Lawmakers Grill CDC Chief Over Ebola Response

October 17, 2014

House Republicans at a hearing October 16 upbraided the head of the Centers for Disease Control and Prevention (CDC) for the agency's response to the Ebola outbreak in Dallas, Texas, in which a Liberian man has died and two nurses have contracted the deadly virus.

Appearing before a subcommittee of the House Energy and Commerce Committee, CDC Director Tom Frieden, MD, MPH, was questioned sharply on the adequacy of the personal protective equipment (PPE) worn by registered nurses Nina Pham and Amber Vinson, and how Vinson managed to fly on a commercial jet while being monitored for Ebola symptoms.

More than anything, though, Republican members challenged Dr Frieden's lack of support for banning travel to the United States from Liberia, Sierra Leone, and Guinea, where Ebola has killed nearly 4500 this year.

"The [CDC's] response so far has been unacceptable," said Rep. Fred Upton (R-MI), who chairs the Energy and Commerce Committee. "We need a strategy, and we need to protect the American people. This includes travel restrictions beginning today."

Dr Frieden repeatedly countered that the current system of screening travelers from the three West African countries for Ebola symptoms and possible contacts with infected individuals before departure and again once they arrive at US airports allows public health authorities to track them here. If the United States attempts to impose the travel ban that House Republicans want, residents of Sierra Leone, Liberia, and Guinea will find roundabout ways of entering the country and elude monitoring, Dr Frieden said. In addition, a ban would hamper the flow of healthcare workers and supplies into the countries, which represent the most important front in the war against Ebola.

"To protect the United States, we have to stop it at the source," Dr Frieden told the Subcommittee on Oversight and Investigations.

Several lawmakers questioned the effectiveness of taking the temperature of travelers either before departure or upon arrival, noting that someone with the Ebola virus may have yet to run a fever, owing to the 21-day incubation period. Rep. Marsha Blackburn (R-TN) also took aim at what critics of the current screening program see as its Achilles' heel — the reliance on travelers to be honest about health, travel history, and possible Ebola exposures.

To make her point, she quoted what Dr Frieden said in a 2011 lecture with regard to patients' medication adherence: "Hippocrates was right — patients lie."

"Dr Frieden, relying on self-reporting and making certain that people tell us the truth before they leave, and then [catching] the fever at the right time if they have a temperature — we've got to do better than this, and we can do better than this," Blackburn said.

Several Democrat members of the subcommittee, however, agreed with Dr Frieden that a travel ban will not protect the United States from Ebola. "It is seen as an easy answer," said Rep. Peter Welch (D-VT). "It may be a psychological answer, but it may not be an effective answer."

No Training on CDC Ebola Advisory, Hospital Official Said

Republican lawmakers also questioned how well the CDC had prepared US hospitals for the possibility of diagnosing and treating patients with the Ebola virus.

"If they walk into any emergency room in Appalachia, Ohio, and start throwing up, does your plan…tell that hospital emergency room what do to?" asked Rep. Bill Johnson (R-OH). Dr Frieden replied that the CDC had distributed "detailed checklists and algorithms" to help clinicians determine whether someone has Ebola.

The discussion of preparedness focused on Texas Health Presbyterian Hospital Dallas, which on September 28 admitted the first person diagnosed with Ebola in the United States — Liberian national Thomas Eric Duncan. Duncan died on October 8. Several unidentified nurses at Texas Health Presbyterian — plus one who has gone public, Brianna Aguirre — have accused the hospital of providing both inadequate Ebola training and PPE that left their skin exposed, charges that the hospital denies.

It became clear in the Congressional hearing that the hospital had received clinical guidance from the CDC on diagnosing the virus, based on the testimony of Dan Varga, MD, the chief clinical officer and senior executive vice president of Texas Health Resources, the hospital's parent company.

Dr Varga said that Texas Health Resources received a CDC advisory about Ebola screening in late July and shared it with all of its emergency department (ED) directors. The information also was posted in hospital EDs. However, when Rep. Diana DeGette (D-CO) asked whether anyone received training on this CDC advisory, Dr Varga answered no.

Both Dr Varga and Dr Frieden fielded queries about the PPE worn by Nina Pham and Amber Vinson, who were exposed to Duncan's vomit and diarrhea when they cared for him in the ICU. Dr Varga said that they both used CDC-prescribed "full protective measures." The gear included water-permeable gowns, surgical masks, eye protection, and gloves. He said that the type of PPE changed once Duncan's Ebola infection was confirmed by laboratory testing on September 30, 2 days after he was admitted. At that point, Dr Varga said, "the level of PPE was elevated to full hazmat style."

Before that point, "there was variability in the use of PPE," noted Dr Frieden. His agency is still investigating how the nurses contracted the virus despite wearing PPE.

National Nurses United, a powerful nurses' union that has championed the cause of their dissident colleagues at Texas Health Presbyterian, has called on hospitals across the country to equip nurses with hazmat suits when they must care for patients with Ebola.

Rep. Michael Burgess, MD, (R-TX) drew attention to the PPE issue when he displayed a photo of Dr Frieden wearing a hazmat-style suit during a recent visit to West Africa. Dr Burgess noted that the suit left none of Dr Frieden's skin exposed, which was necessary in part to protect him during chlorine decontamination.

"Let me ask you — what kind of stockpile of this PPE do you have available for [US] healthcare workers?" Dr Burgess said.

Dr Frieden replied that the CDC is studying different types of PPE for Ebola care, with an eye to user-friendliness. The degree of recommended protection depends on the risk for contamination, which increases when a patient is vomiting or having diarrhea, he said. "There's no single right answer."

Conflicting Accounts of Vinson's Air Travel

In the hearing, Dr Frieden also addressed the air travel of Amber Vinson shortly before she reported on October 14 that she had a low- grade fever, which led to her admission at Texas Health Presbyterian. She flew on Frontier Airlines from Dallas to Cleveland, Ohio, on October 10 to prepare for her wedding. On October 13, she flew back to Dallas on the same airline with a temperature of 99.5° F.

Dr Frieden has said that Vinson should not have flown on Frontier Airlines or used any form of public transportation because she was being monitored for Ebola symptoms. CNN reported yesterday that Vinson informed an unnamed CDC official about her fever on October 13 and was not told to stay off the plane. Dr Frieden told lawmakers that there had been a conversation, but "to my understanding, she reported no symptoms to us."

Texas Health Presbyterian transferred Vinson on October 15 to Emory University Hospital in Atlanta, Georgia, one of four US hospitals with biocontainment units considered state of the art for Ebola care. Yesterday the Dallas hospital transferred Pham to another one of those units at the National Institutes of Health Clinical Center in Bethesda, Maryland.

The CDC had announced previously that the agency was contacting passengers who flew on the October 13 Frontier Airlines flight with Vinson. Yesterday evening, they expanded that contact list to include passengers who had been on the October 10 flight from Dallas to Cleveland (Frontier Airlines flight 1142). The agency has asked all passengers to call its contact number (1-800-232-4636), after which they will be interviewed by a public health office. "Individuals who are determined to be at any potential risk will be actively monitored," the agency said.

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