generally nih's role. bart that's role to support advanced development of products. barta is and will support the advanced development of vaccines and therapeutics and get them scaled up so that if they work they can be used in a mass vaccination campaign or in therapies. >> thank you. i yield back. >> now recognize mr. wax man for five minutes. >> thank you, mr. chairman. dr. frieden, you and other experts have said numerous times the key to protecting americans from ebola is stopping the ooh disease at its source in west africa. can you explain the approach in west africa to contain the spread? >> in brief to identify patients with ebola promptly, get them isolated and cared for safely. and in the event that individuals die, have them buried respectfully and safely without spreading disease. to turn off unsafe care and unsafe burial. that's what ef we have done until now. the size, scale and speed requires now remains daunting. instead of dozens or a handful of cases, thousands of cases to deal with. >> so would you say the approach is working but epidemic is moving too quickly to keep up with the amount of cases? >> i think the decrease in cases in some areas within west africa is proof of principle that the approach works. but we're still very far from the finish line. >> what are the consequences of failure in africa? >> if we are not able to stop the ebola epidemic in west africa, the risks are very high that it would spread to other parts of africa because of travel within africa. if that were to occur it could be a matter of years before we would be able to control it and the threat to the u.s. and other countries would be proportionately greater. >> some people say if that's the concern why not seal off africa and not let other people travel here from africa. would that solve the problem? >> from the standpoint of public health we look first at protecting americans from risk. protecting americans from threats. we have systems in place that trace each person who leaves one of the three affected countries, each person who arrives to the u.s. and follows them for 21 days. we have had people who developed fever who called up the health department with the 24/7 number that we provided to them and have been safely transported and safely cared for and have been ruled out for ebola. the systems rely on knowing where people are coming from and how they are getting there. >> the president asked for more money in the supplemental budget. a big portion of that goes to our efforts in africa to try and stop and contain this disease. but some of that money is going to be used right here in the united states to enhance u.s. government response to the ebola outbreak. the request includes $621 million for cdc for domestic ebola response. can you give a brief summary of what programs and initiatives are covered by this funding? >> thank you. these would allow us to work with states so all travellers are traced on a daily basis. if they become ill, they are promptly and safely taken to a facility ready to care for them. it would result in safer hospitals, not just from ebola but other infectious disease threats. there is a small research component the to allow us to implement a vaccine trial, probably in sierra leone. in the coming months. to determine whether vaccination works. other research would help us with rapid diagnostics so we could detect more rapidly if someone dame ill. we also would support all jurisdictions to be better prepared for ebola and other infectious disease threats, have safer hospitals, more rapid response and work closely with the state -- between the state and hospital systems within the state on infection control generally, ebola and other deadly threats specifically working closely with the funding for asper and other parts of hospital preparedness. >> it seems to me that it shouldn't be partisan in any way for us to give a grant of money the president requested to deal with the terrible epidemic in africa. the request is quite balanced in helping us deal with the situation as we now have it. in past times we've always had bipartisan support. talking about here in the united states, what if we had a pandemic flu. that would certainly be a lot more dangerous because of how well -- how fast it would spread. would these funds help us to deal with that? secondly, are we prepared for a pandemic flu? do we have a stockpile of the medications. are we ready -- as you said we don't know what will come next. but if that happened, are we ready for it? >> we always work to be better prepared today than yesterday and better prepared tomorrow than we are today. a pandemic of influenza remains one of the most concerning possibilities, the funding in the emergency funding request would assist this country, health departments, hospitals, the health care system, the public to be better prepared for ebola and other infectious disease threats such as the pandemic influenza. yes. >> thank you. >> i now recognize dr. burgess for five minutes. >> before i start my questioning i would like to submit for the record this document from the american hospital association for the record for today's hearing. >> without objection. >> dr. frieden, the administration's additional funding request states money will go toward 50 ebola treatment centers throughout the united states. some states, texas, has already started to designate sites on their own. so will state designated centers be included in that number 50, or will that be in addition to? >> i will comment and dr. lurie may want to continue. our approach is to strengthen the statewide systems. it would be the states responsible for, in collaboration with states and hospitals, in determining which hospitals would be used. what we have asked each state to do is four things related to the active monitoring program. first, establish the program including information flow from the state health department to local health departments. second, establish a 24/7 hotline for any traveler who thinks they have ebola to call so they can be safely managed. third, establish safe transport between wherever the person calls from and the facility that the state decided would be the facility to assess or treat them for ebola. the fourth is to work with their hospitals to identify facilities that are able to do that assessment and treatment. >> let me add it would be great if you had a 24/7 hotline for hospitals when they find that that suspected patient is on their doorstep at 3:00 in the morning. dr. lurie, let me ask you the same question. the 50 centers designated in the president's budget request is that in addition to the state designated centers or would those two state designated centers in texas full under the purview of the 50 centers that president obama's describing? >> as dr. frieden said, our process and plans have been to work through the states to identify facilities. ive the process works basically -- >> naake real simple. the two centers governor perry designated in the state of texas. do those fall under the parameters of what the president's budget request as it exists today? >> the funding will go to the states and the states in conjunction with the hospitals will determine which of the hospitals will serve as infectious disease containment centers or the ebola treatment centers system i guess that's as close as i will get to an answer. let me ask you a question. dr. lurie, do you report to ron clane? is that someone in the hierarchical reporting structure you have? is he a person to whom you report? >> i report to the secretary. i interface with mr. clane on a regular basis. >> in your testimony you say that under the national response framework, my office, your office, is responsible for coordinating the emergency support function number 8 response which is listed here. so where does mr. clane's responsibility fall in the emergency support function number 8? >> so during different kinds of events in the united states, whether they are national disasters or other kinds of emergencies, either fema is activated and as it is for hurricanes and floods and i know we have worked together in texas on a number of those things. fema is has activated an emergency support system number 8. public health and medical services are activated under that framework. >> let me interrupt you. that's under the coordination and control of secretary burwell. is that correct? >> emergency support function 8, yes. >> does mr. clane have a role? >> in this situation we have not had a declared national emergency. fema has not been activated. however, we have a very serious situation in the united states and mr. clane is the national coordinator -- >> let me interrupt you for a moment because my time is going to run out. i guess it's not fair to say that you have an emergency plan, but do you have a very serious situation plan that you are working under? >> we are doing aggressive planning both for what we have in the here and now and for the what-ifs. we work across hhs and the rest of the components of the federal government on the what-if planning. >> i will assume you will be able to make the details of the plan available to the committee staff? >> it is -- continues to be in draft. we continue to work through what ifs with the partners across government. yes. >> yes was the answer. >> yes, when we have the rest of the plan together. it's something that's a whole of government plan. it is not an hhs plan. >> it's time. dr. frieden, i have to ask. we had two nurses at prbt presbyterian hospital infected. i have to tell you. when you get the call at 2:00 on a sunday morning that a nurse is infected you don't have confidence that things are working the way they were outlined. do you have insight as to how those nurses became infected and what we can do to protect our health care workers going forward? >> we don't know how those infections occurred. the evidence points to them having been infected in the first 48 hours after mr. duncan was admitted to the hospital, before his diagnosis was confirmed. that's consistent with the period of time between on set of similar. toms and exposure. it's consistent with the set of similar. toms and exposure. it's consistent with the observations team of the team a. it's consistent with the observations team of the teaand. it's consistent with the observations team of the teand . it's consistent with the observations team of the teaand. it's consistent with the d exposure. it's consistent with the observations team of the teaand. it's consistent with the observations team of the teaand. it's consistent with the observations team of the teay6a. it's consistent with the observations team of the teajan. it's consistent with the observations team of the tea0an. it's consistent with the observations team of the teaand. it's consistent with the th personal protective equipment. that's why cdc strengthened the martin of safety and established new guidelines for personal protective equipment that in collude as two critical components practicing repeatedly so the health care workers have comfort with the equipment they will be using and direct observation3 is important to have treatment centers available around the country. because i could just tell you the average icu is not set up for that type of activity of the donningen and offing of the protective commitment. i have a problem with the time frame. mr. duncan's family never became symptomatic. i would suspect it is later in the course when he was throwing off massive amounts of viral particles where the greater risk for exposure to those health care workers occurred. i'm sure you and i will have future discussions about that. i will yield back. >> just to clarify, during that time mr. duncan, at what point did he disclose he was in western africa and exposed to ebola. >> my understanding is he disclosed that he was from west africa on the earlier emergency department visit on the 25th of is september. of september. he was admitted on the 28th of september. >> thank you. now mr. green is recognized for five minutes. >> thank you, mr. chairman. to follow up my colleague from texas i know our state has designated two locations. two months ago i was at texas meddle call a center in houston and there was interest in trying to do that, too. that may not be one of the two locations that the governor has designated. but i have a question later for dr. gold from the university of nebraska. how it was unique that the university of nebraska created the facility there and how it happened. let me get to my question for you dr. frieden. what is the process and timeline for updating and communicating changes for protocols to local health care providers. we know there was an issue about that last month. what is the process or have the processes changed at the cdc from what we did, say, in october? >> with respect to cdc guidelines we used the latest data, information and experience to develop guidelines. we consult widely with affected parties for input. when we have a clear set of guidelines that we communicate, we then disseminate those throughout a wide variety of networks. >> what we have learned is personnel protection from the experience at texas presbyterian and how the lessons are shared with other hospitals. so woo we can avoid the same errors. again, the feeling somebody shows up at 3:00 at one of my e. again, the feeling somebody shows up at 3:00 at one of my not for profit hospitals in an urban houston, how are they going to deal with that? >> we are dealing with this from both sides of the equation. first, the patient side. what we have done is for every single person coming from west africa, they are greeted, asked detailed questions, the temperature is taken and they are provided a care kit that includes a thermometer, a log for taking their temperature, a wallet card with 24/7 number to call. we have already had multiple times in the past few weeks individuals take their temperature, find they had an elevated temperature, call the number, be safely transported to and safely cared for in a facility. they all ruled out for ebola. but the system worked in those cases. we can't guarantee it will work in every case. that's why we are working with hospital very intensively throughout the u.s. to prepare them for the possibility that they could have someone with ebola. we had hospital visits by rapid preparedness teams to more than 30 hospitals and ten states and continue to work intensively with the health care system so that they are increasingly well prepared to address a possible case of ebola. >> the cdc is not a regulatory agency. how can you provide clarity over the cdc's authority and responsibilities and setting and enforcing these protocols? do you have authority and enforcement over hospital settings? >> cdc provides guidelines and information and tools and feedback to facilities. we do not regulate in that area. that would be up to other entities within the federal and state governments. >> okay. dr. lurie, without a commercial market, the manufacture of many counter measures like those against ebola and infectious diseases require private partnership. they recognized this when it created a drive by providing a stable source of funding so that a reliable market was in place. as you know, the development and medical count he shall measure for biological threat agent can take a decade or more and often a billion dollars to develop. u.s. government research on ebola counter measures goes back a decade but yet it was not enough to provide us safety for the current situation. how much investment do you believe is needed for ebola, vaccines and drugs to allow us to get to the chance of successfully developing a product? >> i didn't hear the last part of the question. >> can you provide us a dollar amount on how much investment you received as needed for ebola vaccines and drugs to allow us the best chance of successfully developing these products. like i said earlier, the you research program in ebola has been going on for a decade. are there resources and how much would we need to do to get that drug. the vaccine. >> absolutely. one of the reasons we now have two vaccines that are finishing safety trials is because of prior investments made across the u.s. government in trying to develop an ebola vaccine and also with ebola therapeutics. as you may know, the vaccines are finishing those early trials and thanks to money provided in the cr. we've been able to accelerate some of the work, both on vaccines and therapeutics. whether they work we will learn over the coming months. with a trial in west africa. at the same time we have now gone ahead and invested in the advanced development of three other vaccine candidates and additional ways of scaling up and making the therapeutics so that we never put all of our eggs in one basket. we want to do better and we will continue to do that through the investments. we support the support from congress, barta, and bioshield in this regard. >> i'm all out of time and i want to thank the panel today. i'm waiting for our second panel. >> i yield back and recognize the chairman for ten minutes. >> congressman green didn't want to brag, but he has a family member who is active at nebraska. we appreciate his family being on the front lines. i think it is your daughter? isn't it your daughter that works up there? so, we want to welcome our witnesses and from the second panel, dr. leahy from texas. we're glad that you're here. my first question i'm going to acting surgeon general. i believe we should treat this as a health issue and not as any other kind of issue. it puzzles me that we have not really effectively put in a travel ban from west africa. i know we have alerted people and all of that, but when we had the hearing down in dallas at the airport in ft. worth, the answer we got is , because we need to send personnel over there, we don't want to prevent people traveling to here. as a pure public health official and the surgeon general, why would we not put in a true quarantine and flat prevent any travel from west africa? >> certainly as stated and have a strong belief in this, is that currently as we have it, the idea of having a travel ban prohibits all travel. there is that sense of travel of health care workers to western africa and i stated earlier, the real resolution to this issue is solving the problem in west africa. at the same time instilling a travel ban has a total loss of control of who enters and how they enter this country. as dr. frieden stated earlier, we've set up these systems. the systems that are in place right now allow us to know where people are coming from. it allows us to track them appropriately through the public health endeavors at the state and local level and to be able ultimately to follow them appropriately and to be able to intervene if symptoms appear and then be able to direct them, detect them appropriately and to instill the right response for that. so right now as the system works, as the acting surgeon general, i find that the appropriate course of action. >> okay. it puzzles me if we were to have a health outbreak like tuberculosis or something, there wouldn't be any question in my area that the texas department of health would put a true quarantine in place. i understand some of the external reasons, but if you are trying to contain an epidemic, a quarantine does work. want to ask dr. frieden, there's been some concern that perhaps we don't really know how this disease is transmitted. unless something came out recently some of the individuals in texas that were potentially infected and put on a watch list had no apparent means of transmission, yet they were symptomatic. is your agency conducting any research right now to see if perhaps there might be more methods of transmission than we think exist today? >> we do a broad variety of research specifically on ebola and the public health spread and epidemiology of it. the two infections that occurred in this country of the two nurses at texas presbyterian are infections that occurred at a time when mr. duncan was highly infectious. he had production of very large quantities of highly infectious material through diarrhea and vomiting. that would be our leading explanation of how they were most likely infected, although we don't know for certain. we describe what we see in africa. people become infected by caring for or touching someone who is either very ill from ebola or who has died from it. we analyzed the amount of virus in a patient's that goes from undetectible from exposed to become ill, and then as they get sicker, the quantities increase enormously. and if someone dies, the quantities are quite large. >> as a medical professional yourself, what's your confident that there is no other method of transmission than we know about today. are you 100% certain there is no other way? 70% certain? >> in medicine we say never say never. so i would not be surprised if there were unusual occurrences of spread from a variety of ways. but the way it is spreading by and large in africa, the way it is spread here and the risk that people here are brought by those two main mechanisms of touching body fluids of someone very ill. i will mention one of the things we looked at in the new guidance is what is done in u.s. health care facility facilities. very different from what's done in african health care facilities. there's more hands-on nursing care. there may be artificial respiration or ventilation of someone and that may generate infectious particles. that's why we strengthened the level of respiratory protection in our guidelines. >> thank you, mr. chairman. my time is expired. >> i recognize mr. braley for five minutes. >> thank you, mr. chairman. i want to clarify the questions that congresswoman blackburn was asking you earlier, dr. lui rie. on october 16th, dr. fauci was kind enough to present you had with some materials and walked us through them, including this product development pipeline, which i think you described in your testimony talking about early concept and product development being the province of nih and the advanced development being the province of barta and commercial manufacturing by the industry itself. and then regulatory review. >> the next page of the presentation dealt with ebola therapeutics in development. my understanding, these are treatments being developed for the sick thomas of the ebola virus, as opposed to a vaccine that would hopefully prevent the virus from spreading. correct? he had a slide that talked about the vaccines that were in or approaching phase one trial. the first one is the glax glaxosmithkli glaxosmithkline. the second was new link genetics. i asked him questions about that at the time. i questioned doctor robinson. in this particular slide, it appeared there were only two companies, zblak sew smith glaxosmithkline and new link that actually had phase one trials ongoing.glaxosmithkline new link that actually had phase one trials ongoing. companies, glaxo smithkline and a new link that had phase one trials ongoing. has there been a change to that since the hearing? >> since the hearing on october 16th, the phase one trial has been under way. they are almost complete and we are analyzing the data and i think we're all optimistic that we can start the next phase of the trial, a randomized control trial, with both of those vaccines in west africa. >> this slide indicated that there was a third company, but they were not expected to engage in phase one trials until the fall of 2015 which is a substantial ways away from where we are today. >> there other potential vaccine candidates in the pipeline. we are supporting some of those. but you're right, they are behind this timeline and we are right now focused on trying to figure out if these vax scenccie safe and effective, and if they are, get them into the use and control of the epidemic in west africa. part of the emergency funding request will be $157 million for barta to continue to accelerate the development and manufacturing of vaccines and therapeutics for the outbreak. >> my understanding from talking to the folks at new link genetics is these clinical trials that have been ongoing at walter reed and the national institute of allergy and infectious disease, any have been progressing well. there's good rapport between the oversight agencies and the company involved, and that there is continuing to be ongoing interactions with the department of defense sponsors as well. which would be the defense threat reduction agency and the joint vaccine acquisition program. is that your understanding as well? >> that is in fact every week once or twice a week i run a call with all of the parties. nih, cdc, fda, barta, dod components, so that we are all joined at the hip through every step of the process. we know what's going on, we share information, we know what to anticipate. fda has been a key partner as well. because in fact it's their regulatory authority. that is what is going to determine ultimately what moves forward and what happened doesn't, as well as obviously the results from the trial. i never thought i would find myself in this situation, but we are racing to catch up with fda. it's a great situation to be in. everybody is working extremely effectively together. >> great. dr. lushniak, mr. barton asked you a question about trying to contain an epidemic with an absolute quarantine. is there an ebola epidemic in the united states right now? >> there is not. the epidemic is at this point in time limited to western africa. once again, that's why we are trying to contain it there. >> one of the things we talked about during these hearings is the importance of focusing on facts and science and medicine. in 1900, the two leading causes of death in this country were influenza, pneumonia and tuberculosis. neither is a leading cause of death because of the response of science and medical health. when you look at the fact that in 2012, there were 35 million people living with hiv around the globe and the case of ebola, 13,000, 14,000 cases, it seems to me with the proper application of science, medicine and public health, we should be able to manage this crisis if we devote the necessary resources on a global basis. would you agree with that? >> yes, i agree. >> thank you. >> you are recognized for five minutes. >> thank you and i appreciate you having this second hearing on ebola and i want to thank the panelists for coming. would have liked to see mr. clane be a part of this. i know the committee's made a request for him to appear. i'm not sure if he's the ebola czar what his real role is if he's not going to be coming before the committees that hold the administration accountable and have some transparency to talk about it. i hope he's not planning just to be the propaganda czar, that he would actually be focused on working with us to get solutions to this. but i do want to thank the panelists that are here. dr. frieden, the last time you were here, we had talked about a number of things. one was the comments that we heard from samaritans of purse to groups that will be on the seconds panel. comments they previously made were blown off, in essence, by your agency. i asked you about that, you said you had heard about it but hadn't looked into it. have you looked into it to see if there are maybe people in your agency to warrant taking advice from people like that seriously enough? can you follow-up on that last conversation we had about those complaints? >> i am not familiar with suggestions or complaints or concerns that have been raised with us that we have not addressed. i received one communication from samaritans purse about the safety of our own staff and we immediately acted upon that. >> at the last hearing i read to you some comments they had made. one was a quote where they said they kind of blew me off. then they made some other comments that implied that maybe they weren't being taken seriously by your agency. never said it was you. but i asked if you'd looked into it or heard about it. your quote was, "i don't know that that occurred," and then you said you would look into it. that's why i asked if you had looked into it since our last hearing. they made some other claims in their testimony that they're going to give today. this is some of the comments that they made. "many public health experts are telling us that we know the disease, how to fight it and stop it. everything we have seen in this current outbreak, however, suggests we do not know the signs of ebola as well as we think we do." do agree or have any response about that statement. >> we are certainly still learning about ebola and the best quay to fight it. that is a critical component of our activities and of the emergency funding request as well. >> they also say the disease has been underestimated from day one. is that still going on? do you think it was being underestimated, maybe now not being underestimated to that level? >> the cdc publications estimated the degree of under reporting could be as high as a factor of 2.5 back every -- over the summer. our sense is that is likely to have decreased in areas. including systems to track the disease and they don't have a place to come in. they are less likely to be accounted for. >> is there new conversation that you had with the administration, especially the white house, about what's been talked about by a lot of our members about having some sort of travel ban or at least a holding period for folks who are over there having direct contact with people in west africa that have ebola, and then come back into the united states to at least have some longer period to look at them to make sure they don't come back with ebola? have you all had those conversations since we last met? >> yes, we have. my top priority as cdc director is to protect the american people. i have said and others have said is that we will look at anything that will reduce the risk to americans. we don't want to interfere with the system that allows us to track people when they leave and arrive for 21 days after at 100% follow-up for most states with people who have come into this country. that type of system if we don't have it will result in a greater degree of risk. >> let me ask you about ron kline. we did ask that he participate in this. he is designated as the ebola czar. have you had contact with him about strategy about how to deal with this? >> he is the ebola response coordinator. i have frequent contact with him. he coordinates the response with different parts of the government. >>. >> have you two had any disagreements on how to approach this? >> we have not. >> who would make the decision? is there a hierarchy right now? >> he has been clear and technical and scientific decisions that are the purview of cdc are made by cdc. >> i appreciate your questions and answers and thanks for coming in. >> thank you to our panelists for your dedicated work on this issue and for appearing before us today. we've heard time and time again that the key to keeping the united states safe is to eradicate the virus at its source. while we've had early indications of momentum beginning to emerge in liberia, it seems as if the situations in sierra leone and guinea are not showing the same promising signs. dr. frieden, in your opinion, do we have the resources deployed in these countries to turn the tide of ebola? and if not, what additional resources are needed? >> the emergency funding request is essential to our ability to both protect ourselves here at home and stop ebola at the source, and also to prevent the next ebola. there are too many blind spots, too many weak links in places in africa and elsewhere where we have large amounts of travel, where we have animal human interface and we have large numbers of people. that's why all three of the cd krchc xo components are all so important. domestic preparedness, stopping ebola in west africa and preventing the next ebola through the global health security work. >> thank you. i know that as of a few weeks ago the count on the ground is four individuals in -- from cdc in guinea. while i know that france is taking the lead on on ebola response in this country, does the united states need to take a more leadership active role, or does it have the capacity to do so? >> >> excuse me. for the cdc specific response, we provide a comprehensive public health approach in each of the affected countries. as of today, we have approximately 175 staff on the ground in west africa. we have the most staff in sierra leone. where the needs are greatest. we also have more than 20 staff or roughly 20 in guinea. but there are additional needs for staff in guinea. we've worked very hard with the african union and with other partners to get french speaking staff there with the cluster in mali, we now have 12 staff as of today in mali dealing with that cluster and trying to stop it at the source. >> what are about engaging on a more international impact. how does the international community get engaged to devote its additional resources to this world health crisis? >> there's been a very robust global response. my understanding is that contributions from other countries total more than $1 billion. the world bank has been very proactive and effective. also we've seen the uk stepping up in sierra leone and increasingly french and eu support to guinea and other areas. >> dr. frieden, we keep hearing that there is a great need for medical volunteers to travel to west africa. do you have a sense of how many medical personnel are needed and how would one get involved? >> for american health care workers with the u.s. agency for international development usaid maintains a website. you can go on that website and volunteer. we ask that americans who want to be involved do so through another organization. they are not going as individuals, but part of an organized approach. there is a broad need for assistance, including french speaking assistance, including not just clinical care but also epidemiologic interventions and public health measures. >> that's reaching out for volunteers. is there activism in terms of recruiting personnel? >> there is quite a bit of effort by individual organizations within the u.s. as well as usaid for our own part at cdc, we are looking at epidemiologists not only among our own staff but former staff and people from the broader health community who may be able to deploy. we are finding this is going to be a long road, taking many months. we need people who are willing to go not just for a week or a month, but several months or longer so they can get that max mall effect by being there. although for the clinical interventions where you are working in the isolation unit, we like to limit that to four to six weeks at most so people can be well rested and minimize the chance of taking a risk that may result in infection. >> dr. frieden, we've heard anecdotally that hospitals across the country are having difficulty sourcing ppe. what is the cdc's role in supplying the ppe supply chain and the allocation of these ppes and could thes ramp up manufacturing of ppe in order to prevent a domestic ebola outbreak. >> from from the cdc, we've already stockpiled ppe to enable us rapidly, within hours, deploy ppe to any hospital within the u.s. that's one of the components of the emergency funding request. but in addition, we've conducted what are called rapid emergency preparedness visits to more than 30 hospitals in more than ten states. one component of that is addressing whether they have sufficient ppe. we've prioritized hospitals near airports, those five airports where people come in, or where large number of the african dice spra live. we understand that not every hospital in america can get any amount of personal protective equipment they want. that's why dr. lurie's office is working with manufacturers to ramp up manufacture and prioritize facilities most likely to need it. we've been working with the strategic national stockpile to have ppe that we could deploy very quickly to hospitals around the country. >> thank you. i yield back. >> thank you. mr. harper is recognized for five minutes. >> thanks to each of you for being here and shedding some light on this evolving situation. both you, dr. frieden, and you, dr. lurie, have told us that this emergency funding request supports non-immediate, not ebola-specific funding as part of this. not all of this would be directly for ebola. would it? >> no, i would disagree with that. the request is divided into two components -- immediate and contingency. all of it is addressing ebola. it addresses it with respect to the cdc in three ways. domestic preparedness for ebola and other infectious disease threats -- because we think it would be most responsible to not only address ebola but also strengthen our system more broadly, stopping ebola in west africa, and addressing the risk that there will be another ebola outbreak, spread of ebola or a disease like ebola elsewhere in the world through it the global health security component. >> could not some of that be handled through the traditional process? >> cdc models indicate for each month of delay in control, the size of the outbreak can triple. so as cdc director, i'm not going to address the mechanism but i can say nat nethat the ne urgent funds and flexibility of those funds is crucial. >> if i could ask you, you commented earlier that 2,000 travelers have been monitored or are being monitored. how many are being monitored this moment? what is that number? >> roughly 1,500. the number of travelers entering is lower than it had been previously. >> who maintains that list of who's being monitored? >> every person who comes through goes through the customs and border protection process. we work in conjunction with cdp. that information is collected from the travelers and within hours we provide it to each health state department. we then monitor for state health departments and resolve challenges if someone is hard to find or moves state to state. >> are there any that were being monitored that you've lost track of. >> a tiny fraction -- actually less than 1% -- have been monitored, then not found. some of those were later found to have left the country to go back on travel or otherwise. the program is relatively new. it only started less than a month ago -- about a month ago and what we're finding is that excellent participation from the states and the travelers. but it is challenging and one of the things that would be supported in the emergency funding request are funds for state health departments to operate those systems. >> of those that are being monitored, how many are being told to seek medical attention? >> we do expect that there will be a steady stream of people with symptoms. just take set of 1,500 adults, you can expect some to have flu, some to have other illnesses. from west africa, more because malaria is common. for example, in the past several weeks, there have been four individuals who used the care kit, check and reporting ebola that we provided them at the airport, took their temperature, found that it was elevated, called the number that they were provided with, were safely transported to a health care facility and safely cared for there. they all ruled out for ebola but they were cared for in a safe way. >> let me ask for just a moment. we talked a little bit today about waste management and what to do about the waste of treated ebola patients. are any of that waste being transported across the country as part of this process? >> my understanding is that some of the facilities are you autoclaving it. then the waste management facilities take this material, then moving it to another state for incineration. >> that is meaning that the waste is being franz porttransp across the country. i don't mean autoclave. but anything that's not being you a though claved is being transported. >> i'm not aware of that category at present. >> if it is being transported but various states are the states notified of that transport? >> i'm not familiar with the details. the epa has been looking at different measures. they've had a meeting with the medical waste hauling industry to get input from them. we've worked with the department of transportation and what we've done in the individual cases is ensure that there is the appropriate authority in place from the federal level from d.o.t. and from the state level for management of waste. >> i yield back. >> mr. long, you are recognized for five minutes. >> thank you, mr. chairman. dr. lushniak, you said that a travel ban -- i think i'm quoting you right -- would cause us to lose contact on how many people travel into this country. what do you mean by that? >> well, right now we have a system. the system is an open system. we know when people are entering. we know where they're coming from. we know through our cooperative efforts with the customs and border protection people of when they are arriving. they're arriving through five airports right now and we have that connectivity. with a travel ban, the essence of a travel ban is no one moves. >> from those countries. >> from those countries. >> that are hot zones. >> but at the same time, there is this potential that people move from country a to country b, from b to c, from c to the united states, and they can very well be from western africa. so in our -- or my assessment of this, in essence web is whis whe right now is a system and a system that works following these individuals coming from western africa -- >> but if we had a travel ban on them, how could we lose track of them? >> well, through multiple routes. it's rerouting from one country to another to another. >> they won't have a passport or visa or something that says where they started? >> again, that system can sort of be worked around, if you will. right now we have a precise system that does allow us to follow people that are coming in, we know where they are coming in from which allows us to follow them. >> i'm from missouri. that doesn't follow to me that if we had a travel ban from these hot zone countries, if they weren't coming in from those countries, how we could lose track of them if they're not coming in the first place. and if they want to do a work-around, we're going to have on their passport where they started. correct? >> potentially if the passports are correct, if nefthey've not n manipulated. >> dr. frieden, let me ask you. you were talking about the travel ban, also. and you said that there's less people coming in now. last time we were here, i think it was october 16th, when you were last in to testify, we were using the number 100 to be 150 people per day. >> from the data that i've seen until recently, it's been closer to 70 to 80 per day. >> it's been cut by about 50% for one reason or another. >> that's my understanding. >> some people seem to think if we just wrote a big check or gave you an unlimited checkbook that this problem would go away. do you think enough money would fix this problem. >> i think we have the ability to stop ebola but that's going to require doing what the emergency funding request asks for, strengthening our system here at home, stopping it at the source in africa and preventing another ebola or ebola-like situation where it is most vulnerable. >> i'm sure you've seen the story of a nurse diagnosed with ebola in mali. she was diagnosed with ebola after she had that's the first time they knew she had ebola. now this, she worked in a hospital, in a care center that dealt with the elite. some people would call them the 1% of mali. but she dealt with people in the elite. also u.n. peacekeepers that had been injured. and after she deceased, they found she had ebola. and they didn't know where it come from. the first ebola death in mali was eight days after we had our last hearing in here. i think it was the 24th of october was the first death. then they went back and they figured out that -- they were trying to figure out how she had contracted this. and then they went back and they found out that there was a 70-year-old gentleman that had come from i don't know if it was sierra leone or where it was, but one of the -- it was guinea. he came from guinea. he apparently -- the person who brought him to the hospital was later deceased. they're not sure if that was ebola. they found out instead of kidney disease he deceased from ebola. it's just disconcerting to me and my constituents how in a hospital, in that area, that they didn't even know. she obviously had symptoms before she passed away from ebola. and one thing just to wrap up real quickly, i know i'm kind of hitting two or three different areas, but dr. spencer, we heard one of the folks on the other side of the aisle earlier say that he self-quarantined, took care of himself. was he not very misleading on -- he didn't answer where he had been. he said he'd been home in his apartment and they checked the subway passes, they checked his credit card, and things and found out that he'd actually been to the bowling alley, pizza parlor and taking public transportation. did he not, in new york? >> so in terms of the mali situation, we have 12 staff on the ground there now. >> right. they have been there how long? >> we've had staff in mali since before their first case. >> okay. >> helping them with ebola preparedness. the 2-year-old who died who you mentioned was unrelated to the current case. the 70-year-old gentlemen who died actually lived in a town that's on the border. >> i'm talking about a nurse that passed away. not a 2-year-old. i didn't mention a 2-year-old. >> the source case for that nurse is the 70-year-old who you mentioned, sir. he lived in the town on the border between mali and guinea. his ebola diagnosis was not recognized. he had other health problems. people thought he died from the other problems and there is a cluster of cases there and we are working intensively to stop it. because given the challenges of mali, if ebola gets in to ma'amly, it's going to be very hard to get out. so we're hoping to be able to stop that. >> i went back three weeks later and tried to sanitize the mosque that he had been prepared for burial in, correct? >> that is my understanding. >> so it's -- i would like to see, as i said back on the 16th, a travel ban. and i still don't understand how you can lose track of people that never came in the first place. i yield back. >> thank you, miss ellmers is recognized for five minutes. >> thank you, mr. chairman. thank you to our panel. dr. frieden, one of the things that i have been doing, reaching out to the hospitals in north carolina, and in my district alone, i have a number of hospitals that are saying that they're experiencing delays in receiving some of the protective equipment, and protective wear that they need. specifically short supply of tyvek suits, shrouds and 95 masks. they're being told that it could be six to eight weeks or possibly even longer. what does the cdc -- what role does the cdc play in this? and why would there be a delay in this equipment? >> we've looked at three levels of hospitals. first the hospitals around the airports. we want to make sure that they have ample supply. also the hospitals, i should say, which are the specialty facilities like nebraska, emirry and nih. second is the facilities where large numbers of people from the african diaspora live where we might have another case. and third is all of the other facilities in the country. given the number of facilities, there is currently not enough ppe on the market, some of the products, to give every hospital as much as they would like. at cdc we have a strategic national stockpile and that stockpile already has enough ppe to distribute to hospitals that urgently need it within hours. we also have worked through the rapid ebola preparedness teams or rep teams with several dozen hospitals to get them ready. when we work with them, we found although they might have shortages, they have been able to meet the shortages. they are most likely to need the facilities. we have ample supplies to the national stockpile. i understand what dr. lurie and her office have done is to work with the manufacturers to scale up so they're working very hard to produce more and prioritize facilities that are most likely to need facilities. for some of the products such as n-95s we have ample supplies in the strategic stockpile. >> dr. lurie do you want to comment on that as well? >> sure. one of the things my office has done since the very beginning is reach out and work with the manufacturers and distributors. i personally have spoken to the leadership at each of the companies and each of them now have gone to 24-7. >> the manufacturing. >> three shifts a day. manufacturing. in addition, they've all made a commitment to work with us and we're actively doing this so that if a hospital is they made a commitment to work with them and we are doing this so if a hospital is on our first list of being really ready to take care of ebola patients or needs ppe urgently, they will prioritize the orders. what they said is because a lot of people are frightened, many hospitals are they think double and triple ordering ppe from different distributors and manufacturers. they want to be sure they get some. part of our job is to be sure working with them that people get what they need. as dr. frieden said through the strategic national stockpile we're confident we can get enough ppe to any hospital that has an ebola patient. we also want to be sure that they have enough. the manufacturers and distributors have developed training material. so you don't have to train on real ppe. they'll go out to a facility and let you use other kinds of samples to practice. >> to practice. >> dr. frieden in relation to travel, i've been in touch with my local hospital -- or excuse me my local airport raleigh-durham international, and obviously that is not one of the five designated airports. but i am concerned about our customs and border protection officers. they're the first line. they would be the first to come in contact. they are not health care professionals. with this increased threat of ebola, is the cdc prepared, or has dedicated additional funds to those airports outside of the five designated to help with training and personnel issues? >> part of the emergency funding request is to ramp up some of the quarantine services. our focus is working in the five funneled airports now, and we've worked very closely with customs and border protection. it has been an excellent partnership and provided training, information. but we understand that there's a desire for more information with the funneling process, we're now able to ensure that almost all travelers go to those five airports. >> one last question. is the cdc working with osha and department of labor helping hospitals to be trained and up and ready for the preparedness? >> yes, osha has been part of the cdc teams and offers its services and information to hospitals that are working on preparedness. >> great, thank you. i just want to say also that i wish that mr. klain was here with us today as part of this panel because i think the information that our new ebola czar -- that he could provide some very important information. so i just want to state that. thank you. >> the gentle lady yields back. now recognize mr. olson for five minutes. >> i thank the chair and welcome to our witnesses. my home is texas 22. it's a suburban houston district. many folks who live there work down at the texas medical center. and they live in rural parts of texas 22. meadeville, texas, with cotton is still king. the ebola case in dallas spooked them. it spooked them badly. two schools in cleveland, texas, shut down for days because two students coming back from cleveland with that nurse who had been exposed. cleveland is closer to houston than it is to dallas. galveston, texas, had a cruise ship docked there, and came home early because a nurse from dallas self-imposed quarantined herself in her cabin. the waste coming from dallas is coming down to galveston. utmb to be incinerated in 55 gallon drums. 1,800 degrees fahrenheit burned the waste from treated ebola cases in dallas. everything goes to galveston comes through texas 22. one common frustration i've heard over and over back home is the deluge of information coming from cdc and all of y'all, it's confusing, and overwhelming. i've heard that from big hospital systems, and small providers. the emergency centers like saint michael's, and my hometown of sugarland, texas. i'm worried about the little guys like saint michael's. i have a question for all three panelists. the first one is for you, dr. frieden. what is your organization doing to ensure that small guys like saint michael's are ready if an active ebola patient shows up at 2:00 in the morning on thanksgiving night? >> three things. first, we are working with the travelers themselves so that they know where to go, they have a number to call, they're checking their own temperatures so that they can promptly identify if they have symptoms and be cared for before they become severely infectious. second, we are providing information through our website and webinars and demonstration and training and practices to hospitals throughout the u.s. as well as hands-on training through our rep teams and our cert teams if there were to be a case. we are working with the state health departments that are key here. one of the critical components of the emergency funding request is strengthening and providing more resources to state health departments exactly for this. to strengthen infection control for ebola, other deadly threats, and things that are daily endangering the health of patients throughout the country. we think that state health departments and hospitals have a critical role to play, and to maximize the impact of that, it will require the resources and it will require taking an approach that addresses ebola, as well as other deadly threats, and strengthens our everyday systems of infection control. >> dr. lurie, how about yourself, ma'am? hhs helping saint michael's? >> helping saint michael's. well, so one of the things that we have done through our hospital preparedness program is reach out to all of the hospitals around the country. hospitals are now organized into coalitions. which are community level collections of hospitals and dialysis facilities and nursing homes and others. texas has a very well-okayed system of this, and reaching out through them, they are able to reach to saint michael's number one, to say if they need personal protective equipment. could they get it through their coalition. if they needed help with exercises and training they could get it through their coalition. number two, as i mentioned before, we've had a very aggressive national outreach and education campaign. it's been open to health care providers, including health care providers from saint michael's and anywhere else around the country. people can take advantage of numerous phone calls and webinars. they've reached nurses. they've reached doctors. they've reached hospital administrators. they've reached ems professionals around the country. at this point we reached over 360,000 people across the united states with this. so finally, it is our goal that every hospital, including hospitals like saint michael's, will be able as dr. frieden says, to recognize a case, to safely isolate a case, and to be able to get help. and finally, through the state hasn't departments, and i know you'll hear from dr. lakey in a little while, they called the state health departments, and if they have questions or concerns about a patient with ebola-like syndrome, the state is in a very good position to help, as well. >> one more question to you dr. frieden. you were quoted on october 2nd. saying, this is a quote, essentially any hospital in the country can take care of ebola. end quote. do you stand by the quote today? any hospital? >> clearly it's much harder to care for ebola safely in this country than we had recognized. it is the case that every hospital in america should be ready to recognize ebola, isolate someone safely, and get help so that they can provide effective care. that's why we established the cert team, cdc ebola response team, that will fly in for a moment's notice for a highly suspected or confirmed case to help hospitals throughout the country. >> thank you, yield back. >> i recognize mr. jones for five minutes. >> thank you, mr. chairman. i, too, want to thank the panel for joining us today. thank you very much. dr. frieden, have any other states also applied stricter standards than the cdc has in terms of how to handle ebola? >> cdc guidelines are just that. for states. and states are free to be stricter than that. we are gratified that most have followed our standards. and really what we say is pretty clear -- >> do you know if any states have stricter standards? >> yes, some do. >> okay. all right. why do you think the states are adopting stricter standards than the cdc? are you confident that your standards and the guidelines and standards are strong enough? >> we believe our standards if followed are protective of the public. they require that people who may be at any elevated risk or some risk, they have temperature monitored every day. by direct active monitoring. that is something that allows us to interact with the person and talk with them and to determine on an individual basis if they should stay home that day or if they might be reasonable to allow them to do other things. >> have you talked to the states that have stricter standards to find out their rationale for the stricter standards? >> i've had some communication with some of the individuals involved. and understand some of their thinking process. the number of individuals who are subject to those stricter standards is really quite small. all of those individuals by our standards should be in what's called direct active monitoring. someone watches them take their temperature each day, has a conversation with them and confirms that they're healthy and don't have a fever. >> okay. have -- the last time that you were with us we talked about having tested the standards. have the standards been fully tested, the guidelines been fully tested across the country, back to what my colleague from texas just mentioned so that every hospital knows what to do? have they been tested? >> the standards in monitoring travelers are being implemented by every state in the country or virtually every state in the country. tracking people coming back from west africa, monitoring -- >> have they been tested? >> i'm not sure i understand your question. but with respect to the -- >> then let me explain the question. going back to my military experience, and i think some of the gentlemen here can understand that, we do things called operational readiness inspections. we don't wait for the bullets to start flying before we know what we're going to do when they do start flying. you come to appalachia, ohio. there are lots of little community hospitals that dot our region. are those hospitals fully up to speed? have they tested and have they signed off on any kind of guidelines that they have tested their ebola process? >> in terms of hospital preparedness, many hospitals have undertaken drills. we have also -- >> has cdc mandated any drills? >> cdc does not mandate that hospitals do drills. we provide guidance, support and resources for hospitals. >> have you recommended that they -- >> yes, and we've been directly involved with them in doing that and we've reviewed for the rep visited hospitals, those that are most likely to receive a case, we have visited those hospitals. we've overseen their drills, we've overseen their preparedness, and we've worked with them on advancing their preparedness. >> okay. it's my understanding there are several ebola centers scattered across the country, also referred to as infectious disease centers. most of them have a patient capacity of one to two people as of right now, most individuals with ebola treated in the united states have been transported to one of these centers to better manage their illness. in the event that a larger number of cases were to show up in the u.s., how does the cdc plan to treat a patient load that exceeds the capacity of available bed space in those centers? >> the challenge of a cluster of ebola would be substantial. and it would be a matter of using all available -- >> define a cluster. >> it would be a handful of cases. could be five or ten cases in a any kind of practical worst case scenario this is something that could be seen. in this case we would use all available local resources. if need be, surging health care workers in, and we would also transport patients to facilities around the u.s. where they could be treated. >> do we have -- i mean, the centers are set up to handle one or two patients because of the unique requirements of the disease. the virus. do we have transportation systems that are capable of transporting ebola patients if that outbreak were to be bigger than one or two that we are talking about. >> we have some transportation facilities for ebola patients in the u.s. we are working with the state department and others to increase the capacity to transport patients. >> what about those who might be transported to other places, would they be receiving lower quality care, in your mind, than at one of the infectious disease centers? >> no we think the quality of care can be provided. it's really an intensive care unit care. and cdc clinicians have consulted on the care of every single patient cared for in the u.s. and provided to each and every one of them access to experimental treatments and state-of-the-art care. >> gentleman's time has expired. >> i thank you. i yield back. >> miss degette do you have questions? she's going to yield at this point. i now recognize mr. griffith for five minutes. >> thank you, mr. chairman. dr. frieden, we'll try to move through these as quickly as i can. so i appreciate short answers. you are aware that the secretary of hhs is able to transfer funding from your department to other departments, isn't that correct? she can take funding from your department, stick it somewhere else, isn't that correct? >> there's limited transfer authority as far as my understanding goes. >> and when that happens, are you -- are you notified, is she required to tell you that she's transferred funds? >> as far as i know, yes. >> and has the secretary transferred funds in 2014 from the division handling emerging and zoo notic infectious disease? >> i don't know the answer to that offhand. i could get back to you -- >> could you get that for me? >> yes. >> and i believe that that -- that particular division would be a part of the ebola response, i'm correct in that? >> that is correct. >> and do you know whether or not the secretary's transferred money from the cdc's global health programs? >> i would have to get back to you on that, as well. >> all right, likewise the same would be on the cdc's public health preparedness and response division? >> i'd have to get back to you. >> and both of those also would be a part of your ebola response, wouldn't they? >> yes, they would. yes, they are. >> now you've indicated that you don't know about whether these moneys were transferred. do you know if any moneys were transferred at all during 2014? >> there's a secretary's transfer but i don't know the details of what has been done in >> okay. and so you don't know the details? so you would not know if any of this was transferred to help support the financial underpinnings of the american -- of the obamacare? aca? >> i do not know. >> and likewise, do you know of any transfers were made to the administration by the administration for children and families to care for increasing number of unaccompanied children who arrived in the united states? >> i'm not familiar with that financial -- >> you're not familiar with that. would you get us the answers to all of those? >> we can certainly read those answers. >> likewise i'm curious the president apparently has requested a fair amount of money and part of that related to ebola and part of that is a $1.54 billion in contingency funding. some of that is supposed to go to hhs. it says in his letter, to make resources available to respond to evolving epidemic, both domestically and internationally. and i'm looking here and it says that while $751 million of that is to go to hhs, it then talks about transferring those funds over to homeland security to increase customs and border control operations. have you been in the loop on that? do you know what kind of money you all are getting and what are they talking about with customs and border control operations? >> we work very closely with the cdp and we understand the need for contingency funds for ebola in case, for example, ebola would spread to another country that required a very intensive extensive response. so that flexibility is a critical component of the emergency funding request. >> okay and that funding request is as was pointed the in an editorial by david sachin, a former director of cdc and a former surgeon general, that request by the president is actually greater than what we've been spending on alzheimer's, isn't that correct? >> i don't know alzheimer's funding details off hand. >> and in regard to mr. klain, have you all had sit-down, face-to-face meetings? >> yes. >> and how many of those meetings? >> i'd have to get back to you with the exact number. >> if you could get me that number i would greatly appreciate that. that would be very, very helpful. now in some of the outbreaks in the past and historically, in ebola that have occurred in africa, isn't it true that there are some times that we have an outbreak and we don't know where the disease actually came from? where it was picked up? >> we have not identified definitively the animal reservoir of ebola. we think it may be bats or bush meat but we have not determined that. we've determined it for a similar virus, marburg, from research that cdc scientists did. >> and the meat i understand, the bats, would that be from excrement? i mean how would the bats spread it? or are they eating the bats, as well? >> well, it may be saliva. it may be bats as mammals carry a lot of pathogens that are similar to the pathogens that infect humans. >> but this is just one of many areas where we are not really 100% sure of how the disease is spread. ta particularly in africa? >> i would clarify. we're not sure of the animal reservoir. from all of the experience we've had spread among human populations is from either unsafe care, or unsafe burial. in the outbreaks that we've assessed so far. >> so, but that's once there's been an outbreak. but there are occasions when the outbreak just starts and nobody had it there before so it couldn't have come from human contact. it had to come from this animal reservoir and we're not sure exactly what animals carry it, whether or not it's, you indicated spittle, excrement, what else, we do know that it's transmitted if you eat a diseased animal. is that correct? >> it may be actually not so much the consumption of bush meat but the hunting and handling and cleaning of bush meat where you may be exposed to blood and other body fluids. >> okay. i appreciate and yield back. >> now recognize ms. degette for five minutes. >> thank you, mr. chairman. i want to apologize to you and the panel for running in and out. the democratic leadership right now is actually working on who our next ranking member of this full committee is going to be. it's not going to be me. thank you for your vote of confidence. and so i just want to ask a few questions and then i'm going to leave you in the capable hands of mr. green. dr. frieden, the first thing i wanted to talk to you about is the contingency fund that has been requested in the emergency supplemental. what exactly is the purpose of that fund and what would it be used for? >> the contingency fund is to deal with the unpredictable nature of ebola. the possibility that it might spread to countries where it is not currently in place and might require very extensive, expensive control measures there. also we might have new interventions, such as a vaccine and need a large and potentially expensive program to implement a vaccine program for affected communities and health care workers. >> why would you need to do that through a contingency fund and not through an additional emergency supplemental, if that situation -- if that situation -- either of those situations presented themselves? >> in the words of one of my staff at cdc in the case of ebola, it's the lack of speed that kills. we need to be able to respond very quickly to changing conditions on the ground. >> and we're seeing that right now in africa, is that right? things are changing quickly in africa. >> absolutely. we're responding to a cluster in mali. we're moving out with cdc detectives in very remote, rural areas, to address clusters of disease before they become large outbreaks. >> do you have a sense of why the number of cases in liberia has recently dropped? >> we believe this is proof of principle, that the approach that we're recommending can work. but we're still seeing large numbers of cases in at least 13 of the 15 counties of liberia. we have seen that decrease taper off so that we have seen a leveling off of cases that have been reported. every one of those cases needs intensive follow-up contact, tracing, monitoring of contacts, and we're still having perhaps between 1,000 and 2,000, new cases, per week in west africa. this is still a very large epidemic. >> and that kind of leads me to my final question, which is you have said repeatedly, and frankly there's been a lot of pushback on this, not just from this committee but from lots of other folks. you've said repeatedly that you don't think that travel bans and quarantines are the way to go about addressing this. and i'm wondering if you can tell us whether that's still your view and if so, why, and if it's not, why not. >> we're willing to consider anything that will make the american people safer. any measure that's going it to increase the margin of safety. one of the things we have done is implement a travel system so people leaving these countries are screened for fever, arriving in the u.s. are monitored for fever, are linked with the local health department. we're now working with state and local health departments to monitor each of those individuals each day and we're seeing very high adherence rates to that. so we have a system in place now. the risk to the u.s. is directly proportional to the amount of ebola in west africa. the more there is, the higher our risk. we have to reduce the risk there by attacking it at the source. but whatever we can do to reduce the risk to this country, we're certainly willing to consider. >> so you would still consider a travel ban if that seemed like the only solution? >> if there were a way to ensure that we didn't lose that system of tracking people through every step of their travel and once here, we would consider any recommendation. but it's not cdc that sets travel policy for the u.s. government. >> right, and what i'm concerned about is if ebola goes to other countries in africa in general, it will be harder and harder to trace where people came from. >> the spread of ebola to other places in africa is one of the things we're most concerned about because it would make it harder to control. we were able to work with nigerian authorities to stop the cluster in nigeria. right now mali is in the balance of where we'll be able to stop the cluster before it gain. s a foothold. the longer it continues, the greater the risk it will spread to other countries. >> thank you very much, mr. chairman. >> gentle lady yields back. mr. terry is recognized for five minutes. >> ask unanimous consent to be able to ask questions. >> yes, you're recognized. >> thank you. dr. frieden, from nebraska, i'm really proud of the efforts of university of nebraska med center. at least we're top in something. it's not football, but it gives us a sense of real pride despite the last patient outcome, which they did heroic efforts. but also in that regard, they seem to have been the ones that, especially in comparison to the dallas baptist hospital, we're kind of the -- that they were setting the standards on the practices. so that begs the question or at least we should ask the question of whether the cdc should develop an accreditation type of program on infectious disease programs to ensure that these hospitals maintain a level of competency in readiness. is something like that ongoing? >> first, we really appreciate the facility in nebraska and their willingness to step forward and the phenomenal care they've provided to all of the patients who have come to them. despite the outcome of the physician recently, we know that heroic measures were undertaken and the staff there really deserve the gratitude of all of us. we appreciate their willingness to consult with other facilities and share their experience because that's critically important. >> which they have done, and again, hospitals like johns hopkins is asking them how to do it is a source of pride. >> what we have approached is something called the rapid ebola preparedness team where we send a team in to work with the facility to outline every aspect of their preparedness and to see how ready they are and to provide recommendations for what more they can do. e we also worked with state health departments so they can determine which of the facilities within their state that are most appropriate to take patients with ebola or other infectious diseases, because they are best prepared for that. in terms of accreditation, that's something we have discussed with the joint commission. whether that makes sense in the long run or not is something we're open to exploring. >> as a layperson, it seems to make sense you would have an area where there is one hospital that has that level of accreditation. and then it begs the question that if they are going to be that go-to hospital in a region or a state, whether there should be maintenance funding behind that. what do you think? >> we certainly believe they should receive resources. there's funding within the emergency funding request both from cdc and from asper to support specialty facilities such as the one in nebraska. >> the question is just to clarify, would that be part of the president's requested dollars? >> yes, it is. >> dr. lurie? >> yes, it is. >> very good. and again, dr. frieden and dr. lurie, one of the experiences here is that we know that, let's see unmc has 11 units but the reality is they can probably only have three patients at a time because of all of the collateral circumstances. so do we need more biocontainment units like what emory and unmc have, dr. frieden? >> we think we need some increase in the number of facilities that can safely care for someone with ebola or another deadly infection. we have been working closely with hospitals throughout the country to increase that capacity and the emergency funding request would enable us to get to the level where we would have a greater degree of comfort with the facilities out there in the capacity. >> just to clarify that some of the dollars that would be in the emergency funding, the president's request would be to expand the number of biocontainment units. >> yes. >> very good. one of the questions about having three patients at unmc, these folks don't have any insurance and they are holding the bag for the funding of those patients. is there anything with hhs, dr. lurie, or cdc, that can reimburse these facilities for the health care costs? >> i believe the secretary burwell indicated in the hearing last week that we're very open to mechanisms that would make them whole for the expenses that they've had. >> open to it and doing things, there's a big gap between those two. is there any further discussions to reimbursing, dr. lurie? >> yes, i think we understand that the cost of caring for these patients is quite substantial. as dr. frieden said, second burwell indicated that she would look forward to working with congress on this issue, yes. i might also just add in terms of the emergency funding that is necessary. it is clear that hospitals that are going to take care of ebola patients need additional training and we very much appreciated the fact that university of nebraska and emory have been now working side by side often with the rep teams to help with that. part of a funding request would also establish something that would look like a national education and training center that would move to another level, i think, of preparedness for hospitals that really wanted to attain that and get help with doing that. >> okay, thank you very much, my time is expired. >> that concludes the questions for this panel. we thank you and also members may have some additional questions. we do appreciate the availability of all of you in responding to us. thank you very much. >> thank you. >> as this panel is moving out, i'll begin to introduce the second panel so we can move forward here and i'll introduce two of the panelists and we'll ask mr. terry to introduce one, as well. we'll start off here first mr. ken isaacs is the vice president of programs and government relations for samaritan's purse. also dr. david lakey is the commission es of the texas department of state health services but is here today testifying on behalf of the association for state and territorial health officials. and mr. terry, if you'd like to introduced the other panelists. >> i would be honored to introduce dr. jeffrey gold the chancellor of the university of nebraska medical center and nebraska medicine. he is recent to nebraska, but certainly making a huge impact, especially with the biomedical containment center where they have hosted three ebola patients and they are setting the standards for how to treat the ebola patients and setting the standards for the employees that come in contact and work with those. unmc is a great facility. they are very forward thinking. they're probably -- they're ranked very high in a lot of areas of care, but it's probably the research that is making them known internationally, and so i'm proud to introduce dr. jeffrey gold. >> thank you. the panel you're aware the committee is holding investigative hearing, and when doing so has the practice of taking testimony under oath. do any of you have objections of taking testimony under oath? the chair then advises you that under the rules of the house and rules of the committee you're entitled to be advised by counsel. do any of you desire to be advise by counsel during your testimony today? all of the panelists have said no. in that case, please rise and raise your right hand. do you swear the testimony you're about to give is the truth, the whole truth and nothing but the truth? all have answered affirmatively. you are under oath. and subject to the penalties set forth in title xviii section 1001 of united states code. i'm going to ask you each to give a five-minute summary of your written statement. we'll begin with mr. isaacs. >> thank you chairman murphy and esteemed members of the council and fellow guests of the commit time for letting me testify today. it's a privilege to be before you regarding the developments of the ebola outbreak in west africa. since ebola entered liberia in march through its explosion onto the international spotlight in july, and even now, when it appears that the disease may have crested in liberia, the world has learned much about ebola. but i want to stress today that we've also discovered that there are many important questions that we simply do not know the answer to, and we need to know the answer to them. i'm going to run through them quickly. i will say as an offside that going last means you have to reshuffle everything you're going to say because it's all been said before. but i think that a good question to know the answer to is how are the doctors who are returning to america becoming infected? some of those doctors have been our staff. some of those doctors have been our coworkers. they were treated at nebraska. and even recently the gentleman in new york, they were all wearing level four gear. how did they get infected? can the virus live in other mammals besides primates, bats, rodents and humans? i have worked and lived in africa for about 25 years and i have eaten my share of bush meat. it's not always bats. it's mostly something like a groundhog. and so what does it mean, where does the virus live? the point is that can it jump into the animal population here, we need to know that. as with other viruses, is it possible that ebola can be asymptomatic? sort of a typhoid mary kind of a thing. we know for a fact of three situations where blood were drawn on patients who were nonfeeble, who were nonsymptomatic and they all three tested positive. one of the problems that exists today in liberia where samaritan's purse is working is that there is no protocol to move blood from liberia to rocky mountain laboratory where these kind of tests would need to be checked. and results found out. i will just say i'm not trying to be a fear monger, but i think there are things we need to look at critically and we should not be afraid to ask questions. if my written testimony, there's one paper from the "new england journal of medicine" that reports that 95% of the cases of ebola incubate in 21 days. the inference is 5% don't incubate until 42 days. we need to know what that 5% means. while the media coverage is already decreasing and people maybe feel like that ebola has peaked, we do not think it has. i totally agree with dr. frieden, i think we need to vigorously and in a sustained manner fight this disease in africa. i think that no card can be taken off the table, and i think that while we hear from many health experts that we know how the disease is spread, we know how to fight it and stop it, the truth is that lessons come at a great and expensive and painful price. and when a new lesson comes about, all the policies are changed. so i heard the word humility used several times today by different members of the panel, and i think that's a good word because ebola is a humbling disease. when you talk to the epidemiologists, they're all over the place. cdc is saying 1.5 million by the middle of january and the world health organization is saying in december, maybe 10,000 people a week. the point is we don't know. several things that i want to say right quick is we're seeing the disease go down in liberia today as it regards empty hospital beds, as it regards deaths and as it regards patient loads. at the same time, we're seeing a significant increase in sierra leone. the country next to it. so it's clear that the disease has not peaked. actually, if anything, i would say that it perhaps has ran its course, and we don't know what its course is. and if you look at the epidemiological charts in sierra leone, it has peaked two times before. so the question really is, are we at a peak? or are we in a trough before the next uprise? practically speaking, i think that a couple things that we need to look at is travel ban, travel restrictions or i like to say travel management should not be taken off the table. the real threat to the united states i do not feel is going to be how many people are sick here. the real threat to the united states is what will happen if the disease spreads into countries that cannot handle it. and i'm not talking about africa. i'm talking about in the subindian continent. i'm talking india, china, pakistan, myanmar, bangladesh, countries that are highly populated that have low public health standards, and have low hygiene standards. you could see a death toll that would be unimaginable and the impact around the globe would affect us, as well. so i think i'm out of time there. thank you. >> thank you. dr. gold, you're recognized for five minutes. >> chairman murphy, other members of the subcommittee, thank you for the opportunity to discuss the ebola outbreak and the nation's response and how the nation can maintain a state of readiness to respond to respond to future highly infectious diseases. i'm jeff gold and i have the honor as serving as chancellor at the university of nebraska medical center. my testimony today will focus on the challenges of dealing with ebola and our nation's readiness to respond to highly infectious diseases. this has been said many times earlier today and well before, the united states is dealing with a serious public health crisis with the ebola outbreak in africa. it's a crisis in the united states has the expertise to contain and to help resolve. one of the most pressing goals to accomplish from the ebola outbreak is how to best leverage the know-how to train and better prepare the nation's health care system to combat future highly infectious threats like ebola here and around the world. the university of nebraska medical center is recognized as a national resource for our readiness to provide care for ebola patients and also our ability to provide training on ebola and other highly infectious diseases. we have successfully treated ebola now in two patients and not in one most recently passed away yesterday. we have provided consultations to many hospitals, clinics emergency departments across the united states including bellevue hospital in new york on how to deal with therapies for patients who arrive in their hospitals or emergency departments, et cetera. our readiness is based upon more than nine years of preparation, protocol development and team training to deal with highly infectious, deadly diseases. as a result, we are now responding to literally hundreds of hospital inquiries across the nation, asking how to prepare if ebola arrives in their community. emory university hospital is experiencing similar inquiries and we are working closely together. one step that we took to respond to the immediate national demand for information and training was to work with apple computer to convert our nine years of protocols and procedures into easily accessible and completely multimedia materials and videos for health care providers that was accomplished in one week. which is now available through apple and through public media, and can be accessed on any personal computer with well over thousands and thousands of physicians and members of the public, who are downloading content specifically about personal protective equipment and others. you might ask why nebraska? why is the biocontainment unit that we opened in 2005 in existence? this followed the 9/11 attacks. it was built upon concerns about anthrax on congressional offices and sars attacks. we recognized that the commonness of international travel increased the chance of global spread of highly infectious diseases. our unit has written and rewritten protocols and procedures and collaborates consistently with national organizations and other medical centers. we rigorously train with local emergency responders, state emergency management and military units through our relationships with stratcom and others. we spend a great deal of time considering the response plan if another highly infectious disease were to occur and how this could be scaled. the university is also a department of defense authorized university affiliated research center, which specializes in developing medical countermeasures to weapons of mass destruction, including highly infectious viruses. we have a history of conducting extensive research in these areas including vaccines, antivirals, early detection, et cetera. what has become obvious from this ebola crisis is that a national readiness plan is absolutely necessary. our biocontainment unit is one of four in the nation. the capacity and the number of units in the nation must be increased and a national readiness plan that trains health care providers must be established. the number of actual beds is under 20. the number of usable beds is under 10. and i assure you that every unit such as ours will always maintain at least one bed if is ever needed for a staff member that becomes ill. that immediately knocks the number down by four, five or six. the university of nebraska medical center and emory are working closely with the cdc and hhs on how training might be most effectively delivered. it must begin soon. and we have done so in advance of any funding considerations. as congress considers funding, i urge that this include a number of items and i will just read them by title as they are contained in my briefing documents. a national training in ebola and highly infectious diseases to develop a tier training system. training should include setting up an accreditation program that independently nationally accredits organizations, emergency departments, et cetera, to establish and maintain their skill level of readiness. an annual maintenance of funding for increased role of existing biocontainment units. to maintain their readiness. we have funded the readiness of our unit totally off internal dollars up to this point. funds to expand the number of treatment centers and existing biocontainment units, specifically to increase bed and staff capacity within existing units as well as new units. and finally, reimbursement for care for ebola patients not covered by insurance. ladies and gentlemen, we have the expertise and know-how to contain ebola and other infectious threats. however in order to do this we must ensure that our nation's health care professionals are adequately trained, properly equipped and rigorously drilled. i thank you so much for this privilege. >> thank you, dr. gold. now dr. lakey. >> thank you chairman murphy and members. for the record my name is david lakey the commissioner of the texas department of state health services. i've been in that role now for eight years. this last month has been one of the most tough as the commissioner of state health services. on september 30th, 2014 the texas state public health laboratory, a laboratory response network lab ro e raer to diagnosed the first case of ebola in the united states. the diagnosis of mr. duncan with ebola set in motion a process we in public health refined through continued use, tried and true public health protocols, including identifying those individuals that have had contact with people that have been infected, making sure that they're monitored, providing care to those that have been infected, isolating those individuals and when needed using quarantine. the magnitude of the situation really was unpress tented. while mr. duncan was one man in one city in one state in the country the outcomes associated with this case did impact the whole state and possibly other parts of the united states. we at the department of state health services along with our colleagues in dallas and our colleagues at the center for disease control and prevention took the responsibility to contain the spread of this disease very seriously. we organized a local incident command structured to handle the event and at a state level we activated our emergency response management centers. while our core mission was simple, in concept, to protect the public's health by limiting the number of people exposed to the virus the challenges associated with carrying out that mission were numerous. the care mr. duncan presented its own challenges. identifying the first person in the united states infected with this disease, the infection control challenges, waste management, and transportation, the availability of experimental treatments and vaccine, training for health care workers on the higher standards of infection control, and personal protective equipment guidance and supplies. when mr. duncan regretfully passed away, we handled issues related to caring of his human remains, which remain highly infectious with ebola for months after death. unfortunately during the care, of mr. duncan two nurses became infected. nurses who had put their lives and their careers on the line to take care of mr. duncan, and to protect the public's health. concerns relating to the handling of these three ebola patients included questions about decontaminating their homes, their automobiles, decisions about how to handle the personal effects, the monitoring of pets, and personal -- or excuse me patient transportation issues. and addressing the public's concerns. identifying potential contacts and locating them and monitoring those individuals had some risk of exposure that also involved many challenges. decisions about who to quarantine, and what level of quarantine, balancing public health, and an individual's rights, providing accommodations for those confined to one location for the 21-day monitoring period. quickly processing control orders. coordinating two symptom checks a day for each person under monitoring. and managing the transportation and the testing of laboratory specimens. throughout all these specific challenges, our experience in dallas exemplified common requirements for successful responses to emergency situations. having clear roles and responsibilities among the various government agencies and entities that are involved, strong lines of communication, and an incident command structure staffed by trained emergency management and public health professionals to ensure the response's cohesive direction. it really requires a partnership at all levels of government, and throughout the state and federal government. the outcome in dallas proved the strength of the public health's process. hundreds of people were monitored in the state. two cases of ebola resulted from the direct care of the case and they were detected early in the disease onset and they recovered. no cases resulted from commune exposure. at this time, like other states, texas is providing active monitoring for individuals who arrive in the united states from one of the outbreak countries. texas has monitored approximately 80 individuals under the airport screening process. texas is also like other states working to ensure that capacity exists in the state to care for patients with high consequence infectious diseases, like ebola. two centers currently are able to stand up on a short notice to receive a patient, and texas is working to identify additional capacity within our state. as ebola screening and monitoring transitions into our routine processes, our focus in texas is now shifting to include complete evaluation of the response in dallas and a discussion of how to improve the public's health response system in texas as a whole. and sharing our experiences and our lessons learned nationwide. governor perry put together a task force for infectious disease and preparedness response to evaluate the texas system and to make recommendations for improvement. we take that extremely seriously. i believe this discussion among governmental and nongovernmental individuals among varied stakeholders, and including experts in pertinent fields will result in a texas and a nation being better prepared to handle the next event. while we do not know what form the next event will take, we do know that there will be another event. as i tell my colleagues at the state and national level, it's my expectation that as a commissioner of health that i'm going to have to manage one major disaster each and every year. one unthinkable event per year. that's why the funding that is provided to states through the hospital preparedness program is very important to what we do. that partnership is really critical. finally, i want to thank my colleagues at both the dallas county health department and the center for disease control for their work and their support and this really is a team effort. thank you, sir. >> thank you. dr. gold i know you have some travel plans. we have about 20 minutes of questions. will you be able to accommodate that. >> yes, sir. whatever your needs are. >> thank you very much. appreciate that. i'll recognize myself for five minutes. dr. gold, you mentioned a number of comments about what needs to be done with the administration's request for funding. i don't know if you had a chance to read it. have you? >> at least in general terms, yes. >> would you know whether or not there's an adequate plan to support the request yet? i don't want to put you on the spot. >> i don't think the granularity is in the written materials that have been provided. >> would you do us a favor as someone at a hospital dealing with this. could you make sure you get to the committee -- specific recommendations? in fact, i would ask that of all the panelists. it would be very helpful to have that kind of granularity. thank you. mr. isaacs, have you been to africa? you've been to africa? >> yes, sir. >> the cdc has guidelines for health monitoring and movement for health care workers in treating ebola patients in africa. now they classify as some risk those professionals who have had some contact with a person sick with ebola while wearing personal protective equipment. you have cited that some people wearing personal protective equipment have still contracted ebola. >> it's an obvious fact, yes. >> so these some risk individuals have no mandatory restrictions on public activities. in fact there's no requirement for returning health care workers to self-isolate or avoid public transportation like subways, bowling alleys, et cetera. i want to add, we have done a survey of members on this side and every single member who asked hospitals in their district has returned comments saying all those hospitals said for the first 21 days, those health care workers are not going near a patient. they will be furloughed, they are to stay home, taking temperature multiple times a day. does samaritan's purse health care workers follow guidelines such as this when they return? >> we actually have written our own protocols and guidelines back in late july when dr. kent brantly who has testified here was coming back. we were bringing out about 40 people. we contacted cdc and asked them what their protocols were. and frankly, they told us just to have our staff check their temperature twice a day and if they got a fever go to the local health department. we didn't feel that that was adequate because we had just come through a very serious bout with ebola and i think we probably had a more realistic encounter with it than perhaps other people had. so we created our own protocols. we check our staff through direct monitoring every day four times a day. we have a little bit lower threshold. and we do keep them in a restricted movement, no-touch kind of protocol for 21 days. >> so you're saying that your protocol goes beyond the cdc recommendations? >> there's no question our protocol goes beyond the cdc. >> cdc says that's not necessary. do you agree? >> well, you know, all i can say -- there was a question a minute ago about cdc disregarding what we're saying. cdc is a large organization. they create a policy. so if you call them and say, well, we think we ought to do this. they say that's not our policy and then they don't engage any further. that's just the reality that we have run into. and i don't mean any disrespect to cdc. i'm very appreciative of them. but for us, we live in a small town. our national headquarters is in a town with 40,000 people. what we have ran into is that the spouses of some of our returning staff don't want them coming home. the returning staff don't want to be around their children. and we don't want to spook everybody in our community. >> you're erring on the side of extra safety? >> we are, yes, sir. >> let me ask you another thing that has to do with a discussion i spook the community. >> youaire on the side of safety? yes. >> i have spoken with franklin grah graham. there are concerns of workers traveling back and forth to western africa. is that a fact that there is difficulties with travel. i think that is one of of the greatest vulnerabilities the united states has to fight the disease in west africa. there is not a dedicated y humanitarian bridge. there is a lot of talk the 21 day waiting period will make it onerous for volunteers and they wouldn't go. i'll tell you what will make it onerous that volunteers have assurance they can't get a flight out. i promise you they won't go. >> how many airlines currently go in and out of south africa? >> i think it's 200 to 250 a we week. >> there are two airliners, brussels air, you get off in brussels you just walk, you're not monitored for anything. the second one is royal air m a monac. if they decide it's not in their commercial interests to fly into monrovia, they will have a quarantine in liberia. what's the backup plan? >> i understand getting supplies to west africa was hard. two times you had to lease plane planes. >> two 747s. >> at a cost of. >> $65,000 each. for cargo logistics, i think we have a great vulnerability there. there is one organization flying a nonprofit, done four flights. that's great. that's not enough. >> make sure what you recommend if the united states could sponsor a charter plane twice a week from the united states to africa so workers and volunteers would have a clear bridge in which case they could be tested before they get on the flight, tested during the flight and test when they land, at one point the united states would simp simplify this process. >> i support the dedicated air bridge from the united states to west africa. there would be a thousand details to work out. if they stop flying for commercial reasons we would have no access. >> to mr. green for five minutes. >> thank you, mr. chairman. thank our panel for waiting today. to follow up, it would also be more center, like you said, going to brussels or somewhere else and just walking around, it would be the testing and i assume these health care workers would love to have that because they don't want to infect their own families. >> dr. lakeky, let me thank you, in october there were unusual stateme statements being made about ebola. when the state of texas made the decision an how you would develop the protocols right after that, i appreciate that. it sounded like everybody was getting back to normal, this is an illness and we can deal with it and how we're going to do it. i appreciate the state saying that. let me go on to some questions. dr. gold, one of the interests i have i said earlier, how did the university of nebraska develop this facility? i think it was open in '05? was it a combination of state, local, university funds? federal, to develop the largest containment lab in the country? >> thank you. the unit was opened in 2005. it was planned shortly after the 9/11 events, the anthrax scares. it was done predominantly on unit funds, to some small extent on state funds and i believe there were some federal department of defense dollars involved in the planning as well. very importantly the maintenance of the staef cost us a third of to a quarter of a million dollars has been born by the medical center. >> i appreciate that leadership. i'm surprised no other university would take that lead and appreciate nebraska doing that. my colleague, nebraska terry knows my daughter is up there and recruited to go there in '09 although when she told me back in the '90s she wanted me to be an infectious disease doctor, i told her, i don't want you to treat me for anything you know about. like most medical professionals, that's her job and we want to make sure we protect them to do that. nebraska center now has treated several patients. what is the spending required to prepare the hospital to treat an ebola patient? >> the direct costs we've experienc experienced, and we've compared notes pretty closely with emory and we're not far apart is presidential $30,000 per day for each patient admitted. the average length of stay, i guess it went down over the weekend a good deal for the two patients that went home, 18 days and they were both treated relatively early in the stages of their disease. that's the direct cost of equipment and nursing care and what the folks at emory have come up with. that does not include the cost of preparation i just referred to and does not include what i call the opportunity cost, a 10 bed unit otherwise used for medical-surgical admissions that would otherwise be completely full with routine patients receiving their care. >> are the policies in place prior to the current ebola outbreak still in use poor has e university of nebraska made changes on guidelines based on real life experiences. >> we do change our policies and procedures and we learned a lot from each patient, particularly the first patient we housed. we put a completely self-contained laboratory unit into the biocontainment unit so specimens are not transported outside the unit. we are very privileged and there's a lot of discussion about waste management. we decontaminate all the waste as it leaves the unit. there's no deportation of waste material outside the unit. it makes it much safer for the unit and also makes it much expensive and for us to have that built into the unit. this is only because the unit was plan ned as it was constructed to 2005, understanding that the disposal of infectious waste would indeed be a big problem from logistical as well as spence and therefore self-contained. >> mr. chairman, i know i'm out of time. i appreciate, from where we were at six weeks ago we've actually evolved and glad experiences we're learning from them. i appreciate the whole panel being here today. >> thank you, gentleman yields back and dr. burgess recognized for five minutes. >> thank you. i want to thank all our witnesses being here today and bearing with what has been a long but very informative hearing. dr. gold, there is a difference between the patient you get at your center. there is not direct access i have ebola and will go to dr. bold's center in omaha, all the patients that came in that thursday night and had to be and the doctor's case had to be winnowed out of the other mode in the emergency room. in your situation, a patient only comes after they've been identified, is that correct? >> thus far the patients we have had midst to the biocontainment unit have come with a dc rrr diagnosis of ebola. given our national reputation, the number of phone calls, e-mails, even emergency visits has actually been quite interesting with people with febrile illnesses saying, please tell me if i have ebola. >> so then patients that arrive in your emergency room, you outline you have a dedicated laboratory handling of the specimens from an ebola patient but that's someone you know about. when it comes to the emergency room, they have fever and headache and all these other complaints, in addition, if someone incomes to do the pcr ebola test. in addition they get a cbc, a urinalysis and any number of other blood tests. these tests would go through the normal auto-analyzers within the lab without knowing that patient actually had an ebola possibility or is that in fact separated out in your emergency room? >> yes, sir, we have put protocols in place and widely shared them for triar screening if there's any suspicion a patient has ha travel history they are immediately sequestered. the there's personal protocol for personal protective equipment and notification of the team and the laboratory specimens are processed through the biocont n biocontainment facilities and deac decontaminated as if they were positive even before we know the results of the pcr. we are doing testing on site and makes it faster and easier, otherwise it would have taken days. >> i would point out that is in a perfect world. in the rough and tumble texas er, all of those protocols would not be immediately available. we'll get back to that. i have to ask you, the typhoid mary analysis you have used,

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