. This timeline presented by able staff 
indicates that.
    So let me begin. My colleagues need to know that Mr. 
Speaker fell down in January and determined something was wrong 
and had an x-ray. But in early March, Speaker underwent a 
procedure to determine the status of his lungs. It was not 
until Thursday, May 10th--now, maybe there is something that 
was left out--that the health official determined that he had a 
multiple drug-resistant, MDR, form of TB. The whole month of 
April is gone.
    Sounds like my building in Houston where people are coming 
in with passports and saying that they sent them 13 weeks ago 
and they haven't got a reflection, but let me compliment the 
passport people working 24 hours a day and 7 days a week. There 
is that gap.
    So I ask that first question to you, Doctor. I think there 
was a failure between you and the Fulton County, I assume, 
Health Department, which speaks to the relationships the CDC 
has with our local health departments. Why did it take that 
long?
    Dr. Gerberding. In this case, the problem is not with the 
public health system, it is with the bacteria. Tuberculosis is 
a very slow-growing organism. When the patient had the samples 
taken in March, they were brought to the laboratory. When they 
began to show tuberculosis, they were sent to the State health 
lab, which is the appropriate procedure.
    Eighteen days after the procedure was done to obtain the 
sample, there was the first diagnosis of tuberculosis, but then 
you have to go through the susceptibility testing, and that can 
take up to 21 to 28 days.
    So there is always a long time frame from the time that you 
get the sample from the patient until the time that you know 
you have a--
    Ms. Jackson Lee. Let me interrupt because those of us who 
are not medical professionals would probably fall victim to 
yielding and saying, she is right.
    Let me just say that we don't have that kind of time, not 
to do the appropriate testing, but I believe in light of the 
atmosphere in which we live, at least the notification, the 
beginning notification of the individual that they are in 
testing, something is wrong, and begin at least some form of 
putting them in a mind-set that they may be a danger.
    I don't believe that was done.
    Dr. Gerberding. When the patient was diagnosed as having 
tuberculosis, the patient was started on treatment, but it 
takes a long time to do the extensive drug susceptibility tests 
that were done; and that is the timeline between when he knew 
he had TB versus when he knew he had drug-resistant TB.
    This brings up a very important point, though, and I am 
glad you mentioned it because we are treating tuberculosis in 
the 21st century like it is the 19th century. We should have 
faster diagnostics everywhere, better drugs to treat the 
disease.
    Ms. Jackson Lee. We should be able to--and forgive me for 
reclaiming my time, because it is short. We should have a 
better sense in place to coordinate between the local health 
authorities, the patient and the testing process.
    I still believe that intervention should have been sooner 
to frame for Mr. Speaker, you may have a serious issue and we 
need to address it and we need to have you be aware, frankly, 
that your travel may be limited. I don't think we did enough.
    And I really need to move on because of the time.
    Dr. Gerberding. Very quickly, I believe the patient was 
notified of his drug-resistant status when the State lab knew 
it.
    Ms. Jackson Lee. We have a time frame that suggests he got 
a letter when he was already out of town and no one could reach 
him.
    Dr. Gerberding. He attended a family meeting and was given 
the information first by his clinician and then reviewed at the 
family meeting.
    Ms. Jackson Lee. Then what did the public health facilities 
do regarding his actions?
    Dr. Gerberding. They actually hosted the meeting and were 
responsible--
    Ms. Jackson Lee. So are you suggesting that because you 
don't have stronger laws, you could do nothing more than host a 
meeting and allow someone to say they had to go on a honeymoon? 
There lies again a question of whether or not we are safer 
today than we were before 9/11, because if we have nothing in 
place--you hosted a meeting; what was the action that you could 
take?
    Dr. Gerberding. I can't speak to the mind of the health 
officer involved, but in Georgia you are required to 
demonstrate that the patient has defied a medical order in 
order to issue an isolation order under quarantine. So the 
reason the officer was delivering that advisory to the patient 
in writing was to make it very clear what the written--
    Ms. Jackson Lee. Is that the letter that came after he had 
already left?
    Dr. Gerberding. Exactly.
    Ms. Jackson Lee. There lies the crux. Let me go to the 
Border Protection operation--
    Chairman Thompson. The gentlelady's time has expired.
    Ms. Jackson Lee. May I ask this last question?
    Chairman Thompson. One question.
    Ms. Jackson Lee. Thank you very much.
    I think your system was completely broken, and beyond 
reading the fact that the English was clear--``place mask on 
subject, place in isolation``--it is my understanding that TSA 
got the information after all of the, if you will, damage was 
done. This gentleman was back in Montreal, and frankly the 
lawyer for TSA did not get permission until 7:30. Who knows 
where the person would have been?
    My question is what is--what orchestrated the failure of 
communication in DHS between Customs and Border Protection, 
TSA, et cetera. One of the issues is the sharing of 
intelligence. What led to that failure of intelligence and 
communication?
    Mr. Basham. Thank you.
    Mr. Basham. First of all, let me just say that at the time 
that CBP was given the information on Mr. Speaker, there was no 
indication that Mr. Speaker was not going to be compliant with 
the orders of CDC; and that was that he was going to return to 
the United States on the 5th of June.
    Up until the point where we determined that he actually had 
crossed the border, we were under the impression that he was 
still intending to return on that date; and we were doing 
sweeps on a daily basis to make a determination of whether or 
not his travel plans would have changed. At that point in time, 
we had no reason to involve TSA in this process as long as this 
person was compliant.
    CDC was talking to him. I believe, Doctor, that was the 
case. That individual decided he was not going to comply.
    Ms. Jackson Lee. Let me end--
    Chairman Thompson. Excuse me.
    Ms. Jackson Lee. I am just thanking him for his answer. I 
yield back.
    Chairman Thompson. I now recognize the gentleman from 
Texas, Mr. Cuellar.
    Mr. Cuellar. Mr. Chairman, I have no questions at this 
time. Thank you.
    Chairman Thompson. I now recognize the gentlelady from New 
York, Ms. Clarke.
    Ms. Clarke. Thank you very much, Mr. Chairman. I just want 
to really associate myself with the comments of my colleagues 
thus far, because this is truly a remarkable event that is 
taking place, and I kind of take it a little bit personally.
    With three major airports within miles of Brooklyn, that I 
represent, and in fact the State of New York being landlocked 
with the Canadian border, the spread of disease through travel 
is of great concern to me; and frankly this is a breach in the 
security of--this type of breach in the security of our Nation 
is just unconscionable.
    As this committee and the appropriate government agencies 
and the media continue to investigate what occurred, I hope we 
avoid finding scapegoats and instead keep the focus on 
understanding how to fix the system where it has failed.
    Let's make no mistake: The system failed. What is so 
bizarre about this event is the fact that this man, Mr. 
Speaker, was aware that he needed to turn himself in and 
intentionally evaded the authorities. And we enabled it.
    I would like to know from those of you who are sitting here 
today, if a similar situation were to occur today, how the DHS 
and CDC would handle it differently, one? And two, is the 
infrastructure in place to prevent a person from flying even 
after changing flights?
    Three, what stops a person from traveling to the U.S. who 
may carry a highly contagious and communicable disease? Four, 
what would the CDC have been prepared to coordinate with the 
international community and the U.S. to contain, quarantine and 
treat the thousands of people around the globe who could have 
been exposed and contracted this highly communicable disease?
    Those four questions I need answers to.
    Dr. Runge. Thank you very much, Representative Clarke. I 
will take the first one.
    CDC and DHS have had a long history of working together 
very well at the field office level even before there was a 
DHS. The MOUs that Dr. Gerberding referred to and the chairman 
referred to are in place, they are being operationalized. But 
the lesson we have learned from this--and as late as this 
morning, Secretary Chertoff and Secretary Levitt spoke about 
this--is that we are not going to keep such information at the 
field level. If we don't elevate it to the National Operations 
Center, then there are tools that we are leaving on the table 
for CDC to use.
    If we look in retrospect and if that had occurred a bit 
earlier, they would have been given more tools quicker to 
respond to this episode.
    So it is very much--although we work very well in 
planning--we are working together on pandemic planning, and we 
have many, many activities together--this does clearly set out 
a need for using the tools that we actually have in place 
through our operations center, through the watch desk that we 
have 24/7/365 to coordinate with TSA and CBP and the operations 
center level at HHS.
    We are very cognizant of that and are putting that in 
place.
    Mr. Basham. I believe your point as well was, are there 
systems in place that would prevent this from occurring again. 
Let me just say that being 100 percent right 100 percent of the 
time, I couldn't sit here and tell you that we are going to be 
able to accomplish that. That is certainly a goal that we have.
    But we have initiated new processes at our ports of entry 
that would not allow, will not allow that which occurred in 
Champlain, New York, to occur again. There are backup systems 
that we have in place that would ensure he could not ignore 
that direct order.
    In terms of our ability to make a determination around the 
world whether someone changes an airline reservation, I have to 
say, we don't have an international system in place. We need to 
work on that, we need to work with our European partners, we 
need to work with our Canadian partners to further enhance our 
ability to be able to do just what you are talking about. Right 
now that does not--without getting into great detail, we don't 
have that.
    Dr. Gerberding. In retrospect, as I mentioned, we realize 
that by giving this patient the benefit of the doubt, we put 
other people, especially passengers, at risk of exposure to 
this bacteria; and we believe that we absolutely need to be 
prepared to take more rapid steps to notify, as Dr. Runge said, 
not just at the field level, but to the national operations 
centers, so that the whole compendium of tools--had we done 
that in this particular case, it would not have made any 
difference in the patient's ability to get into the United 
States, but we don't want to ever be there again.
    Ms. Clarke. I know my time has expired, Mr. Chairman.
    I raised a question of outbreak. I raised the question of 
outbreak because that could have been the natural progression 
of this particular incident. Thank God it is not, as far as we 
know, but think about all of the locations that this gentleman 
traveled through. He went to France, Italy, Greece, New York, 
started in Atlanta. He could have infected thousands. They 
could have then infected hundreds of thousands.
    I don't know that we are prepared as a nation to take on 
the quarantining and the testing that something of this 
magnitude points to. And I am raising it because I want us to 
be prepared, should this ever happen again, for what the 
consequences could be to our Nation and to the world in which 
we live.
    Thank you very much, Mr. Chairman.
    Chairman Thompson. Thank you very much. The time has 
expired.
    I now recognize the gentlelady from California for 5 
minutes, Ms. Sanchez.
    Ms. Sanchez. Thank you, Mr. Chairman. I am sorry that I 
missed the earlier testimony and some of the questions from my 
colleagues. I apologize. I was doing body armor over in the 
Armed Services Committee this morning, a hot topic today.
    The problem I see is, no matter how many safeguards we put 
in, it always comes down usually to an individual, an 
individual having the right training. We all see it every time 
we go through the airport system and the security system, that 
we are treated in different airports in different ways and 
different manners by different people; and it comes down to 
this training of our people who are responsible for many of 
these very important things.
    It seems that there were a lot of breakdowns in the system, 
but one was--my understanding--the gentleman who said, this guy 
doesn't look sick. Now how much training are we providing to 
our people at the border, and do we need more, do we need an 
additional class in something like this or--I mean, the next 
time it will be something different.
    So I would ask you, what do we need to do to ensure that 
our people are up and trained at these ports of entry?
    Mr. Basham. Well, let me just say, Congresswoman, this is 
not an issue of the training that this person had, which in 
fact he did have on a yearly basis. He did receive training. 
This was clear disregard of a very clear instruction as to what 
to do with this person. It was not about whether he had the 
ability to make a medical assessment, which he is not there to 
do in the first place. He is there to follow instructions; he 
failed to follow instructions. We are taking appropriate action 
on that individual.
    But let me just say that we have, in fact, built in 
additional safeguards at our ports of entry that would prevent 
that individual from being able to make that decision 
independently, that they can't at this point in time disregard 
a clear order to refer that person to secondary. They don't 
have that option when they have an exact name match.
    Ms. Sanchez. Great. What about placement of a nonterrorist 
on the no-fly list? Had that occurred before or is this 
something new?
    Dr. Runge. Representative Sanchez, we had spoken a bit 
earlier--in the memory of the Director of Intelligence for TSA, 
this was the first time in his memory that anyone who was a 
nonterrorist had been put on what we are referring to as an 
adjunct to the no-fly list, so we don't confuse it with those 
who are in fact terrorists. That is actually why it took a bit 
of time, about 4 hours, before it went out after we received 
the name from CDC.
    So this is probably a first. And actually--I think they did 
quite well actually to get the airlines notified within about 4 
or 5 hours.
    Ms. Sanchez. The person who took that call from CDC--when 
CDC said, we have a problem here, and you should be stopping 
anybody who gets on a plane, who is this guy--what was the time 
frame there? And because this was the first time, did the 
people handling this know that they had jurisdiction or ability 
to put this person on an adjunct list?
    Dr. Runge. As a matter of fact, yes. The CDC contacted my 
office at about 1:00 with the information that this had turned 
into something that appeared to be a noncompliance situation, 
that no longer was he going to keep his reservation and follow 
the instructions of the person he had been communicating with, 
but in fact he had absconded.
    Dr. Lange in my office quickly convened a conference call 
with TSA and with CBP and CDC through the National Operations 
Center to discuss next steps. The CDC inquired as to whether 
the TSA could put him in a no-fly situation. The answer was 
``yes.''
    The CDC then called us back with the name of the 
individual, and at that point, within a short period of time, 
the Deputy Administrator for TSA made the decision that on her 
authority--that is, a separate piece of legislation beside the 
terrorism one that you all have granted TSA--they could enter 
this person on a no-fly list.
    There was a confab of attorneys from Justice and DHS to 
decide exactly the right way to do this, to make sure that it 
could be done, since it was a novel situation; and that 
decision was reached over a couple hours of time, and he was 
added to the no-fly list about 7:30 p.m.
    I just point out, he crossed the border the same day about 
an hour and a half earlier.
    Ms. Sanchez. I have one last question.
    It seems to me--and, Mr. Ahern, I had the privilege of 
being with Homeland Security out in Rome where this had just 
happened at the time, and you have very capable people there, 
by the way.
    It appears to me that Mr. Speaker was evading. Are there 
laws on the books to go after somebody who puts somebody at 
risk in that way? Because to go to Poland from Rome and to go 
to Canada to come into the U.S.--and I think, as I walked in, 
Mr. Green said, he went to Canada, the assumption there, I 
think was, he didn't go through Mexico because we have a much 
tighter security point there; and that points to one of our 
weaknesses.
    But are there laws or do we need to go back and take a look 
at somebody who could potentially infect so many people in the 
world?
    Dr. Gerberding. I think I can answer that, in part.
    If the patient is under a Federal isolation order, we 
certainly have legal recourse. The patient was not under an 
isolation order because he left the country before it could be 
issued.
    He could have been placed in isolation by the Ministry of 
Health in Italy, and if we had appreciated, as you said, that 
he was evading the situation, we certainly would have pushed 
for that earlier in the course of events.
    But there are different legal authorities in different 
nations, and the Nation of jurisdiction is the Nation in which 
the person is currently present, and that does complicate 
things. But we can, through the authorities in the agreements 
that homeland security is creating, at least prevent people 
from flying from one location to another. I know that system is 
in the process of being strengthened.
    Ms. Sanchez. Thank you, Mr. Chairman. I think maybe we have 
to take a look at tightening that.
    Chairman Thompson. I agree.
    I will now yield 5 minutes to the gentleman from 
Massachusetts, Mr. Markey.
    Mr. Markey. Thank you, Mr. Chairman. Let's think about it 
from the other perspective.
    Mr. Basham, would you be happy if a Canadian citizen had 
landed at JFK? The Canadians knew that he had a resistant 
strain of tuberculosis, and they did not notify you that this 
threat was now out into New York City; and at 3:00 that 
afternoon they are not telling you, and it is now some time 
that is going to lapse.
    Would you be happy with the Canadian Government if they did 
not tell you anything?
    Mr. Basham. Congressman, I would be very unhappy if I 
thought they knew and had that information on the travel of 
that individual and did not notify.
    We didn't have the information, Mr. Congressman, that he 
was going to be flying into Montreal and making a land entry in 
Champlain, New York, so there--we need to strengthen some other 
points in our data-sharing. But we--had we known that this 
individual was going to land in Montreal, we would have in fact 
alerted the Montreal officials, and I am sure they would have 
taken action.
    Mr. Markey. When did you notify U.S. officials that he was 
in Montreal, that he was in Canada?
    Mr. Basham. He entered at Champlain, New York, at 6:18 on 
the 24th. Due to our sweeps at our National Targeting Center, 
we--
    Mr. Markey. When did you know he was in Canada?
    Mr. Basham. We didn't know he was in Canada until we had 
already realized that he had crossed the border and we notified 
CDC that he was, in fact, in the United States.
    Mr. Markey. In the United States.
    I am just trying to understand this. The Border Patrol 
already had this in their computer at the point at which he had 
crossed; is that correct or am I wrong on that?
    Mr. Basham. What happened on the 22nd of May: We entered 
Mr. Speaker's information on his travel and the fact that if 
Mr. Speaker arrived at one of our points of entry, very clear 
instructions that he was to be referred for secondary 
inspection, and then a series of cautions would be put in 
place--put a mask on him, put him in a ventilated area, 
isolation, and then notify the CDC.
    We were tracking the airline reservation systems and the 
data that we had at our NTC.
    At 12:32 a.m. on the 25th in one of these--when we were 
sweeping the system to try to determine whether Mr. Speaker had 
in fact entered one of our ports, that is when we realized that 
he had, in fact, entered on the 24th at 6:18.
    We then immediately made the notification to CDC, who then, 
as I understand it, reached out and contacted Mr. Speaker and 
gave him instructions.
    Mr. Ahern. I think it would be important--
    Mr. Markey. Did you notify the Canadian public health 
officials when you notified all U.S. points of entry? Did you 
notify them simultaneously?
    Mr. Ahern. If I could add to the commissioner's question.
    Mr. Markey. No, I need the answer to this question. Thank 
you.
    Mr. Ahern. We did notify through the Canadian authorities 
within 15 minutes after we realized he had entered the United 
States. Those would be our counterparts within the Customs/
Border authorities on the--
    Mr. Markey. How about the public health officials in 
Canada?
    Mr. Ahern. They were not notified by us. We did not know 
the individual was going there, thus posing a health risk to 
Canada. So I would defer to CDC.
    Dr. Gerberding. Shortly thereafter, but I can't tell you 
what time-- we can get that for the record--Dr. Butler Jones, 
who is the Canadian counterpart, and I were also communicating 
by email during this time.
    Mr. Markey. Can I ask if the father-in-law, Dr. Cooksey, 
has had an x-ray to determine whether or not he has TB?
    Dr. Gerberding. I don't know the details of Dr. Cooksey's 
medical history myself, but he has stated that he has been 
tested for tuberculosis and is negative.
    Mr. Markey. Have you been able to determine that he has 
been tested?
    Dr. Gerberding. We have initiated an internal review at CDC 
to look at a number of issues around his involvement in this 
situation, and we also have reached out to the Inspector 
General to make sure that we have an objective assessment of 
all of these details. So we are very interested in 
understanding exactly what his situation and role is.
    Mr. Markey. Do you know when he had the x-ray to determine 
if he has TB?
    Dr. Gerberding. At this point, I don't have details of his 
medical history or documentation. I am relying on his written 
statements. But that is exactly why we are doing this internal 
review.
    Mr. Markey. Is it possible that something can cause a 
false-negative TB skin test?
    Dr. Gerberding. You can have a false-negative TB skin test 
if they are improperly conducted. But this person has been a 
person who has worked in the laboratory for more than 30 years, 
and I think we have confidence that skin testing would have 
been appropriate in this case. It is part of our Occupational 
Safety and Health program at CDC that people who work in 
laboratories have to go through periodic testing by our 
officers who are in a position to do these.
    Mr. Markey. Is it possible Mr. Speaker got TB from his 
father-in-law?
    Dr. Gerberding. No. We have absolutely no reason to suspect 
that. We actually have 25,000 isolates of TB in our laboratory 
that we have completely fingerprinted, and we have compared 
those to the patient's isolate and there are absolutely no 
matches.
    Mr. Markey. Thank you, Mr. Chairman.
    Chairman Thompson. Thank you very much.
    Several members have asked for a second round of questions, 
especially since Dr. Gerberding was a little late coming in. 
For those who wish to remain, please do so.
    Dr. Gerberding, one of the things a lot of us are concerned 
about is, now that you have had an opportunity to review this 
incident, what would you do differently now if a similar 
incident occurred?
    Dr. Gerberding. There are three main areas that we think we 
can improve. The first relates to our ability to support the 
State in isolating the patient before he leaves the country, 
and we have already initiated the process of assessing our 
current authority to prevent exportation, as well as any 
additional support for that that we would need in the future.
    A second dimension relates to the speed of our 
notifications, both the speed of our notifying to Homeland 
Security, the speed of our notification to the World Health 
Organization and affected ministers of health. In this case, we 
definitely could have sped up our notification process, but 
unfortunately in this case, even if we had done notifications 
early, it would not have mattered because the systems were not 
in place to find the patient and prevent him from doing exactly 
what he did.
    The third area that I think is very important, which is 
basically a CDC issue, but it will come up again, is that our 
government does not have a mechanism to support the transfer of 
patients with communicable respiratory diseases safely, 
efficiently and affordably under these circumstances. The 
options for any citizen right now who come down with a 
communicable respiratory disease while traveling include, 
number one, pay out of your pocket for a Medivac to come home; 
number two, pay the DOD to bring you home in their equipment 
with their isolator; number three, stay where you are in 
isolation until you are treated long enough to be 
noninfectious, which for usual TB is a couple of weeks; number 
four, pay out of your pocket; and lastly, number five, our 
State Department has loans for people to get assistance in 
paying for their travel to come home.
    We believe in a situation like this, where it wasn't just 
about the patient's illness, but he was posing a threat to 
others--not just Americans, but others--that we should assume 
an ethical responsibility to help the patient get home 
affordably, and so we need an aircraft that has respiratory 
isolation capability in it.
    CDC does have a plane. We talked at length about any 
possible configuration of that plane that would allow us to 
protect the pilots, the law enforcement officials, his wife and 
other passengers on the plane.
    Now, on a long flight, which from Rome would have been a 
long flight back to the United States, we could not safely fly 
him on our aircraft. So we have learned a lesson that we need 
to invest in the capacity to reengineer our plane so that we 
can get patients with this kind of condition home. We may need 
authorities to spend Federal dollars to transport patients in 
these issues, and we will--we just came from the Appropriations 
Committee to ask that question.
    But I think had we been able to guarantee the patient an 
affordable mechanism to get home, he would have been unlikely 
to evade us in Europe, and we could have avoided at least the 
second half of the contact tracing and the exposure trackdown 
that we had to do.
    It is unfortunate, and I can tell you that the whole issue 
around CDC aircraft and why we have them and how much they cost 
has been of great interest to some members of the press, but 
for me as a CDC Director, I must tell you this is a capability 
we have to have at the agency, and in many cases it has saved 
lives.
    In this case, it could have saved at least half of the 
problems that we are dealing with today.
    So those are the three main lessons that we are focusing 
on.
    Chairman Thompson. So at what point internally will you 
look at this situation? Or have you just moved the entire 
review over to the IG?
    Dr. Gerberding. No, sir. Last Tuesday afternoon, I 
assembled the entire CDC team for a formal after-action report, 
actually conducted by a former three-star general used to 
exercising and training people, General Pete Taylor; and we 
went through, stem to stern, what happened up to that point and 
what lessons we needed to learn so we could begin actioning 
those lessons already.
    We will continue to have these after-action reviews 
because, for us, this is an ongoing investigation; we have to 
find all these passengers. By the way, we have found 92 percent 
of them so far. We have to find all these passengers, test them 
now and test them again in several weeks to make sure they 
didn't acquire tuberculosis and so on and so forth.
    So we are still in investigation here. I know you all are 
trying to end the DHS part, but we have got months to go before 
we are done.
    So the CDC agency after-action will happen inside our 
agency. I am sure we will be doing this together with Homeland 
Security in the future, as well as the internal review and the 
additional review we have requested around the circumstances of 
the father-in-law from the Inspector General.
    Chairman Thompson. Thank you.
    I yield 5 minutes to the gentleman from Indiana, Mr. 
Souder.
    Mr. Souder. Thank you, I wanted to clarify, Dr. Gerberding, 
was this the first individual case you have ever given to 
Homeland Security?
    Dr. Gerberding. Yes, sir, I believe it is. Because I am the 
only CDC Director that has interfaced with Homeland Security; 
it was created after I became the Director. This is the first 
time that we have requested these procedures be undertaken.
    Mr. Souder. The person behind you seems to be suggesting 
that might not.
    Dr. Gerberding. Let me clarify my answer. In terms of 
creating a no-fly order, yes. But in terms of interacting with 
CBP, we do that continuously.
    Mr. Souder. What about on the border? As opposed to no-fly, 
what about alert to the Border Patrol?
    Dr. Gerberding. CDC has quarantine offices that are 
literally side by side with the CBP, and I have actually just 
come from one in the Pacific Rim. I visited Miami, New York, 
Washington, Minneapolis, Los Angeles. I have been in these 
quarantine stations, and the first thing I notice, this is a 
team. The CBP people are there with the CDC quarantine officers 
and they work these things at a staff level all the time.
    Mr. Souder. Has there ever been a warning that would come 
up on a screen to Homeland Security before?
    Dr. Gerberding. There has been one other situation that was 
also an individual who has tuberculosis.
    Mr. Souder. We caught him and held him?
    Dr. Gerberding. We haven't had to catch and hold at the 
border yet.
    Mr. Souder. So this was the first one where they interfaced 
with CBP.
    Do you give other types of less specific, rather than 
watching this person? We are concerned about--at one point we 
were looking at bird flu fairly closely.
    Dr. Gerberding. We still are.
    Mr. Souder. In tracking that, do you give information to 
Dr. Runge and CBP of what they should be looking for, and does 
this appear on anybody's screen?
    And I have training questions, but that is another subject. 
I want to know what your interface is with them that goes to 
actionable intelligence for the agents.
    Dr. Gerberding. It happens at every level.
    It happens in the field, as I just mentioned, staff-to-
staff in the specific quarantine environment. It happens to the 
regional network of airports and ports that fall into that 
network of responsibility. But it certainly also happens in 
Washington, happens operation center-to-operation center. So we 
are very connected throughout our respective organizations.
    Mr. Souder. I mentioned earlier that I visited in Florence, 
Arizona, a detention center for OTMs, other than Mexicans. 
There in the health area we have a tuberculosis isolation ward, 
because people for a period of time are going to be together. 
Are you familiar with that?
    Dr. Gerberding. I have not visited the facility.
    Mr. Souder. Dr. Runge, do we have other places along the 
border? Is it just for the OTMs, the other than Mexicans? Or 
what kind of--explain that to me because clearly it is enough 
of a problem, we have a fair number of people that go through 
isolation.
    There were one or two individuals there when I was there. 
This suggests it is a fairly common occurrence on the southwest 
border because only a small percentage of them are OTMs.
    And we don't catch everybody, in case anybody didn't know 
that.
    Dr. Runge. You are correct. The Immigration Health Service, 
the Immigration and Customs Enforcement division DHS uses for 
the detention facilities at the border, are the health care 
deliverers for everybody whether they have TB or any other 
illness on the border. There are about 400, I believe, 
physicians and nurses who are part of the Immigration Health 
Service that we at DHS utilize, from the United States Public 
Health Service. There are TB detention facilities in at least 
several of the facilities, and I can't tell you the exact 
number.
    Mr. Souder. When we deport an individual who has been in 
isolation, do we tell that country that we are deporting them 
back to?
    Dr. Gerberding. Absolutely.
    Mr. Souder. I am concerned, as well, that we didn't tell 
Canada that one of the premises of the whole homeland security/
border protection that we are trying to work on the north 
border and south border is the North American perimeter.
    The Canadians are very justifiably upset that we only give 
them information on a need-to-know, if the person lands in your 
country and does damage, we will let you know that we knew. 
That doesn't fly, so to speak.
    I am concerned about Italy, but I am really concerned 
because we have the longest unprotected border in the world 
with Canada.
    Dr. Gerberding, do you view Canada differently? Are you 
more active with them with bird flu, the tracking that we are 
doing in Alaska, through Canada, in the bird flight. Same thing 
with Greenland, we have to have that cooperation--particularly 
with Canada.
    Dr. Gerberding. The Canadian Health, we are sister agencies 
and we share training. We have participated in joint tabletops. 
We are very seamlessly networked.
    Mr. Souder. Why do you think they didn't get this warning?
    Dr. Gerberding. I have to defer to the border warning as an 
issue that is not CDC's to own; but we didn't know if the 
patient was going to be in any one of the 193 countries.
    Mr. Souder. Why wouldn't Canada--and Mexico, for that 
matter--be an unusual concern to the United States? Because if 
they are going to come into the U.S., the only way would be 
somewhere near us to cross; and why wouldn't the CDC being 
sharing this information in particular with Canada and Mexico?
    Dr. Gerberding. We were following the World Health 
Organization international health regs, which require us to 
report to the World Health Organization and they, in turn, make 
the decisions--
    Mr. Souder. That would be something I would suggest, that 
there needs to be a high priority where we have a strategy--
    Dr. Gerberding. Exactly.
    At the time the patient was actually flying to Canada, we 
assumed that the next morning we were going to be negotiating 
with him how he was going to get home. And so at that time I 
was not speculating--and I wish I had speculated, in 
retrospect--if he is not going to come in through the U.S., 
what would be the other likely ways, and of course Canada and 
Mexico would be obvious.
    Mr. Souder. Is there any discussion in CBP about how to 
protect agents so they don't have a disincentive to release? In 
other words, this is a potentially highly contagious TB. He has 
a warning on his screen. This could have been bird flu.
    We, in effect, are hoping they are patriotic American 
citizens to do this, but depending on what we have in the 
border stations, they are at risk.
    Mr. Ahern. I think in this circumstance I would not agree. 
I think the lookout showed very specific actions to take to be 
able to isolate, ventilate, place the mask.
    We also have personal protective equipment for our 
officers, as well, so they can handle these situations; and 
frankly, that is what the annual training that is provided to 
them is, basically personal protection.
    I would like to go back to your last point, if I might, 
with Canada. Certainly, as has been discussed in this hearing 
previously, there was no indication the individual was 
traveling through Canada.
    Mr. Souder. Let me--the problem here is that it isn't a 
question of whether there are indications of going through 
Canada, that we have these embedded groups, that there is no 
indication that a cocaine dealer is going to go through Canada; 
but we swap the information that we have got a person on the 
loose, so to speak.
    If there is a terrorist coming from Pakistan, we don't wait 
until we see if they come through Canada, so that they can help 
us on the Canadian side; we tell them the information before 
they get there on the assumption they might. Because if we have 
a North American perimeter, they have got to have the same 
information at their airports and border crossings and ways to 
get into Canada or--in effect, we have to tighten up the north 
border. There are hundreds of miles with nothing on it.
    Our assumption is the Canadians are going to have the same 
amount of information, with very few classified cases, that we 
do; and what you are saying is, if we knew they were going 
through Canada. Well, that works for drugs, terrorists. Do we 
only tell the Canadians if we think they are going through 
Canada?
    Mr. Ahern. I think what you point out is exactly the point 
I wanted to make in reference earlier, but not in enough 
detail.
    It is clear we need to have greater access to information 
for flights and people coming into North America, not just the 
United States. We need to expand what we currently get on a 
very limited basis with Canada so we have complete visibility.
    With that come a lot of issues. I am not trying to be a 
bureaucrat, giving you excuses here; I am trying to lay out 
some of the issues with the negotiation, sovereignty, 
information-sharing issues that we are going to work through as 
we go forward. We have already begun those discussions in the 
last couple of days with Canada on this particular issue.
    As was even asked by the Congresswoman from New York 
earlier, about what more could we be doing throughout Europe, 
again each one of these agreements has to be negotiated through 
a group like the EU or individually on a binational basis. The 
reservation system we have are on individuals coming directly 
through the United States; it is clear that we need to have 
greater visibility into the global transportation chain, so we 
can identify people of risk who are looking to evade.
    We need to work on that with all deliberate speed so we can 
shore up some of those vulnerabilities.
    Chairman Thompson. Thank you. We have been more than 
hospitable.
    Mr. Basham, one question to that: What if the guard who 
allowed Mr. Speaker to come in said, I did it because I didn't 
have the protective gear that I should have had in my location?
    Mr. Basham. You are asking if he made that statement?
    Chairman Thompson. Have you surmised that everything that 
this guard needed to protect himself from this TB situation was 
available to him at his station?
    Mr. Basham. Yes, that was available to him. And actually 
the only response that this officer needed to take was to push 
a button that referred this individual to secondary for 
immigration. Those individuals would then have had the proper 
equipment and knew the proper response. They have all received 
the proper training.
    So I am quite confident that that individual at that 
location had exactly what he needed in order to carry out his 
clear responsibility.
    Chairman Thompson. I don't want to dicker with you, but 
some people are saying to us that that officer did not have a 
mask available to him at that site.
    Mr. Ahern. I would say, certainly on the primary, he may 
not have had one available, but the instructions refer to 
secondary. It would begin that process at that point in time.
    Again, without getting into the individual's actions--and, 
Congressman Lungren, I want to first assure you, we are moving 
with very fast speed, and I would be happy to provide further 
detail. We are not being bureaucratic in our answers or 
evasive, but there are rights and processes available to the 
individual. But I can assure you, from my review of the 
circumstances thus far, that is not the circumstance in this 
particular case at all.
    Chairman Thompson. Well, I guess the point that I want to 
raise is that I want to make sure all our employees--if a 
notice goes up that says, ``place mask on subject, place in 
isolation,'' that we in fact also would have similar equipment 
available to the employee that is expected to put the mask on 
the particular person we are trying to stop.
    I think there is a question as to whether or not that mask 
was available to that particular guard. Again, if the mask is 
not there, then I hope we have solved the problem going forward 
to make sure that all our guards have everything they need to 
do their job.
    I now yield 5 minutes to the gentlelady from the Virgin 
Islands.
    Mrs. Christensen. Thank you, Mr. Chairman. I will try to be 
brief in my questions. Dr. Gerberding, I guess, and maybe some 
of the other--Dr. Runge might want to answer also.
    In my reading it seems that there is a lot of variation 
between the States in quarantine protocols and procedures, and 
I am wondering if you have guidelines that you share or do we 
need to do something more to standardize those procedures.
    I notice that CDC has relinquished its quarantine to 
Denver, and I am wondering if Colorado has one of the better or 
one of the weaker quarantine procedures.
    Dr. Gerberding. All of the States have the capacity to 
isolate people with tuberculosis or quarantine them, but they 
do differ under the mechanisms for doing that and the criteria 
for stopping and starting.
    We have not recently reviewed that across the board. In 
general in our country, because of something called the model 
public health law project, all of our States have inventoried 
their capacities needed for preparedness and have initiated 
regulatory and statutory improvements in that. So we are at a 
point now where we can reinventory and see if there is anything 
that needs to be cleaned up.
    Dr. Gerberding. I doubt we will ever get 100 percent 
consistency. That is why we need the Federal authority to 
override on what the States can do, so that we are there when 
their system doesn't work or when they need our help, we can 
use our authorities to step in and protect people.
    Mrs. Christensen. OK. A couple of questions have been asked 
about the long time it takes to get the cultures and the 
results of the susceptibility to antibiotics. I celebrated my 
35th reunion a couple of years ago from medical school. And 
when I was in medical school it still took the same amount of 
time. Can you just help me to--is anything being done to reduce 
the time that it takes to get a TB result?
    Dr. Gerberding, thank you so much for giving me a chance to 
make this point. I said before we are fighting TB with 19th 
century methodologies. There are ways to speed up the 
identification of at least isoniazid resistance and some of the 
first-line drugs. But that equipment is expensive and many of 
our State health departments cannot afford the latest and 
greatest technology.
    Mrs. Christensen. Which gets me back to my budget question.
    Dr. Gerberding. I think that there are budget questions in 
terms of domestic tuberculosis control here. As we develop 
different techniques they are inevitably going to be, at least 
on the front end, more expensive. And we have the haves and 
have-nots. I was just in Guam, for example, another one of our 
territories, obviously, and they have no capacity to test for 
drug resistance anywhere in the Pacific Rim right now and they 
cannot send samples anywhere to have them tested.
    Mrs. Christensen. The countries they are close to have some 
of the highest rates of TB.
    Dr. Gerberding. Exactly. So we have some real gaps in our 
authorities and responsibilities and investments in this area. 
Having just come back, I am involved in trying to identify--and 
working with Dr. Castro, sitting behind me--to see if we can do 
a better job of supporting this capability everywhere.
    But having said that, we can never do the tests faster than 
the bacteria grows. And in this particular patient, his first 
sample took 18 days to grow. So it is a slow grower and that 
meant it took a long time to find out it was XDR.
    Mrs. Christensen. And my last question will be--I haven't 
heard what was shared with the Italian Government, OK. I think 
I have come to understand that we can only--our list only 
applied to flights coming to the U.S., so that is why we didn't 
know the person who was traveling to Canada. But what was 
shared with the Italian authorities that could have prevented 
this?
    Dr. Gerberding. We are running into time line issues 
between time in Rome and time in Atlanta. So forgive me if I am 
not precise in this. But we first reconnected with the patient 
when he was in Rome at about 12:30 a.m., his time, on May 23. 
And at that time we had some conversations in the middle of the 
night for him about what should happen, what should he do. The 
next day we reached a member of the Ministry of Health who runs 
a program there for training purposes, who has a former CDC TB 
expert, and we asked for her advice. And then Dr. Castro, 
following that, notified the Deputy Minister of Health in Italy 
that we had the situation and that we may be needing their 
assistance to isolate the patient.
    The TB expert was planning to come and visit with the 
patient the next morning, and he had already left. So that was 
our informal mechanism of connection.
    We also notified the World Health Organization on the 24th. 
The WHO said, you know, right now the patient is not here, but 
we don't know where he is. This is not an incident of 
international public health emergency, but when you know more, 
let us know more, and then we will initiate formal contact with 
Ministries of Health. And the next day we got the itinerary, 
thanks to DHS, and we were able to go back and reconvened the 
conference call of the health ministers in the places where he 
had traveled and explained to them what was going on. So it was 
a 24-hour delay before the health minister was formally 
notified through the deputy mission. But I think, again as I 
said earlier, we were treating this person as if he was going 
to cooperate with our recommendations and our advice, and for 
the second time he proved us wrong.
    Mrs. Christensen. Thank you. Thank you, Mr. Chairman.
    Chairman Thompson. Thank you very much. Mr. Lungren, Mrs. 
Lowey is going to run to a meeting. If you could bear with us 
for a little while, I will try to get--she has some dynamic New 
York questions to ask.
    Mrs. Lowey. I wanted to thank the Chairman and my 
colleague. And I apologize, Dr. Gerberding, I was here earlier 
listening to the testimony--you know life here on the Hill. So 
if I could just ask you a few questions and then in the time 
allotted respond as you will.
    One problem I have had with the response is that on May 17 
public health officials knew that Speaker had disregarded their 
request by flying to Europe 5 days earlier. And when Speaker 
chose to travel to Europe against either the recommendations or 
orders of public health officials, alarms should have 
immediately been sounded across the board.
    First question: Why would CDC or any DHS agency trust 
Speaker to just remain in Rome after contacting him on May 23? 
Why wasn't someone there, even if from the Italian Government, 
which my colleague referenced, immediately? And on May 24, 
Speaker drove from Champlain to Albany, stayed the night, drove 
to New York City the next day. It is my understanding that 
someone from CDC spoke to Speaker via cell phone between Albany 
and New York. By then we knew he had traveled back to the 
United States against the wishes of CDC and DHS and then he 
misled a CBP officer at the Champlain crossing. This is clearly 
an individual who couldn't be trusted.
    Why were the New York State Police not contacted, at least 
to escort Speaker to Bellevue Hospital? If CBP knew what kind 
of car Speaker was driving and his license plate, wouldn't he 
have been relatively easy to pick up? Why do you now trust 
Speaker, who posed a public health risk, to drive himself 
voluntarily to the largest and most densely populated city in 
the country? And if Speaker were a suspected terrorist, not 
just a public health risk, would local first responders have 
been contacted?
    So I appreciate the fact that you are having an in-depth 
investigation, but these issues to me are so obvious, I find it 
extraordinary that you responded the way you did.
    Dr. Gerberding. First, let me admit that we distinguish how 
a terrorist should be treated from how a patient should be 
treated. And we are very medically minded at CDC, and I think 
our default premise is that we will trust the patient until we 
have good reason not to. And as I said earlier in my testimony 
here--
    Mrs. Lowey. Don't you have good reason not to?
    Dr. Gerberding. Exactly. That is the important point here. 
We at CDC learned about the patient on--that the patient may be 
in Greece or Europe, wherever, on May 18. We initiated an 
investigation to find out if that was true or not. Our first 
step was to call Delta Airlines, which was what he had been 
ticketed on, to find out did he travel, when did he travel, and 
so on and so forth. They had no record of him leaving the 
country. So we were not sure whether he was in the United 
States or whether he was abroad. He could have eloped in 
Georgia, for example, because of these issues and the medical 
advice that he was given.
    So when we took steps to try to put him on the CBP--give me 
the right words--watch list, lookout. Lookout. We knew that 
they would be looking for him if he crossed one of our borders, 
but also that they would sweep periodically to see if he was 
listed on any flight itineraries that might help us recognize 
him.
    When he returned from Italy--first of all, when he arrived 
in Italy we did make contact with him in the middle of the 
night, as I mentioned. And I think in retrospect that is the 
point at which we should have said, look, we cannot trust this 
person. He may say all the right things but he is not likely to 
follow our instructions, or we can't guarantee that he is 
following our instructions. So I think in retrospect a more 
aggressive intervention at that point is something that we wish 
we had done.
    The fact that we were thinking that he was going to receive 
care and that we had initiated help, and we were trying to be 
as helpful as we could, dissuaded us from taking, I think, the 
aggressive steps that in retrospect I believe we should have 
taken. The patient flew into Canada. We were notified several 
hours after he crossed the border, and we met him as he entered 
New York City with the order of quarantine, which was the 
authority we need in order to engage law enforcement, arrest 
him, and otherwise interact with him.
    We had notified New York State and city health authorities 
that this was in play and engaged their help. And everyone 
agreed that this plan made sense, and so he--in this case was 
extremely cooperative. We were in touch with him throughout his 
progress, and fortunately he did cooperate.
    Mrs. Lowey. I don't know if anybody else has a comment. OK. 
Well, I understand there is an in-depth investigation. But I 
guess what disturbs me, Mr. Chairman--and we see this with many 
hearings we have had--until there is an emergency, until there 
is an incident, we don't see appropriate procedures in place. 
So I would hope that as a result of this--and you said we would 
treat this person different from a terrorist. But if a 
terrorist wants to come in--and you recall what we did with 
anthrax, and we are very concerned about avian flu coming into 
New York City with this kind of strain, and I don't have the 
knowledge you have of TB or avian flu or another serious 
illness, and we don't know what the future is--could be a grave 
threat to all of us. So I hope this does get the in-depth 
investigation it appears to be having.
    Dr. Gerberding. May I just comment, sir?
    Chairman Thompson. Yes.
    Dr. Gerberding. I would like to just make two quick points. 
First of all there have been 72,000 people diagnosed with 
tuberculosis in the United States since I have been the CDC 
director, and we have never had to do this before. So most 
people do cooperate. And the spirit of giving a person the 
benefit of the doubt is something that has been generally a 
reasonable approach. In this case, we should not have continued 
that assumption as time went forward.
    But the second point is that when the patient came into New 
York City, I think like the passengers on the airplanes who 
have a reason to be concerned, they were in confined spaces 
with him for long periods of time, that is why we are 
investigating him; but I just want to for the public reassure 
that brief contact or being close to a person with even this 
deadly strain of TB for brief periods of time is not a health 
hazard. And we don't want people to be unnecessarily alarmed 
about exposure risk for this instance, and to just remind 
people that it is an airborne disease that does require 
prolonged shared breathing space. That is why we couldn't use 
the CDC plane to bring him here, but we could use the CDC plane 
to fly him down to Atlanta. If this were a pandemic influenza, 
very different story. And I think your point is very well 
taken.
    Mrs. Lowey. Thank you very much. Thank you, Mr. Chairman.
    Chairman Thompson. The gentlelady's time has expired. 
Recognize the gentleman from California for as much time as he 
may consume.
    Mr. Lungren. Thank you very much.
    Dr. Gerberding, you said you had 70-some thousand cases of 
TB since you have--or there have been since you have been 
director of CDC, and this is the first one you have had to 
issue an alert on. Is this the first one where the person that 
had the TB had a father-in-law that worked at CDC who also 
worked in the area of TB?
    Dr. Gerberding. I can't answer that. But I do know this--
because I don't know the health histories of all the people at 
CDC--but this is the first time I have had to issue a Federal 
isolation--
    Mr. Lungren. I understand. But my point is, you say we 
should have acted sooner, and we didn't know he had gone to 
Europe and we were trying to find out where he was. Wouldn't it 
be something to just ask his prospective father-in-law who is 
working in your operation?
    Dr. Gerberding. The father-in-law was also traveling, so he 
was apparently at the wedding or with the patient or someplace, 
because he was not at work. He was not reachable on his cell 
phone until he returned to the United States.
    Mr. Lungren. Nothing was done differently because you had a 
high-ranking employee who happened to be involved with this 
individual?
    Dr. Gerberding. Actually, this has to do with the division 
of responsibilities at CDC. But the quarantine officer 
responsible for this investigation works at Hartsfield Airport. 
He was not aware that the father-in-law was a CDC employee when 
he initiated the steps of this investigation. So there is a 
separation of information in our organization on that one 
dimension.
    Mr. Lungren. In your investigation, I presume you are going 
to ask the father-in-law as to what advice he gave the son-in-
law with respect to whether he could travel?
    Dr. Gerberding. Those are exactly the kinds of questions 
that I am sure will be looked to in the internal review. But 
what we really have here is a man who has been a fine scientist 
at CDC, who had two compelling responsibilities: one to his job 
and to the government and to his division, and the other to his 
family.
    Mr. Lungren. I understand that. I keep hearing this, and I 
empathize. But you know, we got 18, 19, 20-year-olds who are 
serving this country in Iraq and Afghanistan. We have examples 
where young men have thrown themselves on hand grenades to 
protect others. We have got people out there who have some real 
guts. They have compelling reasons to want to live and to want 
their families to see them. And you know there is a lack of 
responsibility here, certainly with Mr. Speaker.
    And I just wonder if there is a lack of responsibility and 
accountability with respect to his father-in-law who knew more 
about TB than I know, who knows more about TB than 99.9 percent 
of Americans.
    Now, let me ask you about this, because I am just becoming 
aware of this expression of XDR which stands for multiple drug-
resistant TB, correct?
    Dr. Gerberding. Multiple drug-resistant TB is a less severe 
form of tuberculosis. XDR means extensively drug resistant. It 
means we basically have lost first-line and most of the second-
line drugs.
    Mr. Lungren. He is XDR?
    Dr. Gerberding. He is XDR.
    Mr. Lungren. Why is that a compelling health risk?
    Dr. Gerberding. There are three dimensions of risk in this 
situation. The first is how infectious is he. He is not at zero 
risk for transmitting but, fortunately, has stayed at low risk.
    Mr. Lungren. But based on what we knew at the time, the 
alert went out that he ought not to be traveling.
    Dr. Gerberding. What we knew at the time was that he had 
been smear-negative and culture-positive, that he hadn't been 
on effective treatment for what he had. We knew that his chest 
x-ray was abnormal. We knew he had a very slow-growing 
organism, a la the questions about the time to detect this 
information. So the assessment at that time was that he was not 
at high risk of transmitting, but it was not a zero risk.
    Mr. Lungren. Then why didn't you send your plane to go get 
him and bring him back?
    Dr. Gerberding. The CDC plane is not configured to isolate 
a passenger with a communicable disease from the pilots, the 
law enforcement agents, that would be necessary for the 
passenger.
    Mr. Lungren. That is why I am a little confused. You 
suggested that people who were on the plane with him from 
Europe to Canada are not at high risk. But if they are not at 
high risk, why would the pilots in the plane that you would use 
from CDC be at an unacceptable risk?
    Dr. Gerberding. We make our decisions based on science.
    Mr. Lungren. I understand. But do you see what I am trying 
to say?
    Dr. Gerberding. It is very important because we use the 
science to use the distinction how long can the passenger be in 
the plane and not transmit to others, and who in the plane is 
at risk. So a long flight from Europe when--at that time he had 
been 2 months without TB treatment, we didn't know whether he 
had become more infectious. That is a health threat and that is 
why we were investigating the patients.
    Now we are focusing on the people who are two rows in 
front, two rows in back. That is where the science says risk 
exists. But when we needed to fly him from New York to Atlanta, 
it is a short flight. The flight from Atlanta to Denver is a 
short flight. We had law enforcement engaged, we had him in a 
mask, and we were able to mask the other passengers.
    Mr. Lungren. I understand that. We are talking about you 
wouldn't send him on a plane from Europe to the United States 
because that was a long flight, correct?
    Dr. Gerberding. Correct.
    Mr. Lungren. But yet he was on a long flight from Europe to 
Canada.
    Dr. Gerberding. Right. That is why we are contacting the 
passengers and testing them.
    Mr. Lungren. No, no, no. I understand that. I am just 
trying to say, we are contacting them because we think it is 
serious enough for them to look at. We don't want to get them 
in a crisis mode because everything you have looked at so far 
apparently shows he was not in a communicable state.
    Dr. Gerberding. That is not correct.
    Mr. Lungren. I am confused. I am really confused.
    Dr. Gerberding. Let me try to explain to you. There are 
degrees of infectiousness. This patient is at the lower 
spectrum, but not at zero. There are passengers on the plane 
who could have acquired TB from him under the circumstances of 
a long flight into Canada. With everything we know about him 
today, that is still the case.
    In our country 17 percent of all tuberculosis is acquired 
from a person who has his degree of infectiousness. So he is 
communicable.
    Mr. Lungren. So my question is, knowing what you know now, 
OK, would you make the same decision with respect to sending 
the CDC plane for him to bring him back from Europe to the 
United States?
    Dr. Gerberding. Absolutely not. I would not put the 
passengers in that plane at risk for more than 8 hours to 
travel with this individual.
    Mr. Lungren. So it continues to be a serious problem?
    Dr. Gerberding. It is a serious problem.
    Mr. Lungren. Let me just ask you--and the Chairman is being 
very kind on the time--but in our public knowledge today, 
unfortunately we don't consider TB to be very serious. I mean 
the average person would not think of that in the same terms as 
we did 40 years ago. When you saw people going to the hospital, 
it was more well known.
    And this also goes to the question of why we treat this 
differently than we do terrorist groups because this is a 
medical condition. We have concepts of rights of privacy. We 
have concepts of someone being able to go to a doctor without 
everything being revealed. But we make an exception in 
communicable diseases such as TB. This could have been avoided 
if this gentleman had acted responsibly.
    What message to the public would you give with respect to 
how we have to ask our individual citizens to be responsible 
when they have been identified with a communicable disease, 
even though--as you say, the various stages of it. And all of 
us want to--we all love denial when we have been told that we 
have a disease. So we will assume that we have the least 
serious form of it.
    And if you give someone an option saying, well, we 
recommend you don't travel because we think it might be this, 
but we can't assure you, what statement would you make so the 
public out there would have some sense of the seriousness of 
that, so that in the future, other Mr. Speakers would say, you 
know something, to protect my fellow Americans--or if I am 
going to Europe, Europeans, anybody--I am going to take this 
burden for 2 months.
    Dr. Gerberding. You know most of the 72,000 people I 
mentioned took the approach you recommended. When there are 
exceptions that is why we have our authorities. But I think 
we--when this is all said and done, we are going to be able to 
look at the true impact of this set of decisions on this 
individual and his family. They should be, you know, enjoying a 
honeymoon or whatever in a much safer context. We are going to 
look at the cost of all of this effort in terms of person hours 
and we are going to look at how difficult this has been for 
passengers who should never have to be thinking about 
acquisition of an infectious disease on an airplane.
    And I think that this has had a tremendous impact on all of 
us, including the workers at DHS and CDC and health 
organizations around the world. We will learn a lot. And we 
have already learned a lot. But I think it is a very sobering 
reminder of our individual responsibility, absolutely, but also 
our collective responsibility to continue to strengthen our 
network.
    Let me just say one thing. If citizens could do one thing 
to help us today, the one thing that citizens could do would be 
to cooperate with completing the information about their 
address, their telephone number, and their e-mail when they 
travel, preferably electronically when we get there. But we 
really need to have systems that allow us to know who is on 
what plane and how to find them very, very quickly. So as a 
citizen, please take that little piece of paper or provide the 
most accurate information you can when you fly, because it 
might save your life.
    Mr. Lungren. You brought up some questions about budget we 
have to consider. You have talked about things that we can do 
and we must do. And I hope that we proceed in that. But we 
can't give a false hope to average citizens that they can get 
away with being irresponsible because we are going to come save 
them and that we will take care of it no matter what they do. 
And I know you didn't intend that, but I just want to make sure 
people understand we will do things we have to do.
    This is a tremendous learning experience. But at bottom, 
people have to take responsibility for themselves and have to 
be held accountable. Thank you.
    Dr. Gerberding. It is a network of shared responsibility 
and everybody has to do their part. Thank you.
    Chairman Thompson. Thank you very much. We now recognize 
the gentleman from Texas, Mr. Green, for 5 minutes.
    Mr. Green. Thank you, Mr. Chairman. And again I thank all 
of the witnesses.
    Doctor, we opened the door for you to make some comments 
earlier about the technology that is available and the lack of 
availability of the technology in terms of the ability to 
diagnose the illness. I would like to open another door for you 
because it is my understanding that we have approximately 1.6 
million people worldwide with TB. Is that about a fair 
assessment?
    Dr. Gerberding. Actually about a third of the world has 
been exposed and infected with tuberculosis. They are not all 
sick.
    Mr. Green. Diagnosed.
    Dr. Gerberding. They have been infected with TB at some 
point in their lives.
    Mr. Green. I understand. But my question to you is, those 
that have been diagnosed, is that about 1.6 million that we 
know of?
    Dr. Gerberding. Our expert says 9 million per year.
    Mr. Green. Nine million people. And the treatment for this 
extreme case is a multiplicity of drugs, probably three or 
four, taken over some prolonged period of time. And you have to 
take it under the supervision of some medical specialist; is 
this true?
    Dr. Gerberding. In general, tuberculosis is treated with 
three or four drugs for 6 to 9 months. This extreme drug-
resistant TB may have to be treated for years, it may require 
surgery, and we don't have very many drugs that will be 
effective at all. So this is very, very hard to treat.
    Mr. Green. Exactly. So here is where I would like to allow 
you to just give us some of your insight. It has been said that 
this is--TB, generally speaking, is a poor person's disease; 
that because poor people have it and they can't get the 
treatment, that it tends to persist; and the people who have 
the ability to make the difference don't do the research 
because it is just not cost effective for them to do so. Any 
truth to this?
    Dr. Gerberding. I think we all believe in the public health 
world that TB and malaria are neglected in terms of the amount 
of research that is being done on them compared to the burden 
of illness, if you look at it from a global view. We are just 
seeing an increase in the investments now. But as I said, we 
are practicing 19th century medicine with a 21st century 
disease here.
    Mr. Green. My final comment and opportunity for you to 
respond is this: Is it not true that the best way for us to 
deal with this--this is sort of a secondary, tertiary, or 
quaternary approach that we are taking--the best way to deal 
with it is at the source, the places in the world where we know 
that the disease itself is being promulgated. Is that not the 
best way? And, if so, should we not try to do more to help the 
developing countries and the world to cope with and manage and 
to eradicate this disease?
    Dr. Gerberding. The World Health Organization, in 
collaboration with CDC and a lot of others places has a program 
called the Stop TB Program. And it is a plan that says we can 
eliminate the transmission of this disease in the world. It is 
a hard job because it is everywhere right now. But in order to 
do that successfully, we have got to invest in new diagnostic 
tools, new drugs, and, most importantly, we desperately need a 
vaccine.
    So the ultimate solution to this problem would be a better 
vaccine than the old-fashioned one that we are using in some 
parts of the world right now. It is not an impossible task. But 
it is going to take a long road ahead, and one of the most 
important barriers to success is going to be having drugs that 
allow us to treat drug-resistant TB.
    Mr. Green. Thank you. I yield back.
    Chairman Thompson. Thank you very much. We now recognize 
the gentleman from Colorado, Mr. Perlmutter, for 5 minutes.
    Mr. Perlmutter. Thank you, Mr. Chairman. I really just had 
a couple questions since we are talking about Colorado. I read 
his quote, you know, that is in my timeline about ``if I don't 
get to Denver I am going to die.'' What is that all about?
    Dr. Gerberding. You know Denver Jewish has a fine 
reputation for tuberculosis treatment and management. It is 
just really the center of excellence. There are many other 
places in the country that can also very effectively treat 
tuberculosis. But this gentleman was interested in having the 
gold standard, and National Jewish certainly meets that 
criteria.
    Mr. Perlmutter. I am curious if, Commissioner, you think 
that--maybe someone has asked this, I apologize, I had to 
leave--whether or not something like this where you have sent 
strict instructions to your border enforcement folks, whether 
this would have happened on the southern border?
    Mr. Basham. I can't say with any assurance that this could 
not have happened on the southern border. But I can tell you 
that the men and women that are out there on the front lines 
completely understand that they have a responsibility for 
stopping any threat that enters this country.
    I believe this was one individual's independent decision, 
and we regard--we don't turn our back on the northern border. I 
mean, we consider the northern border to be as much of a 
responsibility and a challenge and a threat that could come 
from anywhere. So it doesn't matter where that individual would 
have crossed, we have a responsibility to stop that individual. 
We had the information. I think that 99.9--no. With the 
exception of this individual, I believe everybody else who had 
that information would have referred that person to secondary, 
and then when in secondary, they would have taken the proper 
precautions to make the alerts to CDC and handled that 
individual as a health risk.
    Mr. Perlmutter. Last question, and again sort of on the 
rhetorical side. I don't want to export our problems to 
somebody else. I don't want to import theirs. If we have a 
citizen--and this is just more for information purposes--a 
citizen of the United States who has some illness like this 
drug-resistant tuberculosis, and they are in a foreign 
country--I mean do we just leave them there, or is there some 
way to get them back to our country in a way that is--you know, 
we have precautions and you know, safety--but get them back 
here to be treated? And this, from what we see here, was going 
to cost this guy an arm and a leg. And, you know, I don't know 
if that is the problem or what.
    Dr. Gerberding. Let me say what I know about options for 
the situation. The patient could pay out of his own pocket. 
Some people can do that. But it would require an air ambulance, 
and that is why it was so expensive because we need to isolate 
his air. The DOD has an aircraft that has an isolator in it and 
we checked to see if that could be made available, and it 
could, but we would have to reimburse the Department of Defense 
to do that. His private insurer, who paid for him to fly to 
Colorado, may have assumed responsibility to bring him home 
from Europe as well. We didn't have a chance to really flesh 
that out because he left before we had a complete picture 
there.
    The CDC has an aircraft. We really wanted to try to bring 
him home in it because it would have been the simplest thing to 
do, but it wasn't safe for the law enforcement agents, the 
pilots, or the other passengers that would have been necessary 
to accompany him on a long trip, which this would have been a 
long trip from Rome to Atlanta.
    The last resource--and may have been the one we looked at 
short of finding a respiratory isolation--that we could provide 
was--the State Department deals with this kind of thing all the 
time. Travelers abroad don't have the means to get home, for 
whatever reason, including a communicable disease, they need a 
Medevac. And they have a program there to provide assistance to 
travelers who need this kind of help.
    So had he followed the instructions to contact the embassy, 
and he was specifically given this information, he might have 
been able to find, as many many other travelers have found, an 
alternative way to come home.
    So there were alternatives. I think what we would like in 
the future when it involves a disease that is potentially this 
consequential to the public health, an XDR TB, or the first 
case of H5 N1, or one of the things that is on the WHO's list 
of public health emergencies, we would like to be able to know 
that CDC could use an aircraft that we run basically, that has 
the appropriate isolation capabilities so that we can take that 
issue off the table. We don't have that capability right now. 
But we had asked for it and we are hoping that we will have 
both the authority and the resources to equip an aircraft to be 
able to provide that capability to us.
    Our CDC aircraft has been very controversial. People 
wonder, why are you spending so much money on these airplanes? 
We need to keep our strategic national stockpile ready. We have 
to be able to fly anywhere 24/7 to support the deployment of 
our stockpile assets. So those two planes are needed for 
readiness, and we cannot count on them to fly to Europe to pick 
up a sick patient.
    In this case our other CDC plane, which we use for a 
variety of nonstockpile-related missions, if we could make an 
adjustment in the air handling there--we have a plan, we know 
what engineering needs to be done, the aircraft company is 
willing to support us in this, and we have done inspections. We 
have had NIOSH in to investigate what is needed to be able to 
do this safely. We just need the final step of approval and go-
ahead.
    But I need to really, for the record here and for the 
public, say that as the CDC director I can't think of any 
agency who has more reason to be able to fly aircraft to save 
people's lives outside of the Department of Defense than this 
agency does. And we have proven many times that when we have 
used our aircraft, we have made a tremendous public health 
difference, whether it is sending botulism toxin or rabies 
vaccine or solving the problem in Panama with the cough syrup. 
We save lives with these efforts. It is expensive, but it is 
like insurance, and I think people deserve that level of 
support.
    Mr. Perlmutter. I see my time has expired. I have a dozen 
other questions, but I--
    Chairman Thompson. We have been very lenient, but we are 
actually going to put them in writing to the witnesses.
    Thank you very much. Let me thank the witnesses for their 
generosity and time to the committee, as well as their valuable 
testimony, and the members for their questions. The members of 
the committee may have additional questions for the witnesses, 
and we ask that you would respond expeditiously in writing to 
those questions.
    Hearing no further business, the committee stands 
adjourned.
    [Whereupon, at 1:34 p.m., the committee was adjourned.]

              Appendix: Addtional Questions and Responses

                              ----------                              

    Questions for the Record from the Honorable Bennie G. Thompson, 
                                Chairman

                 Responses from Dr. Julie L. Gerberding

These answers are based on the information developed and identified by 
CDC to date.
    1. Current U.S. public health policy requires that the CDC be 
apprised when MDR-TB appears also to be extensively drug resistant, so 
that CDC can provide laboratory confirmation of XDR-TB. Given the 
increasing incidence and prevalence of all types of TB, including MDR-
and XDR-TB, should the CDC be apprised sooner? If so, how?
    CDC Response: Please note that the number of new cases of TB has 
been declining every year in the U.S. The number of TB cases that are 
found to be drug-resistant is relatively the same every year.
    Currently, CDC receives reports of all verified cases of 
tuberculosis. CDC provides laboratory confirmation of XDR TB, as 
needed. Upon request, CDC performs drug susceptibility testing for 
Mycobacterium tuberculosis isolates referred from state or other 
authorized health facilities that may not have the capacity to test 
themselves or that may want a second confirmatory test. CDC 
epidemiologists are satisfied that cultures received for drug 
susceptibility testing are sent to CDC in a timely manner. CDC's drug 
susceptibility testing relies on growth of TB bacilli, which is a 
notoriously slow-growing bacteria. The process requires 1 month to 
complete. However, when performed properly, it allows laboratorians to 
quantify the portion of the bacteria in the isolate that are resistant 
to a drug, which is important for predicting if a TB treatment regimen 
is likely to fail.

    Question 2.: Should advanced laboratory diagnostics for XDR-TB be 
distributed to state public health laboratories so that they can 
conduct these tests at the state level? If so, would the CDC create an 
XDR-TB laboratory protocol to be put through the Laboratory Response 
Network, or would the CDC use a different mechanism to disseminate?
    CDC Response: Ideally, all states should have the capacity to 
conduct second-line drug susceptibility testing or the capacity to 
refer isolates for this testing. Not all state public health 
laboratories conduct these tests because drug susceptibility testing 
for the second-line drugs is a difficult procedure to standardize and 
maintaining the proficiency to perform these tests reliably when only a 
few tests are performed each year is challenging and expensive. 
Proficiency to perform these tests requires an understanding of many 
elements, including origin of and criteria for drug resistance, potency 
and stability of drugs during laboratory manipulation, anti-
mycobacterial activity of drugs when incorporated into different media, 
and reading, interpreting and reporting of results. To assist state 
public health laboratories with obtaining the necessary information on 
susceptibility to second-line drugs, states may submit isolates to the 
CDC laboratories for drug susceptibility testing to second-line drugs. 
About 20 of the state public health laboratories take advantage of this 
service.
    National guidelines recommend second-line drug-susceptibility 
testing for strains with rifampin resistance or resistance to any two 
anti-TB drugs (National Committee on Clinical Laboratory Standards, 
Susceptibility Testing of Mycobacteria, Nocardiae, and Other Aerobic 
Actinomycetes; Approved Standard. NCCLS document M24-A [ISBN 1-56238-
500-3]. 2003). These recommendations were reiterated by CDC in a recent 
MMWR published in March 2007. CDC communicates these and other 
guidelines to TB control programs through the CDC Morbidity and 
Mortality Weekly Reports and Recommendations, ``Dear Colleague'' 
letters, communication between program consultants and grantees, and 
educational webinars.

    Question 3.: Due to the nature of the TB organism and the small 
amounts of the organism in clinical specimens, it was difficult for all 
of the organizations testing for TB at the local, state, and federal 
level to grow the organism quickly and in sufficient quantities to even 
allow for drug resistant testing to occur. How close is the CDC to 
creating testing protocols that will allow for testing with much 
smaller amounts of the organism, as well as other advanced procedures 
that would allow for quicker growth, and diagnostics that would allow 
for quicker identification?
    CDC Response: Currently, culture-based tests are the standard, 
validated methods for drug-susceptibility testing of M. tuberculosis 
isolates. Protocols for rapid tests for detecting rifampin (a first-
line drug) resistance (based on detecting mutations associated with 
this particular drug) have been validated and are available in a number 
of public health laboratories. However, public health departments may 
opt not to use this test because of the resources required to validate 
the findings, or they do not have sufficient numbers of cases to make 
this worthwhile.
    However, this does not address the problem of the need for rapid 
second line drug tests. Rapid, molecular based tests have not yet been 
developed to detect resistance to the second-line anti-tuberculosis 
drugs because we have not yet identified the mutations that are 
associated with resistance to each of the second line drugs. Basic 
research is still needed to identify the genetic basis of resistance to 
each of the second-line drugs. The National Institutes of Health and 
CDC are funding and participating in such basic research as well as in 
translational research to use this information to develop reliable 
rapid diagnostic tests.

    Question 4.: At what point was contact tracing begun by the state 
of Georgia? When was that information obtained by the CDC and 
incorporated into its contract-tracing activities, if at all?
    CDC Response: A contact investigation was initiated by the Fulton 
County TB Control Program following the patient's first visit to the 
Fulton County TB clinic on April 25, 2007. CDC and the State of Georgia 
began working together on contact tracing related to the case on May 
28, 2007.

    Question 5.: What procedures exist for federal agencies such as CDC 
to contact passengers on airlines? It is our understanding that CDC 
could not effectively obtain passenger data, and finally asked the 
Department for help to obtain the information. However, there is no 
protocol in place for such a query. What protocols should be put in 
place to get CDC such passenger information?
    CDC Response:
    Procedures:
    Contact tracing is a public health tool used by CDC and Quarantine 
(DGMQ) to notify travelers of their exposure to communicable disease 
threats during commercial flights (or on other conveyances). It is a 
time-intensive and laborious process. CDC does not have direct access 
to passenger manifests or traveler contact information and must rely on 
the cooperation of airlines, federal partners, and other ministries of 
health to obtain passenger information.
    When CDC is notified (usually by a state department of health) that 
a person with a communicable disease entered the U.S. or traveled 
between states, CDC initiates a contact tracing investigation so that 
passengers and crew believed to be at risk of infection are notified 
and appropriate public health measures are implemented. Initial steps 
in this process are to verify disease diagnosis and risk of 
communicability and to verify travel information (e.g., travel dates, 
carrier name, flight number, departure date and city, arrival date and 
city, ill passenger seat number).
    Once CDC has confirmation of the disease and the flight 
information, protocols to obtain passenger data are followed. Because 
no federal mandate requires that airlines collect, store and provide 
passenger contact information to CDC in case of a public health event, 
CDC reaches out to many different potential sources of passenger 
contact data and compile relevant information.
    To obtain a manifest for international flights arriving in the 
U.S., CDC must issue an order requesting the manifest from the 
airlines. To do this, CDC has developed a formal Manifest Order and a 
protocol that is followed when requesting passenger data from the air 
industry. The formal Manifest Order, signed by the CDC Director, 
requires the airline to provide CDC with passenger names and seat 
numbers. It allows both the airline and CDC to share personal data 
while respecting patient privacy. CDC also relies on Memoranda of 
Understanding (MOU) signed between HHS/DHS (2005) and CDC/CBP (2007), 
which allow for the sharing of passenger data held by DHS agencies. 
Steps to obtain passenger contact data from CDC partners include:

        1. Notify the air carrier that they should begin to compile 
        necessary data and inform them that a formal Manifest Order 
        from CDC will be forthcoming
        2. Serve the air carrier the formal Manifest Order that states 
        the carrier is obligated to provide data (that it has 
        available) to the CDC
    Often manifests only contain the name of the passenger and the seat 
number, so CDC also requests Customs Declaration Forms from Customs and 
Border Protection (CBP) (inbound international flights only), on which 
passengers are required to provide a U.S. destination or residence. It 
is important to note that the Customs Declaration Forms request only 
the address while in the U.S., not telephone numbers, so contacting 
individuals by using this information remains a challenge. CDC also 
requests that CBP provide additional passenger data from its Advanced 
Passenger Information System (APIS) and Passenger Name Records (PNR) 
databases.
    In addition to the steps described above, CDC, primarily through 
its collaborative response to the Polonium incident in the UK, has also 
begun to work with the Department of State to obtain additional contact 
information for passengers who are US citizens. A protocol for 
obtaining such information is being formalized.
    CDC manually reviews the passenger information it receives from the 
various sources to determine the passenger's contact information. This 
information is then compiled into an electronic database and reviewed 
for quality assurance (e.g., frequently the address and phone number 
provided by airlines refer to the booking or billing agencies and not 
the passenger). Data are then imported into CDC's secure eManifest data 
system, which automatically sorts passengers by states and sends a 
secure notification and passenger contact information to the state 
public health agencies. Each state is then responsible for notifying 
passengers identified as living in their jurisdiction. For passengers 
who are foreign nationals, CDC notifies the foreign embassies, 
consulates or Ministries of Health and provides whatever contact 
information is available. The outcomes of these notifications and 
actions taken are then reported back to CDC.

Contact investigation for the TB case:
    For this case, the contact tracing investigation began May 25 when 
CDC learned the patient's full itinerary. CDC learned on May 18 that 
the patient had traveled internationally; however, his exact itinerary 
was not known. During May 18--25, efforts were focused on preventing 
the patient from continuing travel, exploring options for his safe 
return to the U.S., and determining his travel itinerary. CDC learned 
of his return to the U.S. on May 25, and contact tracing was initiated 
that day.
    The process for requesting manifests noted above is used when 
flights are U.S. carriers. In this situation none of the flights the 
case took were U.S. carriers or had landed in the U.S., so CDC had to 
rely on foreign governments to obtain names of passengers on those 
flights. On May 25, CDC requested that Public Health Canada initiate 
efforts to obtain the manifest of the patient's inbound flight to 
Montreal. Canada promptly received the manifest from Czech Air and 
began matching manifest names with their customs declarations. On May 
30, they confirmed that no U.S. citizens or residents were on board 
Czech flight 0104 other than the patient and his wife.
    On May 25, CDC also spoke directly with French health authorities 
and requested assistance in obtaining the manifest from Air France for 
the outbound flight from Atlanta to Paris. CDC also requested 
assistance from Transportation Security Administration (TSA) in 
obtaining the manifest information for those flights. TSA offered to 
work with their French counterparts to obtain the manifest and 
passenger contact information for Air France.
    Recognizing that the process of CDC's reaching out to passengers 
can be time consuming and ineffective, the flights of concern were 
released publicly through a Health Alert Notice and press conference on 
May 29. These notices included CDC phone numbers for affected 
passengers to call so they could be directed for evaluation and 
testing.
    On May 31, CDC received the following manifest and passenger 
information:
         Via TSA, Air France Flight 385 manifest which included 
        the entire list of all 435 passengers. The list did not 
        differentiate between U.S. citizens or residents and non-U.S. 
        citizens or residents and did not contain contact information.
         Via European Centre for Disease Prevention and Control 
        (ECDC)- a list of the 26 U.S. citizens and residents seated 
        either in the same row or two rows behind or in front of the 
        case. This list included any contact information that French 
        Health Authorities were able to obtain.
         Via Delta (Delta is a Code Share with Air France), 
        passenger locating information on those U.S. passengers who 
        made reservations through Delta.
         Via DHS (CBP), contact information for U.S. citizens 
        and residents on Air France 385 (APIS records of the 2 
        flights).
    Due to poor data quality and completeness, CDC requested assistance 
from the U.S. Department of State to obtain additional contact 
information for U.S. citizens and residents. CDC also contacted foreign 
embassies or consulates located in the U.S. for assistance in obtaining 
additional contact information for foreign nationals residing in the 
U.S.

Improving the Process:
    CDC is working on a variety of activities to improve its ability to 
request and receive timely passenger contact information.
         Operationalization of the MOU with DHS: Memoranda of 
        understanding between HHS/CDC (2005) and CDC/CBP (2007) are in 
        place to ensure rapid sharing of information between government 
        agencies to facilitate contact tracing on international 
        flights. CDC and DHS have had a series of meetings to discuss 
        and draft standard operating procedures (SOPs) by which to 
        operationalize these MOU. These SOPs will ensure the quick 
        exchange of information and will address when and whom to 
        contact in case of a public health threat on an international 
        flight.
         Quarantine Regulations: In 2005, CDC/HHS proposed 
        changes to 42 CFR Parts 70 and 71 that would update and clarify 
        interstate and foreign quarantine regulations. Included in the 
        proposed changes are requirements for airlines to collect 
        passenger contact information and transmit it to the Federal 
        government. CDC is currently finalizing this rule.
         eManifest: In response to the Severe Acute Respiratory 
        System (SARS) outbreak, CDC developed the eManifest system, a 
        robust, web-based secure system that can rapidly access 
        passenger contact information provided by airlines to 
        facilitate emergency public health investigations by state and 
        local health departments. In 2004, CDC signed an MOU with Delta 
        Airlines to develop and pilot test strategies that might later 
        be shared with all U.S. carriers around three areas: airline 
        passenger/crew data capture and contact tracing, emergency 
        response, and communications and education. Currently, only a 
        few airlines submit electronic manifest data, which are often 
        incomplete; therefore CDC still relies on other sources of data 
        to obtain reliable contact information and manual entry of 
        these data into an electronic database, which can then be 
        imported into eManifest.
         Passenger Locator Forms: CDC uses Passenger Locator 
        Forms when illnesses are identified during travel. These forms 
        are distributed to passengers who have been potentially exposed 
        to a communicable disease, allowing CDC to contact them to 
        provide relevant public health messages and/or coordinate 
        necessary treatment and care. These forms are scannable to 
        allow rapid conversion of paper forms to electronic data which 
        can be imported into the eManifest system

    Question 6.: The finding of MDR-TB by the Georgia State Public 
Health Laboratory caused them to alert the CDC so that it could test 
for XDR-TB. Was this the proper protocol to follow? What is the formal 
procedure by which CDC is asked to perform this analysis? Should CDC 
have been asked to perform the testing earlier?
    CDC Response: CDC is a reference laboratory that routinely assists 
state and local public health laboratories conduct testing, 
particularly drug susceptibility testing, on M. tuberculosis isolates. 
State public health laboratories may request CDC assistance at any 
time. The Georgia State Public Health Laboratory is one of about 20 
state public health laboratories that rely on the CDC laboratory to 
assist in drug susceptibility testing for second-line drugs. The 
Georgia laboratory followed the established, appropriate procedure in 
alerting CDC that this culture be tested.

    Question 7.: Why did a CDC staff member physically go to the 
Georgia State Public Health Laboratory to pick up the specimen? Was 
this the proper protocol to follow? Does the CDC dispatch its own 
personnel to physically pick up TB specimens from public health 
laboratories throughout the Nation and its territories? If not, what 
caused the CDC to decide it needed to physically pick up the specimen 
this time (acknowledging the very small distance to drive between the 
main campus of CDC and the Georgia State Public Health Laboratory?
    CDC Response: In response to the threat of MDR TB, CDC increased 
funding to strengthen public health laboratories and placed emphasis on 
providing prompt and reliable laboratory results. When an isolate is 
identified that requires priority testing, CDC works with the state 
public health laboratories to conduct that testing as rapidly as 
possible. In almost all cases, the most time-effective and cost-
effective method for getting an isolate to the CDC laboratory is for 
the state public health laboratory to send it to CDC using one of the 
commercial overnight delivery systems. An exception is the Georgia 
state public health laboratory for which the most efficient method is 
courier. On occasion, one of the CDC laboratory employees stops by the 
public health laboratory to pick up specimens since the lab is in close 
proximity to CDC's campus.

    Question 8. How does an ``isolation order'' differ from a 
``provisional quarantine order''?
    CDC Response: Based on authority contained in section 361 of the 
Public Health Service Act (42 U.S.C. Sec. 264), CDC may apprehend, 
detain, or conditionally release individuals arriving into the United 
States from a foreign country or moving from one state into another who 
are reasonably believed to be infected with or exposed to certain 
specified communicable diseases. On November 30, 2005, HHS published a 
Notice of Proposed Rulemaking proposing updates to communicable disease 
regulations found at 42 CFR parts 70 and 71. 70 Fed. Reg. 71,892 (Nov. 
30, 2005). As part of this process, HHS proposed new procedures for the 
issuance of a ``provisional quarantine order'' and a ``quarantine 
order.'' While not yet finalized, CDC followed administrative 
procedures similar to those in the proposed rule. A provisional 
quarantine order imposes a public health restriction that, for example, 
may include, isolation, quarantine, medical monitoring and reporting, 
or some other form of public health intervention. Such an order is 
temporary in nature and may be superseded by a permanent order that 
continues the public health restriction until the individual is no 
longer considered to be infectious.

    Question 9.: There appears to be confusion about what prohibitions 
health officials can place on an individual with an infectious disease. 
According to Dr. Gerberding, health officials ``usually rely on a 
covenant of trust to assume that a person with tuberculosis just isn't 
going to go into a situation where they would transmit disease to 
someone else.'' At this point, does CDC believe that a covenant of 
trust should be the basis of national and international public health 
policy?
    CDC Response: In the vast majority of situations when a patient is 
diagnosed with an infectious disease and told not to travel, the 
patient operates under a covenant of trust. The state health department 
advises the patient, explains what needs to be done to provide 
protection, and the patient generally cooperates. If the patient does 
not cooperate, the state has the legal authority to isolate or 
quarantine the individual. Each individual state is responsible for 
intrastate isolation and quarantine, and the states conduct these 
activities in accordance with their respective statutes. These 
authorities vary a great deal by state. In Georgia, for example, a 
court order is necessary for a patient to be isolated involuntarily, 
and the patient must first demonstrate that he is not compliant with 
medical advice. Therefore, in this case the state could not issue such 
an order until the patient actually did something that was against 
medical advice. If a state felt that it could not adequately isolate a 
patient, it could contact CDC to determine whether Federal quarantine 
authorities could be used. Federal authorities allow CDC to act in the 
event of inadequate local control, if the patient has a specified 
communicable disease and is moving between states, or if the patient 
has a specified communicable disease and represents a public health 
threat to other persons who may then be moving between states.
    This TB case raised a number of issues that CDC is examining. One 
issue is whether state laws need to be strengthened to give states the 
ability to restrict the movement of patients before they demonstrate 
noncompliance with a medical order. If a state believes the patient has 
a strong intent to put others at risk, the health authorities of that 
state need to have the authority to take action absent documentation of 
intent to cause harm. CDC has been supporting work being done by 
Georgetown University and Johns Hopkins University to develop the 
Turning Point Model State Public Health Act and the Model State 
Emergency Health Powers Act. These Acts were developed as planning 
tools to assist state, local, and tribal governments in assessing their 
current public health laws and to identify areas that may need updating 
or improving.
    Secondly, the underlying issue that this case raised is how to 
maintain the balance between the needs of the patient and protecting 
the public's heath. In this situation, CDC constantly gave the patient 
the benefit of the doubt, failing to use the most aggressive measures 
earlier in the process; however, in future such situations CDC does not 
want to go so far in the opposite direction that the result is 
unnecessarily restricting the movement of people. This balance will be 
difficult to attain. CDC is reviewing the lessons learned from this 
case and ensuring transparency in decisions, their timing, and how 
lessons can be applied in the process.
    CDC is also examining the application of its quarantine authority 
to situations of patients moving out of the country. Historically, the 
use of quarantine has been devoted to keeping people out and containing 
them. This case represents the first time that CDC has had to address 
preventing a person in the United States from leaving.

    Question 10.: Why the CDC chose to notify the local Atlanta CBP 
remains unclear. Department officials admit that CDC did not notify 
Customs and Border Patrol HQ in Washington. Why did the CDC notify the 
local Atlanta CBP and not simultaneously communicate with the 
Department of Homeland Security--the Office of Health Affairs, CBP HQ, 
or any other Departmental entity?
    CDC Response: CDC quarantine stations have developed strong 
partnerships with their local DHS partners and typically work directly 
with them at the local level The Atlanta Quarantine station took the 
lead on the initial part of the investigation until it was determined 
that additional resources and broader expertise were needed.
    As a result of this case and at the request of HHS and DHS 
leadership, a team of individuals from DHS, HHS Washington, and CDC 
(DGMQ and DTBE staff) met to review the response to the recent XDR-TB 
case and to develop standard operating procedures (SOPs) for future 
such responses. The SOPs are intended to formalize actions in three 
areas:

        1. CDC/DGMQ requests for DHS assistance in taking actions to 
        protect the public from infectious threats during travel and at 
        U.S. ports of entry;
        2. Internal CDC/DGMQ procedures for determining the need for 
        requesting DHS assistance, recognizing that DHS actions to 
        protect the public's health may restrict an individual's 
        movement; and
        3. CDC/DGMQ communications with international partners around 
        the issue of public health threats and the crossing of 
        international borders.
    The meeting resulted in draft SOPs for immediate use; these drafts 
are being revised in response to critical review. This is just one 
component of CDC's evolving partnership with DHS counterparts at ports 
of entry.

    Question 11.: According to Department of Homeland Security 
officials, CDC suggested to Speaker that the federal government had 
ways of keeping him from entering the U.S. Was this proper use of 
protocol? Does CDC believe that this threatening statement caused 
Speaker to become frightened and disregard CDC directives to either 
stay in Italy to seek medical attention or find a safe way to get back 
to the U.S. that would prevent others from being exposed?
    CDC Response: On May 22, a CDC quarantine officer spoke with the 
patient in Rome, Italy, and informed him of his XDR TB diagnosis; 
explained the severity of the disease; instructed him to terminate all 
travel and to cease use of commercial air carriers; and initiated 
conversations about isolation, treatment, and travel alternatives. The 
patient was offered assistance in finding appropriate airborne 
isolation facilities in Italy and agreed to cancel his planned travel 
to Florence the following day.
    On May 23, the same officer spoke with the patient in Rome and 
informed him that CDC would help him get the best care at a hospital in 
Rome (which had been identified) while options for safe return were 
explored, including air ambulance options. The patient was instructed 
to call American Citizens Services in Rome, and this contact 
information was provided to him. In addition, CDC explained that a 
former CDC staff member and TB expert working with Italian Ministry of 
Health would meet with the patient the next day to provide assistance. 
The patient provided hotel information for where he was staying so the 
Italian health official could visit with him the following day. During 
this call the patient was told he was on a CBP watch list and that 
airlines had been notified. The patient was informed of these 
procedures, not as a punitive threat, but to remind him that CDC was 
taking the situation very seriously. Again, he indicated that he did 
not plan to travel and would meet with the Italian health official the 
following day.

    Question 12.: When was the use of an air ambulance or other modes 
of transportation recommended and/or discussed with Speaker to 
transport Speaker back to the U.S. (as opposed to privately chartering 
an airplane that would have cost about $50,000)?
    CDC Response: When the CDC official spoke with the patient in Rome 
on May 23, a number of different options were discussed to safely 
repatriate the patient, including air ambulance and chartering a 
private plane. The patient also asked whether the CDC plane was an 
option.
    On the afternoon and again in the evening of May 24, CDC officials 
convened to discuss options for transporting the patient back to the 
United States. The appropriateness of transportation via DOD or the CDC 
airplane, the safety and health of crew and pilots, and CDC's legal 
authorities in this setting were all examined. However, before any 
decision could be finalized regarding the use of the CDC plane or other 
means of transportation, CDC learned that the patient had already flown 
commercially into Canada and then re-entered the United States via 
rental car, and thus, the discussion of the use of the CDC plane for a 
trans-Atlantic flight was discontinued.

    Question 13.: Dr. Gerberding has indicated that the decision not to 
utilize the CDC jet to transport Speaker was made based on scientific 
evidence indicating that transporting patients with TB for flights over 
eight hours would be dangerous to others riding in the same airplane. 
However, the flight could have been split into legs. For example, 
flight time from Rome to London is 2.5 hours. Flight time from London 
to Reykjavik is 3.0 hours. Flight time from Reykjavik to New York City 
is 6 hours. Flight time from New York City to Atlanta is 3.0 hours. 
Please provide the scientific justification for not utilizing the CDC 
aircraft for flights of less than eight hours duration. When can and 
does the CDC fly person using its own travel assets or those of the 
Department of Health and Human Services?
    CDC Response: Breaking down the flight into shorter flight segments 
would not have substantially lowered the overall risk to the co-
travelers or pilots (assuming they were all on board with the patient) 
throughout each leg of the journey. The risk increases cumulatively as 
more time is spent in close proximity with someone who can transmit the 
infections. So, if all persons were on each leg of the journey 
together, then the risk would have been basically the same as in one 
long journey, or perhaps even greater given the additional time needed 
for multiple-take offs and landings. In theory, the risk of each 
individual would have been potentially lower if you had no co-travelers 
or caregivers accompanying the patients and a different crew of pilots 
available for each leg of the flight. This was not the case, however, 
and logistically would have posed its own challenges. In addition, 
frequent ground stops would have potentially increased the number of 
potentially exposed persons on the ground, especially if the plane had 
to be serviced, or entered for any reason, or if the patient had to 
exit the plane for any reason.
    The use of the CDC plane to transport a sick person from one 
location to another must comply with Federal Travel Regulations, be 
recommended by the CDC Director, and have HHS Assistant Secretary for 
Administration and Management (ASAM) approval. Using the plane for this 
purpose also requires approval from the General Counsel if any non-
Federal travelers will be traveling on the CDC plane. Careful 
consideration is also given to the current medical condition of the 
patient and the safety of the crew and attendants before a decision is 
made related to the transport of an ill or infectious patient.

    Question 14.: Was the CDC under the impression that the Department 
placed Speaker on the ``no-fly'' list based on the CDC conversation 
with CBP Atlanta on May 22?
    CDC Response: On May 22, CDC quarantine officials contacted the 
Atlanta Customs and Border Protection and requested the patient be 
placed on the CBP watch list. CBP confirmed that the patient's 
information had been placed on its watch list later in the day.
    After speaking to the patient on May 22 and 23 and learning that he 
intended to return to the U.S. in early June, quarantine officials 
contacted Delta and Air France to request that he be prevented from 
boarding.
    Once it was learned that the patient had left Rome and his exact 
location and intention to travel were unknown, CDC contacted the 
Transportation Security Administration (TSA) on May 24 to request the 
patient be placed on a no-fly list to prevent the patient from boarding 
a commercial aircraft destined for the U.S.
    The patient was put on the no-fly list at 15:15 EDT on May 24, 
2007.

    Question 15.: Notification of foreign governments is an important 
issue to resolve. What policies and procedures are in place to notify 
foreign health authorities (like the World Health Organization) in 
situations such as this?
    CDC Response: The International Health Regulations, which went into 
effect in June, 2007, provide policies and procedures to notify foreign 
health authorities. CDC followed the International Health Regulations 
and notified the World Health Organization and Italy on May 24. On May 
25, WHO notified France, the Czech Republic, Greece, and Italy.

    Question 16.: European governments were notified by WHO. Did the 
CDC itself also notify any European government (especially in those 
countries on Speaker's wedding and honeymoon itinerary)? If so, when?
    CDC Response: Although CDC's Division of Global Migration and 
Quarantine was notified by the GA Department of Health on May 18 that 
the patient may have traveled internationally, Georgia Health Officials 
were unable to provide an itinerary or confirm his whereabouts. During 
May 18--22, CDC staff communicated with the Fulton County Health 
Department, GA DOH, the airlines and the patient's family members to 
seek additional information about the patient's travel itinerary. The 
attempts were unsuccessful.
    On the evening of May 22 EDT (May 23 in Rome), CDC learned that the 
patient was in Rome. Later that same day, Italy was notified through 
informal channels. CDC reached out to a former CDC staff member, a TB 
expert who works for the Italian MOH, and she confirmed that she 
notified Italian authorities on May 23. Dr. Ken Castro, Director of the 
Division of Tuberculosis Elimination, formally notified Italy on May 
24. On May 24, CDC notified WHO; and on May 25, WHO subsequently 
notified France, the Czech Republic, Greece, and Italy. On May 25, CDC 
notified the Public Health Agency of Canada and requested that the 
manifest be requested for the patient's inbound flight to North 
America. On May 25, CDC spoke directly with French Health Authorities, 
alerted them to the situation, and requested assistance in obtaining 
the manifest from Air France.

    Question 17.: Did CDC ever suggest to Speaker that he turn himself 
into the U.S. embassy in Rome? If so, did the CDC also notify the State 
Department that they had given Speaker this option, so that they 
communicate this to the embassy and prepare their medical personnel for 
Speaker's arrival?
    CDC Response: The patient was instructed to call, but not 
physically go without calling first, to the American Citizens Services 
(ACS) in Rome, explain his situation, and seek their assistance in 
repatriation. This instruction was given to him very late in the 
evening (Rome time). Before CDC could contact ACS in Rome the following 
day7, the patient had left the hotel.

    Question 18.: What international procedures are in place to notify 
CDC (and vice versa) of the results of the testing? Would Italian 
health officials have had to start all over again with TB testing, or 
could Speaker's medical information been transferred easily? What role 
if any would WHO have played in the testing?
    CDC Response: CDC would not routinely be notified about the results 
of such testing by physicians in another country, but in cases where 
CDC is collaborating with other health authorities the information 
likely would be shared. Physicians with responsibility for treating a 
patient usually want to run and analyze test results themselves prior 
to treating the patient. However, physicians routinely consult with one 
another on test results as well as treatment options once patient 
permission has been documented. WHO would not have had a direct role in 
patient testing.

    Question 19.: Why did the CDC send Speaker to New York City when he 
was a potential health risk? What safety procedures did CDC advise him 
to follow as he traveled from Albany to New York City? Why didn't CDC 
go to get him before he could possibly infect other people?
    CDC Response: Once CDC officials reached the patient on his cell 
phone, officials determined that the risk for both the patient and the 
public was significantly less if he traveled directly to a nearby 
hospital to be evaluated then if he were to drive all the way to 
Atlanta, which would likely have meant numerous stops and a possible 
hotel stay. During this call, CDC officials instructed the patient to 
report directly to the isolation hospital in New York (Bellevue 
Hospital), where he would be served a quarantine order for isolation 
and evaluation. He was also given specific instructions as to how to 
protect the public from possible exposure, including the wearing of 
face masks and staying out of crowded public areas. He followed this 
direction, and at Bellevue was served a Federal order of provisional 
isolation and medical examination, authorizing medical evaluation and 
respiratory isolation for 72 hours for infectious TB.

    Question 20.: Please describe the communications between the CDC 
and HHS as this situation unfurled. Who made the decision for the CDC 
to have a press conference warning the public about Speaker?
    CDC Response: CDC kept HHS informed as the situation developed 
using existing chain of command structures to facilitate operations and 
communication (CDC Director's Emergency Operations Center to the DHHS 
Secretary's Operation Center). CDC held a press conference to alert 
passengers on the Air France and Czech Air flights that they may have 
been exposed to a person infected with extensively drug resistant 
tuberculosis (XDR TB).

      Questions for the Record from the Honorable Mike Rogers, a 
          Representative in Congress from the State of Alabama

    These answers are based on the information developed and identified 
by CDC to date.
    Question 1.: What modeling and simulation capabilities does CDC 
have to identify the migration of contaminants inside facilities and 
conveyances?
    Much of CDC's modeling and simulation capabilities to identify the 
migration of contaminants inside facilities and conveyances is being 
done through two ongoing projects, ``Computational Fluid Dynamics in 
Control Technology'' and ``Aircraft Cabin Airflows.'' Together, these 
projects have partnered with Boeing Commercial Airplanes, national 
laboratories, and universities (including the FAA Center of Excellence 
for Aircraft Cabin Environmental Research) to answer questions about 
how particles are transported by the airflow patterns on a commercial 
airliner. Specifically, the Boeing 767 was studied, both experimentally 
and through modeling. The particles at issue here are droplets expelled 
by the infected passenger. Several journal articles and technical 
reports have resulted. The tools developed in these projects can be 
applied to XDR-TB. CDC also has an ongoing collaborative relationship 
in bioterrorism prevention and preparedness work with Sandia National 
Labs (which partners with LLNL) and Pacific Northwest National Labs.
    The aircraft involved in the current incident are likely to have 
somewhat different cabin airflow patterns than the Boeing 767. However, 
through consultation with Boeing engineers, informed estimates can be 
made that relate the previous research to the current aircraft. We are 
also able to construct a model of any aircraft cabin, using 
computational fluid dynamics (CFD). The details of the cabin geometry, 
such as seats and ventilation inlets, would require information from 
the manufacturer of the aircraft. A complete particle transport CFD 
model would be several months in the making.

    Question 2.: Is there value in CDC knowing when a contamination has 
occurred, rather than for people to come forward with symptoms?
    For tuberculosis, there are years of study that indicate that the 
primary mode of transmission is from person-to-person and there is no 
existing evidence that would suggest that the general environment of 
aircraft or other facilities, for example, environmental surfaces would 
play a role in the transmission of tuberculosis. A recent study, 
conducted by British Airways suggests that the aircraft is a low-risk 
setting for environmental transmission of TB. Where transmission has 
occurred it usually involved close contacts and highly infectious 
individuals. Therefore, there is no supporting evidence that would 
necessitate any changes to the routine cleaning practices currently 
used on aircraft or other transportation facilities. Environmental 
transmission has been associated with healthcare facilities and certain 
medical procedures. In these instances, contaminated medical devices 
(primarily attributed to inadequate cleaning and disinfection or 
sterilization of medical equipment) have played a role in healthcare-
associated TB cases.

    Question 3.: How long does an aircraft or facility remain 
infectious after it has been contaminated? For example, how long would 
a facility that was contaminated by highly pathogenic influenza or 
anthrax remain contaminated?
    The possible duration of persistence after contamination is 
organism-dependent. In addition, the relevance of ``contamination'' 
varies with the organism in question, since even though an organism 
might persist, it may have zero potential for delivery to a susceptible 
person in a manner that would lead to infection. If an aircraft were 
contaminated by a highly pathogenic strain of avian influenza virus 
from a passenger who had been confirmed subsequently as infected, the 
potential infectiousness of any ``contamination'' would depend upon 
many factors. If the passenger had been coughing, surfaces in an area 
of 1--2 meters (about 6 feet) from the passenger could become 
contaminated. The concentration of H5N1 virus in expelled large 
droplets or small particle droplet nuclei is unknown. The persistence 
of viability of expelled respiratory secretions on surfaces depends 
upon several factors including the concentration of virus, temperature, 
and humidity. If the passenger had not been coughing, the area of 
contamination would be minimal. There is currently no evidence to 
suggest that inanimate objects or contact with human respiratory 
secretions has resulted in H5N1 virus transmission to people. However, 
routine hygiene should incorporate appropriate cleaning of surfaces in 
the aircraft that are likely to be contaminated by ill passengers at 
any time.
    Anthrax spores present a special case because they are able to 
persist in the environment for years. Decontamination strategies for 
intentionally released anthrax spores should not be generalized to 
other less durable organisms such as respiratory pathogens.

    Question 4.: In your view, how valuable is the ability to cleanse 
or decontaminate conveyances such as aircraft and facilities after 
exposure?
    Environmental surfaces become soiled with respiratory secretions 
and other potentially infectious material wherever humans are present. 
Therefore routine hygiene should include appropriate cleaning of 
surfaces that are likely to be contaminated by ill individuals. In a 
passenger aircraft, surfaces that are easily contaminated include arm 
rests, tray tables, and lavatory surfaces. These frequently touched 
surfaces should be the focus of routine cleaning to reduce potential 
for transmission of respiratory and other pathogens. Cleaning agents 
must be both demonstrated to be effective in inactivating 
microorganisms and compatible with the maintenance requirements for the 
materials on the aircraft. When an ill passenger is identified, e.g., 
an individual suspected or confirmed to have had avian influenza, 
cleaning should focus on the listed surfaces within about 6 feet of 
where the individual was seated, and on the lavatory facilities the 
individual may have used. Efforts should always be made to assist any 
passenger with respiratory symptoms to cover their coughs and contain 
their respiratory secretions with tissues, and to use proper hand 
hygiene during and after the flight. Special decontamination strategies 
may be useful when faced with a situation such as an intentional 
release of anthrax spores.

                                 
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