House Homeland Security Committee Hearing Transcript on Coronavirus

Mr. Thompson: (00:00) Ms. Underwood to introduce our next witness. Ms. Underwood: (00:03) Thank you, Mr. Chairman. I want to welcome Dr. Ngozi Ezike, the director of the Illinois Department of Public Health. Dr. Ezike is a board certified internist and pediatrician who has dedicated her career to improving health outcomes and healthcare access for the people of Illinois. She has served in public health roles for the past 15 years in my home state of Illinois. Dr Ezike received her undergraduate degree from Harvard and her medical degree from the university of California San Diego. She completed her internship and residency at Rush Medical Center where she is an assistant professor of pediatrics. I want to thank Dr. Ezike and her team for working around the clock to respond to the recent coronavirus outbreaks in Illinois and sincerely appreciate her taking the time to share her expertise with us today. Thank you. Mr. Thompson: (00:46) Thank you very much. Finally, we have Dr. Julie Gerberdine who's served as the director of the Centers for Disease Control and Prevention from 2002 to 2008 she currently serves as executive vice president and chief patent officer for strategic communications, global public policy and population health at Meric. She is also co-chair of the center for strategic and international studies commission on strengthening America's health security. Without objection, the witness's full statement will be inserted in the record. At this point, I'd like to defer to the ranking member for an opening statement. Mr. Rogers: (01:31) Thank you, Mr. Chairman. I apologize for being late. I've got two hearings going on simultaneously, but this is a great panel and I look forward to their testimony. As I said yesterday, our hearts go out to those who have lost their loved ones and those who are currently undergoing treatment. This is a global event that requires global response. I know many of our international partners are working diligently as part of a united effort to understand and address COBIT 19's spread. Unfortunately, some of the actions taken by other countries may have hindered a comprehensive response to this new virus. I remain concerned that Chinese officials knowingly withheld essential information from both public and international health community in the most critical stages of this outbreak. I'm sure that the early days of this outbreak will be under intense scrutiny once this crisis is over. My deepest concern for the moment is the level of preparedness at state and local level. Mr. Rogers: (02:21) I've heard directly from state and local responders, medical professionals and emergency managers that are dealing with an increasingly concerned public. We have a very distinguished panel of medical professionals here today. I'm interested in hearing from them on what assistance frontline health professionals need from the federal government to effectively deal with this crisis. I'm also pleased that Dr. Gerberdine is here today. Dr. Gerberdine was director of CDC for most of the Bush administration. She has led a very effective response to the [inaudible 00:02:50] attacks and the outbreak of SARS and managed more than 40 other emergency responses. I'm very interested in hearing about her experience and how lessons from managing those public health emergencies can be applied to the COVID 19 outbreak. Finally, I'm interested in the panel's honest assessment of the risks from the virus. Your expert medical opinion is invaluable in reassuring the public during times like this. Mr. Rogers: (03:14) It's also very important for political leaders to avoid fanning the flames of hysteria. Our job should be to support the medical community and provide them with the resources they need to handle this and future outbreaks. That's why I'm very pleased we will be considering a supplemental appropriations bill today. Hopefully this funding will help speed along with this important diagnostic treatment and vaccination resources that will alleviate this crisis. Thank you Mr. Chairman and I do have one UC request that we enter this into the record. Mr. Thompson: (03:42) Without objection. Mr. Rogers: (03:43) Thank you sir. I yield. Mr. Thompson: (03:44) I now ask each witness to summarize his or her statement for five minutes beginning with Dr. Inglesby. Dr. Inglesby: (03:54) Chairman Thompson, ranking member Rogers and members of the committee, thank you for the chance to testify today about COVID 19 my name is Tom Inglesby and I'm the director of the Johns Hopkins Center for Health Security. COVID 19 was first recognized on China at the end of last year and as of yesterday has infected somewhere between 85,000 and 90,000 cases worldwide, and killed over 3,100 people across 65 countries. Patients who become sick with COVID 19 most often have cough, fever and in the more serious cases underlying viral pneumonia. In China approximately 80% of those with this illness had mild symptoms, 15% required hospitalization, and 5% developed critical illness. The virus has a one to 14 day incubation period and is spread primarily via respiratory droplets between persons at close contact, and the elderly and those with underlying medical conditions are at highest risk. As of yesterday, the US had confirmed 118 cases of COVID 19 including eight deaths. Dr. Inglesby: (04:56) The majority of those cases are returning travelers or repatriated persons from China, but for about 20 cases there is no connection between any known case of COVID 19, which suggests that in those places there is some level of community transmission of COVID going on. Emergency supplemental appropriation is currently being negotiated between Congress and the administration. In 2014, 15 Congress appropriated five point $4 billion for the Ebola response. In my view, COVID 19 will require perhaps twice as much or more given its respiratory transmission and the likelihood that it is going to be widespread around the country and so all jurisdictions will need to prepare and respond. Healthcare systems should be planning to provide care for large numbers of critically ill patients as we've seen has been required in China and in South Korea and Italy. They will also need very strong infection control strategies, including access to personal protective equipment as well as other kinds of engineering and administrative controls and hospitals. Dr. Inglesby: (05:59) The federal government should be engaging at the highest level of industry regarding PPE manufacturing and maximizing the supply of this critical medical material. Steps should be taken to make sure that routine medical care is not disrupted as it has been in China where we saw that clinics entirely unrelated to COVID 19 were disrupted, including cancer clinics, dialysis clinics, and other important medical facilities. Public health agencies are working to isolate suspected cases around the country and to help ensure isolation of high risk contacts. If cases increase significantly, it may no longer be possible to isolate all cases and contacts and there may need to be a shift, probably will need to be a shift in strategy and at that point public health agencies will need to focus on surveying the population for the overall level of COVID 19, advising how the public can be tested and how it needs to be isolated when sick and working with political leaders at the state and local level to consider social distancing policies that will do more good than harm. Dr. Inglesby: (07:07) CDC has been doing all lab testing until this week, but testing is now getting going and public health labs around the country. I believe we will see considerably more cases diagnosed around the US in the coming days as we've seen in the last week. Large scale testing at clinical sites around the country will require clinical diagnostics companies to create high throughput clinical tests because CDC and public health labs were not designed for the kind of high throughput clinical testing that will ultimately need to take place. Vaccine development is likely to take at least 12 to 18 months and one of the world's experts is to our left. So you'll hear more about that. We should be developing ... As we develop an effective vaccine, we should also be developing means to mass manufacture it, which is not necessarily the normal process for vaccine manufacturing, and ideally that should be occurring in multiple sites around the world. Even if the US is the country to develop the vaccine, there will be huge demand for the vaccine around the world. Dr. Inglesby: (08:05) Antiviral or antibody based medications could also be developed far sooner than vaccine and similarly plans for mass manufacturer of those products should also be underway should those be successful. One of the themes of our preparedness in this country needs to be close partnership between government and industry because industry is the place where diagnostics on a large scale, PPE, medicines, vaccines, hospital equipment are being manufactured. So there is no way around having a very close effective partnership and making sure that those industries are well aware of the support that they will receive from the government to do that work. Dr. Inglesby: (08:42) Finally I'd say that it's very important from this point forward for the federal government to be speaking in a single consistent voice about what's happening. I think a daily briefing as we did in 2009 H1N1 about what's known, what's unknown, how we're learning to fill the gaps in information should come out of the government on a daily basis, and I do think that should come from our health officials, either at HHS or CDC because they are closest to the science and to local and public health agencies around the country. Thank you for the chance to testify today and I look forward to your questions. Mr. Thompson: (09:15) Thank you for your testimony. I now recognize Dr. Ezike to summarize her statement for five minutes, Dr. Ezike: (09:26) Chairman Thompson, vice chair Underwood, ranking member Rogers and distinguished members of the committee. My name is Ngozi Ezike, I'm the director of the Illinois Department of Public Health and I thank you for inviting me to speak about the novel Corona virus and the preparedness and response efforts of the Illinois Department of Public Health. Even before our first Illinois case was identified in January, a strong federal state, County and local coordinated effort was enacted and enabled our state to be a leader in addressing this rapidly developing outbreak. The CDC quickly deployed a team to Illinois after our first case was announced and was essential in partnering with us through the response. They have been equally responsive with our recently announced third and fourth cases. The Illinois congressional delegation supported our request for immediate approval of an emergency use authorization for the COVID 19 test, which has been invaluable in the effort to containing illness. Illinois was the first state in the United States to validate this test and to begin testing in house, a capability that we've had for the last three to four weeks. We began sentinel surveillance testing this week, enabling Illinois to better determine how much COVID 19 is circulating within our community. Our success in testing raises a new concern, however. Will we have enough reagent to maintain and increase our testing? We are requesting that CDC provide an uninterrupted supply of testing materials. The ability of states like Illinois to test samples lessens the burden on the CDC. We encourage CDC to expedite additional reagent shipments to Illinois and other States. Illinois has utilized and proven its capabilities in the past when responding to the domestic cases of SARS, H1N1, Zika and Ebola. IDPH recently participated in Crimson contagion. This is a national tabletop exercise that used a COVID 19 like outbreak that was said to have originated in China in the US. However, surge capacity remains something that is not able to be sustained for extended periods of time. Therefore, emergency supplemental funding is necessary. Dr. Ezike: (11:59) Illinois encourages Congress to appropriate funds enough to reimburse Illinois and other states for the cost associated with this aggressive response. Public health infrastructure such as data management, information sharing and operations management are essential just for day to day function, but they're vital in the settings of public health emergencies. For example, during this response, the state health department is closely monitoring the availability of airborne infection isolation rooms. These isolation rooms are providing ... Are proving critical in the treatment of these patients by controlling the spread of the virus to the public and healthcare workers. We inventory these beds daily as an indicator of disease rates and to adjust surge capacity estimates. An important support for this capability came from Aspers's hospital preparedness program. Given the transmissibility of COVID 19 isolation sites are required to house affected persons. It's challenging to find establishments willing to take on isolation or quarantine patients. When COVID 19 began in Illinois, the city of Chicago was given very little time to set up screening operations at O'Hare and establish a requisite quarantine site. Chicago has continued to maintain both its screening operation and quarantine site at an enormous cost. Without reimbursement and ongoing money for future expenses, governments will likely struggle to maintain these critical public health interventions. Additional attention must be given to mitigation strategies of the state. We are also working closely with longterm care facilities to implement mitigation strategies aimed at protecting what would be our most vulnerable citizens. In addition to these community mitigation approaches, we encourage the public to employ their own strategies to keep themselves healthy. We've said it over and over, the frequent hand washing, the staying home when ill sanitizing frequently touched surfaces. Individuals should take care to rely on trusted sources of information such as the CDC. Public health security is homeland security. Our country is nothing without the health of its people and we can all work together to ensure that we continue to support this response and decrease the potential negative effect and impact on the people of this country. In closing, I wish to again thank the committee for its invitation and the attentiveness to Illinois successes and opportunities in responding to COVID 19. Thank you. Mr. Thompson: (14:48) Thank you for your testimony. I recognize Dr. Gerberdine to summarize her statement for five minutes. Dr. Gerberdine: (14:56) I am very honored to be here and also to testify with such distinguished experts at the table. I'm here wearing several hats. I am currently the chief patient officer at Merck where I have served as the president of the vaccine business for a number of years and more recently as the chief patient officer who contributed to the development and deployment of the Ebola vaccine in the Democratic Republic of the Congo, which is now licensed even though it was created on the fastest possible track and so far we've been able to contribute about 300,000 doses of the vaccine. This week the director general of the WHO indicated his optimism that that outbreak has finally come under control. I'm also witnessing as the co-chair of the CSIS commission on global health security, which submitted this report to the record. The commission is a bipartisan ... Includes bipartisan members of the Senate in the house and has the stated purpose to advise the Congress on steps that can be taken to improve our global health security. Dr. Gerberdine: (16:03) The report was written before Corona virus was recognized, but I think many of the recommendations which are summarized in my written testimony are present and really apply to the situation that we are experiencing today. I would be remiss if I didn't mention that I'm also on the executive committee of BIO, the biotechnology innovation organization. Today many of the CEOs of bio are here in Washington to brief members of Congress. About 40 of these companies have innovations in molecules and platforms and are stepping up to try to contribute to the prevention and treatment of the Corona virus outbreak. So we're lucky that we live in a country that has such a vital bio technology organization. And finally, I am the former CDC director in a past life where we were dealing with anthrax and SARS and many other outbreaks. The first Corona virus outbreak, SARS, challenged the United States and challenges the world. And I think we learned many lessons which are relevant to where we are today. Dr. Gerberdine: (17:10) I don't have time to give the full picture of the US public health situation, and I think my colleague has expressed it from a state view very eloquently, but I would say that it's important to remember where we are in the outbreak right now from a US perspective. There are really three main phases of outbreak response. The first is detection, and that happened in China and was reported fairly early in the process, but we don't have full detection because we haven't had full testing and we still don't know whether the cases we're detecting represent the tip of the iceberg and how much of the iceberg is undetected yet we haven't tested or because many patients are asymptomatic, which I in fact suspect. The second phase is the phase of trying to contain the outbreak where it starts, and I don't think in the history of the world we've seen a more dramatic demonstration of that than what occurred in China and then what has occurred in countries around the world who attempted to keep the virus out of the country. Dr. Gerberdine: (18:11) It was a heroic effort. It wasn't perfect, but it probably did buy us some time and for that I think we should all be grateful. Where we are now is in the phase of slowing the spread of the virus. It's here. We're doing everything we can on the front lines of public health to identify and isolate cases, to quarantine people who may be exposed or incubating, and to managing the social system that promotes spread. But we have to balance that effort to slow things down by recognizing that we also need to sustain our essential services. Our businesses need to run, our medical supply chain needs to operate and our security and safety need to be also part of our overall response capability. So we're going to be seeing a lot of local decision making. Dr. Gerberdine: (19:04) If you're looking at it from a high level view, what's going on in Chicago might look different from what's going on in some other part of the country, but you know that each individual location has to make decisions in the best interests given the state of the outbreak in their particular community. One of the most important lessons that I wanted to emphasize in my opening statement is something we've learned in every outbreak and that has to do with the importance of trust. We must have credible leadership at every level, federal, state, and local. We must have clear and consistent communication from trusted individuals who are knowledgeable about public health, healthcare and the science and evidence of public health interventions. And we must have a spirit of collaboration, not combat, a spirit of health protection and not politics. Thank you. Mr. Thompson: (20:03) Thank you very much. I must add, we hear from a lot of witnesses on this committee and what you've told us has been quite sobering to set at least, but quite informative. So I'd like to compliment you at the beginning of the questions. But one of the things that each one of you talked about was the need in a situation like this to have effective communication, and there seems to be mixed messages to the public from the administration at this point regarding the severity of this outbreak. Many of my constituents have repeatedly called asking for clarity on many issues, citing inconsistencies made by the high level administrative officials. How would you assess the US government's communication with the public regarding the risks presented by this outbreak and what can the federal government do better? Dr. Inglesby, we'll start with you? Dr. Inglesby: (21:16) I think that the state of the outbreak has changed a lot in the last month and we have a very big federal government with many different people working on this. And so there have been days when within the government there had been different messages issued. I don't think that was necessarily intentional. I think that partly, it's people kind of catching up to where we are in the outbreak, but I do think it will be very valuable for the government to be speaking with as much as of a single and consistent voice as they can, as is possible in a big government. And I do think it's ... On the one hand, I think it's very important to say what the data, the risk is at this moment. I think many of the risks statements have been said from the government today. The risk is very low for any particular American and that may be accurate for today, but I think it would be helpful for Americans to understand risks going forward. Dr. Inglesby: (22:13) What do health officials believe is likely to happen in their communities? Not in an alarmist way, but just so that people can be informed to begin to take measures as we heard my colleagues talk about, to try and diminish their own risks, to make sure that they're staying home when sick, to make sure that they are washing their hands properly, disinfecting after they touch public surfaces. So I think consistent messages that empower the public would be useful. Even if we don't know exactly what will happen next, we do expect this disease to continue to spread in the country. At this point. It'd be useful people for to know that. Mr. Thompson: (22:47) Dr. Ezike. Dr. Ezike: (22:52) And in Illinois, our intersection with the federal government has been primarily with the CDC and we have had intense communication and collaboration. We are on hours of calls together every day, seven days a week. We have had federal CDC staff come on site to help us directly with our investigations. And then with the FDA, they were the ones that gave us the authorization to be able to test. And that ability to test and being the first state being able to do that has been very instrumental in being able to quickly identify our positive versus our negative cases. So we have seen how good communication, collaboration and coordination between the federal state and our local health departments, how that integration has been successful in giving us a pretty good response in Illinois. Mr. Thompson: (23:51) Dr. Gerberdine, you have gone through this in another life. Can you kind of talk about the same issue as it relates to communication and the public needing to hear a consistent voice? Dr. Gerberdine: (24:11) Sure. I'll try to share a couple of things that I think I learned along the way. The one that was the hardest for me was that you can't communicate enough. That it really does take, like you said, daily regular, what do we know today that we didn't know yesterday? What don't we know and what are we doing to find out? And then what can you expect going forward? One of the hardest things about being in the very early phases of a outbreak like this is that we don't really know what to expect. This is new and we're learning as we go. So preparing people for change, for decisions that we make today might be different from decisions that we make next week. These are very important things and to just acknowledge them. Dr. Gerberdine: (24:53) People don't panic if they're given straightforward information. They panic when they hear confusing and conflicting information and they don't know who to trust or who to believe. I think the other important lesson that I learned was the importance of governors in the communication. We tend to think that everything is Washington and federal and if we do our job right, it will just automatically flow through the system. But as you know, governors have a great deal of authority in their states and they need to be brought into the communication and information flow because they influence a whole number of important decisions at the state and local level. So making sure that they are connected to the federal response is critical. Mr. Thompson: (25:38) Well, and I thank all of you for saying that, because yesterday the administration's coronavirus task force held a press briefing that was closed to cameras and audio recordings. And that's troubling in a time like this because information is very important. So if you hold briefings, I think they should be public, recordings should be made because it's the consistency of the message that provides the confidence that's so important during these troubling times. Mr. Thompson: (26:20) So my plea to the administration is going forward, please allow at the briefings to have the press, there, have the cameras rolling, have the recordings being made because all this adds to strengthening the level of communication required in a situation that we're in now. So I wanted to make sure that the administration hears so future press briefings will be open from a transparency standpoint to the public. And I think all three of you have kind of said that that's so important in situations like this. I yield to the ranking member. Mr. Rogers: (27:09) Thank you Mr. Chairman. Dr. Gerberdine, you made in your opening statement reference to the fact of the lessons learned from your time in your previous life. What lesson have we most learned from this outbreak given that it's in its early stages that we need to take heed of? Can you think of one in particular that stands out? Dr. Gerberdine: (27:31) I will say the global lesson is that we are going to see infectious diseases spill over from the animal kingdom on an increasing basis for a number of reasons. And that there are common sense things that the global community needs to rally behind, like not having wet markets where live animals are congregated together and create the opportunity for this spillover to occur. Dr. Gerberdine: (27:58) I think from a US response perspective, the lessons are are summarized in this report and that is that we do a pretty good job of stepping up when there's a crisis, our response machinery takes time to get in place, but eventually we get there and we do a pretty good job of managing an outbreak, but we shouldn't have to do it in a crisis mode. We need to invest, we need to take our countermeasures across the finish line. We still don't have a SARS vaccine. We do not have a MERS vaccine. We do not have a Zika vaccine. We are partially there, but then the effort gets abandoned. So we need to stay the course and complete the job so that we can take some of these threats off the table. Mr. Thompson: (28:44) Dr. Ezike, you talked about quarantine and tell me more about what you think the appropriate facility would be styled like to be a good quarantine facility. Dr. Ezike: (28:58) Thank you for the question and let me start by distinguishing the quarantine sites versus the isolation sites. Mr. Thompson: (29:06) Define those two. Dr. Ezike: (29:06) Yeah, so quarantine, we use to talk about people who don't have symptoms, who are asymptomatic, and when I talk about isolating people, maybe we needed some sites for home isolation for people who maybe are already showing symptoms. The goal would be for people who are already sick to actually keep them out of the hospital. If they don't require a hospital level care, ICU care, we really want to keep those people out of the hospital so that we don't pose that additional to the health care workers and sicker people in the hospital. Mr. Thompson: (29:45) Do they need to be exposed in any way to other individuals who have no symptoms? Dr. Ezike: (29:50) Please ... Can you please repeat the question? Mr. Thompson: (29:52) Did those individuals who are starting to show symptoms need to be exposed to anybody else that doesn't have symptoms? Dr. Ezike: (29:58) That's what we're trying to avoid. And so in cases where, as a person has contracted- Dr. Ezike: (30:03) In cases where a person has contracted the virus but they're not sick enough to require hospitalization, we'd like to have a space, an isolation location where that person could be safely housed until they were no longer infectious. Mr. Rogers: (30:18) What were the characteristics of a place that would safely house somebody who is showing symptoms? Dr. Ezike: (30:22) Right, so if someone lived alone, there would be no problem. They would just be in their home, but if someone had a family, we wouldn't want to infect them. We wouldn't want to expose them to their family. The settings that we have used or look to use are we need like a motel where you have individual rooms with their own entrance where the air is not shared, where there's not a common lobby where people would have to congregate. You want individual settings where they can minimize exposure to other people. Mr. Rogers: (30:56) What if somebody had to go to the hospital? What should a hospital prepare for as far as rooms or capacity that does not expose people to other emergency room personnel or patients? Dr. Ezike: (31:06) Yeah, so again, it comes around coordination. Ideally, if you knew someone was concerned or the clinician who had talked to the person hopefully by phone and identify them as an at-risk for having the virus, that we would have a system in place where they could be safely transported to the ED or whatever location, but not be exposed to people where the initial people who are interacting with this suspected person could already be in full personal protective equipment. We've had hundreds of people who were just doing business as usual and then after the fact found out that the patient they were taking care of had the Coronavirus and that has resulted in them having to be at home for 14 days waiting to see if they develop symptoms. Ideally, we would have robust communication, be able to bring them into a safe space, ideally not even into the hospital. If we could create some kind of drive through testing sites that are away from the hospital, if there was some offsite location where you avoid contact with sick people in the hospital and healthcare workers. We don't want to do anything to compromise our capacity in terms of healthcare workers where they're all home waiting to see if they contracted something and not able to provide frontline services. Mr. Rogers: (32:32) Thank you. I yield back. Mr. Thompson: (32:33) Thank you very much, chair recognizes gentleman from Rhode Island. Mr. Langevin for five minutes. Mr. Langevin: (32:39) Thank you, mister Chairman. I want to welcome my witnesses here today. Thank you for your testimony, Dr. Gerberding in particular, welcome back before the committee. You testified before as many times when you were the head of the CDC including hosting me in a a congressional delegation at CDC for a site visit there, so deeply appreciate your leadership. I'd like to continue on this high end of state preparedness and what states should be thinking about right now. Yesterday, I spoke with the governor of Rhode Island, Governor Raimondo about the emerging public health threat to our state, which has already seen one confirmed case of Coronavirus and several presumptive cases. Any additional thoughts in terms of states preparedness right now, what they should be thinking of in terms of surge or alternative sites? Because that's been my concern is that people who are sick, they're going to go to the hospital. That could very easily overwhelm the public health system in addition to infecting sick patients already that are at the hospital or equally important, the healthcare providers that are caring for people. Any additional thoughts in terms of what states can be thinking of right now preparing for the eventuality that this might become community spread and that we should have alternative sites? Dr. Ezike: (34:00) That's of course, exactly what we are working on throughout our agency. We're trying to develop ... We're developing guidance for different locales. We're developing guidance for our local health departments so that they can advise schools. We want schools to start thinking about contingency plans so we can't be over-prepared. I think the adage is if you fail to prepare, you're preparing to fail. Just thinking through possibilities, thinking through the options for telework, looking at your agency, your company, and seeing which people in your agency if this surge could stay home and still maintain the operations of the company or the business, which people don't have to come in, how do we minimize those situations? Going through different scenarios, looking at our, again worried have a top of mind are our long-term care facilities because there is a very high risk population and making sure that all the long-term care facilities, assisted livings that they are looking at their infection control programs, that they're making sure that they're following them, that they teach and reeducate their staff on infection control measures. Think now about what are the appropriate ways that co-house people, if there's more than a person in a room. Thinking through all the possibilities, that's the preparedness part. Mr. Langevin: (35:29) Let me ask you this, if I could, as we know of course, the workplace is an area of particular concern with respect to viral transmission. To that end, the CDC and state leaders, including our governors, strongly recommend that people stay home for work who are sick, which is common sense. However, for many people, especially hourly workers staying at home, can mean choosing between putting food on the table or paying bills or stopping the spread of the virus. I know Governor Raimondo was trying to look at creative solutions to make sure that the Rhode Islanders are not forced to make this impossible choice, but Dr. Ezike, how is Illinois addressing this problem and what should the federal government be doing to help? Dr. Ezike: (36:15) Yeah, that's a really real concern. I'm thinking of one person in particular who actually wanted to leave the hospital before we had test results because they express that exact concern that I only get paid when I show up to work, and being here is costing me and I'm the primary breadwinner for the family. We know in the hospital setting, we have had great collaboration with our hospital leadership, and so when they have told employees to stay at home, they know that they will be paid, but we need to have some kind of a payback for people who are set up to stay home. Dr. Ezike: (36:55) If we want people to comply with our public health interventions, it can't be at a detrimental cost to them and their family in terms of their economic subsistence, so making funds available to reimburse people for the time that they have to be at home to comply with our public health measures will help people to follow our public health measures as opposed to avoiding being tested because they don't want to incur the results into isolation. Mr. Langevin: (37:20) Hopefully, that's going to be addressed in a supplemental that Congress is dealing with, we'll have a mechanism for that. Dr. Gerberding, Any thoughts before my time runs out? Dr. Gerberdine: (37:29) I just wanted to say one thing about schools because we learned in studying the previous influenza pandemics that early school closure was a critical component to helping the slow down spread in many communities. This outbreak is somewhat puzzling because less than 1% of the cases are in kids and so that may be because they have very mild disease and they don't get tested or they are not noticed to have the disease or perhaps they have some immunity from from prior normal Coronavirus, common cold-type exposures. We really don't understand that until we have serologic testing we won't really understand that whole tip of the iceberg, but I think we will see situations where school closure makes sense in the short run, but we very quickly need to learn what is the role of children in spreading the diseases with this Coronavirus because it'd make a huge difference whether or not schools are closed. Closing schools is extremely disruptive. It may be necessary, but we need to I think build the evidence base to understand how to use that tool. Mr. Langevin: (38:32) Very good. Thank you all. Mr. Thompson: (38:35) Thank you very much. Chair recognizes gentleman from New York for five minutes, Mr. King. Mr. King: (38:40) Thank you, mister Chairman and let me thank all the witnesses for your testimony today. There's reports from New York this morning, which I think shows the rolling impact of this disease. It was a lawyer from Westchester County who was diagnosed yesterday. This morning it turns out, that his wife and two children and the neighbor who drove him to the hospital for the test all have it. One of the sons is a student at Yeshiva University and the school was being shut down now because of that. This is the growing impact you can have in a metropolitan area like New York or Chicago or Los Angeles, Boston, any of them, how quickly could this spread. I'm not trying to spread fear here because I think this can be controlled, but when you just see that one impact of one person, one family and his neighbor and students, how quickly that can spread. I assume he may be taking the train and the subway to work that day. He works in lower Manhattan where he just by being on an elevator, walking through the hallway, he runs into a hundreds of people. Dr. Inglesby: (39:44) In Wuhan where this first occurred, the estimate by some of the most prominent modelers in the world was that the epidemic was doubling every week. We don't know whether that will be the same here, but we do see most, we saw a very prominent clustering in families and in people who have close contact. I think we should presume that there will be relatively rapid spread in our communities. We are beginning to take measures to try and change that, but I think it could spread rapidly in communities around the country. Dr. Inglesby: (40:21) Fortunately, I think many of the cases that you just described will have very mild illness. They won't even have ... If they didn't have a contact with their father, they may never have been recognized. They may have had the illness and then never had it diagnosed. We're going to learn a lot about the illness and what it looks like in America in the coming weeks and we should be prepared to kind of move in different directions. I do think that some of the social distancing measures need to be considered in places where we have high exposure and lots of cases recognize such as the communities in Washington state, which are having a lot of disease recognized. At some point, I don't believe some of those measures will scale any further and we won't be able to quarantine or isolate in the way that we're doing now. It'll be too many people to do that, so we'll have to shift strategies to things that are more community-based. Mr. King: (41:08) Doctor? Dr. Ezike: (41:12) In the cases that we've seen in Illinois, we have seen how a single individual after being diagnosed, when we try to look back at the time that they could have been incubating, the places they would have been, the different settings, maybe if they interacted with the healthcare system as an outpatient and then was sent home and then maybe came back. One person could have contacted up to, I mean in our case that I'm just thinking of specific examples, 150 people and so then those people are all looked at but and that if someone happened to have flown or gone to a mass gathering, then the numbers could be a lot. Dr. Ezike: (41:55) Absolutely, to your point, a single case can spread to many people, but we have also seen as Doctor mentioned that it's been the closest contacts that we have seen so far. We have not had any of the healthcare workers who have been exposed to the patients before they were detected, before they were in full personal protective equipment, none of those people have come back positive. We hope that that is a sign that will continue, but the idea is to minimize the number of cases because it does have the potential to spread exponentially. Mr. King: (42:35) Doctor? Dr. Gerberdine: (42:36) Just think about the very first patient diagnosed in the United States who had traveled to China and came back with the virus and was a good citizen and stepped forward when he just didn't feel well long before he had fever or pneumonia, so they were able to sample his respiratory tract as he was developing progressive illness and learned that early on when you might not even recognize that you were very sick, his upper airway was full of virus, so he was probably potentially quite infectious early, even early in the course of his disease. Dr. Gerberdine: (43:12) Later, he went on to develop pneumonia and of course with pneumonia, with your coughing or you're getting airway procedures in a healthcare setting, you have the risk of becoming a super spreader, which means that your respiratory secretions are being disseminated into the environment. We saw that with SARS and with MERS. The good thing about that in the US is that we are pretty good at hospital infection control and we can usually minimize that kind of spread. Stepping back and thinking about the transmissibility of this Coronavirus versus the community transmission of SARS, this is a much more transmissible situation. We saw very little community transmission and another way of thinking about it as in SARS, in eight months we had 8,000 global cases. With Coronavirus, there were 8,000 cases in two weeks. Mr. King: (44:04) I just feel sorry for the guy who drove him to the hospital for the test, he ended up ... I guess no good deed goes unpunished. The neighbor who drove him to the hospital's come down with it now too, so thank you very much for your testimony. Appreciate it very much. Mr. Thompson: (44:15) Thank you, Chair recognizes gentleman from California, Mr. Correa for five minutes. Mr. Correa: (44:20) Thank you, mister Chairman. I want to thank you for holding this most important and timely hearing. January, Orange County, my County, the first patients who tested positive for Coronavirus in the United States, one of the first ones. Now we have 43 of these cases in California and I was looking at my phone right now, we just reported the second case in Orange County yesterday. In response to the news report, I wrote to the Center for Disease Control and Prevention, asking them to please share clinical information on the Coronavirus patients with medical professionals to help doctors diagnose, evaluate and treat Coronavirus. I would presume that right now we don't know how many folks are infected out there so we really don't know the death rate out there. We don't know if this is worse than flu, yes or no? Am I correct on that? Dr. Inglesby: (45:17) You are correct. At this point in China, the overall number of people who've died have been about 3%, close to 3% between two and three. We don't think that that will be ultimately the case fatality rate of this disease because as Dr. Gerberding said, probably a substantial number of people who haven't been diagnosed who have mild illness, which will mean the case fatality rate will go down, but we don't have any surety about that yet. We believe it is and as comparison, seasonal influenza is somewhere in the order of one in 1,000 people die from that disease or less depending on the year. Mr. Correa: (45:54) As we get more information, we have a better picture and therefore, possibly this is a better evaluation, a better handle on this emergency. Dr. Ezike, are we doing enough at the federal level, are we working with the Homeland Security, with local states to address this issue? Are the resources communication that are going to do a better job to get a handle on this crisis? Dr. Ezike: (46:21) I think at the forefront of what you just mentioned and in terms of identifying the details and the full epi-picture is the ability to broadly test. We can't know what the rates of infection are if we don't diagnose the infection. I think that is so critical. The Sentinel Surveillance, that would be a helpful tool, involves looking at people just generally in the community to see what the levels are in the community without a known travel history, without a known exposure to a confirmed case. Currently in Illinois, we're trying to start that process, but we have to tread lightly because we don't want to run out of testing supplies and we need also test the people who are connected to the last two cases that we just recently identified, so I think making sure that testing supplies are available broadly where people can test without reservation, I think is an important thing that the federal government needs to give the states and hospitals the ability to do. I think that's pretty central to the effort being able to diagnose in the first place. Mr. Correa: (47:47) Dr. Gerberding, you said something that really bothered me, which is we've had past similar crises, similar situations yet we don't finish the job. We haven't developed vaccines, treatments for these other cases in the past. Yet, as you said, we're going to continue to have these kinds of situations that jump from animal infections to humans. What can we do at the federal level to compare and be there consistent in terms of addressing these crises so they don't turn out to be such a major challenge as we move forward? Dr. Gerberdine: (48:23) Thank you. I'm so grateful that the Congress is going to provide an emergency supplemental for this, but if we were investing properly for our broad Homeland Security and the issue of health threats, infectious disease threats, we would not need emergency supplementals anywhere near the scope and magnitude that you're facing right now. We need to improve the support for the CDC's surveillance capability. I think we've learned that we also need to make sure that they can scale testing as quickly as necessary to avoid the bottlenecks that we've seen. I think we need to make sure that our state and local health departments have the capacity. They will soon run out of laboratory time, space and people to be able to do all of these tests and they will need support from the federal government to scale their capabilities. They'll be working 24/7 literally, so we haven't built into our system of preparedness that surge capability. It might be fine if this were a rare situation, but let's just think back for a few years we've had SARS, we had avian influenza, we had a pandemic in 2009, we've had Zika, we had to worry about Ebola and now here we are with this new Coronavirus. This is not a one-off situation. This is going to be our new reality and we need to upgrade the investment that we're making in the front line of public health. Mr. Correa: (49:53) Thank you. Mister Chair. Mr. Thompson: (49:55) Thank you. The Chair recognizes gentleman from North Carolina, Mr. Walker. Mr. Walker: (50:00) Thank you, Chairman Thompson. Dr. Ezike, first of all, let me thank your panel for being here today. Dr. Ezike, yesterday, my home state of North Carolina announced its first case of Coronavirus. The patient in North Carolina had recently returned from Washington state where an outbreak had occurred. How is your state monitoring patients arriving from areas that have many confirmed cases? Dr. Ezike: (50:27) Right now for interstate travel within the US, there is not a specific mechanism, a formalized mechanism to say, "Oh, this person came from California," where that information would be used is if the person developed symptoms and hopefully a very astute clinician taking a travel history and then would notice in asking questions about where you've been recently. Somebody would say, "I was in Washington or I was in California." That would raise the level of suspicion, the index of suspicion that, "Oh, that could be maybe a higher risk." At that point, they would reach out to the local health department to get the PUI number to get the authorization to test. We have more formalized processes that where we ... Through the customs and border control and the Department of Global Migration and Quarantine where they come from China or Iran, certain countries that we will get that and automatically do the monitoring. For interstate, that's not in place now. Mr. Walker: (51:36) Yeah, and anybody on the panel can speak to this is it ... I believe it's my understanding that the deaths that we've seen in Washington state for the most part are senior adults with maybe some respiratory issues. Is that your understanding? Dr. Ezike: (51:49) I don't know of all of them, but I think the majority, I know for a fact the majority of them are. I can't speak for every single case. Mr. Walker: (51:56) All right, and Illinois successfully, what are you doing to maybe limit the spread of viruses that states like North Carolina can emulate? Dr. Ezike: (52:05) Again, right now some of the ... We don't have other countermeasures besides the standard public health measures in terms of self-quarantine or staying home when you're sick and using hand sanitizer and washing hands. We're giving that message out broadly, but I think again, our Sentinel Surveillance will be helpful so that we can identify if there are pockets of the state that actually have circulating virus that we're not aware of. I know that the whole state might not see some kind of surge at the same time. It's going to be focal and local in certain communities and so we just want the ability to identify that as soon as possible. Mr. Walker: (52:49) All right, thank you. Dr. Inglesby, you discussed the incubation period is five days and someone who get infected has no symptoms. The question is this, what do you suggest the government does to minimize the risk of asymptomatic transmission? Dr. Inglesby: (53:08) I think that's a very difficult question. I'm not sure there is anything in specific that we can do about asymptomatic transmission because all of us are asymptomatic. I don't believe any of us are necessarily infected with Coronavirus, but we wouldn't know. I think ultimately, the goal of communities as this virus begins to spread is to try to lower the peak of the epidemic, to slow it down so that our healthcare system is not overburdened with very sick people. Some of the measures that public health agencies and local governments are going to start to consider will be should we cancel public gatherings, where thousands of people get together for a sports event or a concert or something else? Should we begin to recommend to our communities that they telecommute if they can and those kinds of things. Mr. Walker: (53:55) A lot has been talked about the quarantine time period of 14 days. Is that a sufficient amount of time? How did medical professionals come to that number and should patients stay in quarantine any longer? Dr. Inglesby: (54:09) I think that number was based on what we've seen from China and the World Health Organization and supported by CDC and that's based on the longest we've seen in terms of incubation. I do think when people come out of isolation, that local health authorities are working with them directly to make sure that they are safely coming out of isolation if they have actually been infected. Mr. Walker: (54:27) Last question for you. There have been a few reports of people testing positive after having recovered from an earlier infection, which is very troubling. That means that brings in other things we won't get into today as far as concerns, as far as where it was actually based or how it was created. If you become infected and recover, is it possible to be infected again or is this a larger issue with testing such as false positives? Being married to a family nurse practitioner, this has been part of our discussion this past week. Would you address that? Dr. Inglesby: (54:56) I think it's the latter. I think the numbers are too small to say anything about reinfection and our judgment is that it's probably a testing phenomenon. Test one day and then the next day, and the test picks it up the next day, but the person was consistently recovering for that whole time. Mr. Walker: (55:11) Last question, just real yes or no. This is something we're debating at home. Washing your hands of course is crucial with antibacterial soap, is that better than hand sanitizer? Dr. Inglesby: (55:21) I don't think there's any evidence that it is. Mr. Walker: (55:22) Okay. All right. Thank you. Mr. Thompson: (55:24) Thank you. Chair recognizes gentlelady from Illinois, Ms. Underwood. Ms. Underwood: (55:30) Thank you, mister Chairman and thank you to all of our witnesses for being here today. Coronavirus requires a whole government response, which means federal, state and local governments must work closely together to fulfill their different roles, but it also requires a public health approach, one that prioritizes risk communication as you all both just ... Or all three of you just clearly expressed and it uses smart strategies to minimize the impact of the virus and keeps communities that we all serve educated and safe. Dr. Ezike, can you tell us more about your department's day-to-day work with the CDC in response to the Coronavirus? Dr. Ezike: (56:07) We have lots of interaction with the CDC. There are hours of calls per day where we get updates, where they will interact with, whether it's the state health officials or the state epidemiologist or the state preparedness and response. There are all departments of the CDC talking to all departments at state and local government. We have onsite support in terms of epidemiologic intelligence service officers. We have go teams that have been deployed to help us with the actual investigations. They have guidance that they're continually putting out and updating to help us disseminate information to our communities in terms of ways that they can get prepared. There's a robust coordination and collaboration. They're listening to the calls. They are listening to us to identify what our needs are. When we say, "Oh, we're missing a guidance related to this," then they say, "Yes, we'll take that back." Then they work with their teams and solicit our input and put out guidance in as timely a manner as possible. There's been a robust coordination and we're happy to partner with the CDC. Ms. Underwood: (57:25) Then is IDPH working with any other federal agencies in this response? Dr. Ezike: (57:32) At my level, that's the primary point of contact. I know that my governor has been ... We are in contact constantly and he's also in contact with the federal government. They outreach directly to him as well to give him the overview and the summaries. There's communication directly with the governor as well as with the different parts of the Public Health Department. Ms. Underwood: (58:01) Are there any areas where additional assistance would be helpful from your perspective? Dr. Ezike: (58:06) Sure, so we can't reiterate enough the need for funding both to make sure that we can accommodate all the employee, whether it's the overtime, whether it's ... We had to in one instance in our state, we had to rent an RV because we couldn't find a motel that would agree to take one of the people that needed to be isolated. We need assistance to pay for the housing options for people who don't have it. I think funds for people who are displaced from work temporarily. Assistance with that. There are ... Our lab, to run the lab, the lab equipment. A single piece of lab machinery is up to $500,000 or more. There's a list of resources that need financial support to maintain our operations. Ms. Underwood: (59:07) In your testimony, you wrote that Illinois conducted an exercise last year, the Crimson Contagion. Can you tell us more about those kinds of exercises and why they're such an important part of your preparation to respond to potential outbreaks? Dr. Ezike: (59:23) In the aftermath of 9/11, we started getting funding for what our office is called, the Office of Preparedness and Response. In that office, it's gearing up as the doctor mentioned, trying to prepare for what are the eventual situations that can arise. Tabletop exercises where you convene with the federal government, multiple states, local health departments, businesses, schools, communities, we had an almost week-long exercise where the ... Dr. Ezike: (01:00:03) Almost week long exercise where the event which was created was a novel virus that came from China and was spreading throughout the world. So that was the scenario that was played out with all these partners at the table. And so thinking through the what ifs, if you will, is part of the preparedness. And so the more prepared you are, then when you see something similar to that, then you switch into response. Ms. Underwood: (01:00:36) Sure. So in your testimony you wrote that responding to the Coronavirus has cost the state more than $20 million in the first five weeks. We've heard from our local public health officials the importance of stable longterm funding. And so we're so pleased to be able to at least have the supplemental to get a down payment and hope to continue to work with our colleagues to make sure that these efforts are well funded. Ms. Underwood: (01:00:57) We know that too many Americans have chosen to skip a visit to the doctor because their costs are too high, their out-of-pocket costs are too high. And so when dealing with an unknown infectious disease, that decision making has consequences, not only for their patient and the family, but for the entire community. And so it's our hope that addressing those kinds of out-of-pocket costs in addition to your public health costs is going to be an important solution to this epidemic. Thank you for being here. I yield back. Mr. Thompson: (01:01:25) Thank you very much. The chair recognizes the gentleman from film Pennsylvania for five minutes. Mr. Joyce. Mr. Joyce: (01:01:31) Thank you, Mr. Chairman. And thank you for the esteemed panel for being with the here with us today. Of utmost importance, it is imperative that we work together, as you have stated on a federal, local, and every level, to fight this problem that we're facing with the coronavirus. To briefly review the timeline, President Trump has taken action, decisive action, to protect Americans and to prevent the spread of COVID-19. In January, President Trump declared a public health emergency, initiated travel restrictions, and mandated quarantines for those returning from affected areas. He also formed the Corona Task Force to ensure a coordinated response among all US agencies and experts. Mr. Joyce: (01:02:22) Since then, the Trump administration has expanded travel restrictions, explored innovative medical solutions and requested additional funding for COVID-19 response resources. Vice President Pence has also been elevated to lead the response and has been appointed Corona Response Coordinator. Vice President Pence also announced just yesterday that Medicare and Medicaid will be covering the coronavirus testing. Mr. Joyce: (01:02:51) The most important questions we need to be asking are where do we go from here and what can be done to mitigate future threats of the same nature? Dr. Gerberding, your expertise and extensive experience in this field serving as CDC Director during the anthrax, the SARS, which is also a coronavirus, the West Nile virus, and the avian flu outbreaks. If you could please prioritize and talk to us about the development of a vaccine. Specifically, you had mentioned that we have not yet completed the SARS evaluation for vaccines. But yet that process has been initiated and SARS too is a Coronavirus. Does that put us steps ahead in the vaccine development? Dr. Gerberdine: (01:03:46) One optimistic point of view is that science has actually evolved considerably since 2003, when the first SARS outbreak occurred. So that the timeline and the ability to have the molecular tools and the immunology tools to speed up manufacturing has significantly improved. At the WHO leadership meeting on vaccines for this Coronavirus, there were 31 innovators there talking about their approach to vaccine development. Unfortunately, all of that development was preclinical. None of those vaccine candidates were in people yet. But that ability to have that much innovation already on the table really speaks to the importance of our biotechnology industry and capability. And I think that's a positive perspective. Dr. Gerberdine: (01:04:35) The reality check, and I know this from the experience we've had at Merck working on the Ebola vaccine, is that getting a candidate vaccine is somewhat straightforward. Getting it through the safety testing, through the clinical testing and frontline conditions, getting those data together, getting it through several regulatory processes, manufacturing it, and in this case, not just for a relatively small number of people in a localized Ebola outbreak, but for the world, that is a daunting task. There are 7.7 billion people in the world and I'm not sure who's going to be left out of access to the vaccine. So it is a big undertaking to have the full completed preparedness accomplished in the vaccine arena. Dr. Gerberdine: (01:05:22) And what concerns me about our current outlook is that we're seeing some over promising and we need not to alarm people when those promises don't actually come to fruition on the timeline people are expecting. We need to be straightforward about the challenge ahead, work hard, invest, support the people who are doing the innovative work. But at the same time, be cognizant that this vaccine is not going to be in people's arms for a long time. Mr. Joyce: (01:05:48) I've always been impressed by American know how, innovation, our approach to science and specifically to medicine. Dr. Gerberding, could you please comment to us what immediate actions can we be taking in Congress to assist and to inform our constituents while we are still awaiting the results of the negotiations on the emergency funding package? Dr. Gerberdine: (01:06:13) Obviously funding is a big piece of the effort in almost any direction that you look. But I also think that there's an opportunity here for Congress to provide its own leadership on the communications front. You are members of state delegations, you do interact with governors and state leaders. And really coming together as a unified whole of government opportunity to get on the same page, for you all to understand what's needed at the state and local level. That creates an informed platform for decision making. And I think as we've heard from our colleague in Illinois, you learn a lot about what's really needed at the local level. Mr. Joyce: (01:06:53) I thank all the panelists for being here today and I yield my time. Mr. Thompson: (01:06:58) Thank you. The chair recognizes the gentle lady from New York for five minutes, Ms. Clarke. Ms. Clarke: (01:07:05) Thank you Mr. Chairman. I thank our expert panelists for bringing your expertise to bear today. It's refreshing to hear facts. And so let me start by saying that yesterday in New York, it was confirmed that we had a second COVID-19 coronavirus case. And as Mr. King has stated, we are now dealing with sort of the fallout and the rapid spread of this illness as a result of a gentleman who had traveled from Westchester County into the city of New York. And we can expect more to come. But this is not the time for fear. It's time for facts. And that's why I'm so happy you're here today. Ms. Clarke: (01:07:50) This crisis is serious, but we can mitigate the Coronavirus if we put science over scoring points. Doctors, not politicians, need to be in the driver's seat as we combat this global outbreak. This isn't a hoax, in the words of the White House, and it's not an apocalypse either. It is a public health emergency, but one we can address with funding, resources, and sound science. Ms. Clarke: (01:08:18) As of yesterday, we know of 105 cases and a death toll of nine persons in the United States. As testing is expanded, the numbers will continue to rise. The federal government and the state and local partners must also rise to the occasion and give each American, not only the care they need if infected, but also the knowledge they need to avoid infection. I look forward to our continued conversation as we guide the American people through this impending crisis. Ms. Clarke: (01:08:56) So Dr. Gerberding, according to the recent article in May of 2018, Donald Trump ordered the NCS's entire Global Health Security unit shutdown, calling for a reassignment of Rear Admiral Timothy Ziemer and dissolution of his team inside the agency. What were the consequences of this action? Dr. Gerberdine: (01:09:21) Thank you for the question. I honestly don't know the answer to your question. I'm a champion of a whole-of-government approach. I know Dr. Ziemer. He's an amazing leader and served as well, first in malaria and then in subsequent public health emergency. So he was an extraordinarily effective whole-of-government leader and I was sorry to see him go. Ms. Clarke: (01:09:45) Yeah, it's important that we have institutional knowledge and that as you've stated in your testimony, we follow the course to its natural end. And unfortunately, when we dismantle or disrupt, we don't benefit from that institutional knowledge. The center for strategic and international studies established the commission on strengthening America's health security to examine the US preparedness to respond to global health threats. The commission published in its final report last year. Ms. Clarke: (01:10:20) Dr. Gerberding, you served as co chair of the commission. The commission's first recommendation was, and I quote, "To restore health security leadership at the White House National Security Council." Why did you believe that restoring senior-level leadership at the National Security Council is so important to ensuring our nation is prepared to combat a potential pandemic? Dr. Gerberdine: (01:10:45) Let me share my personal experience while we were involved in a very serious whole-of-government effort to prepare for an influenza pandemic. At the time, the Secretary of Health and Human Services was Secretary Mike Leavitt. And Secretary Leavitt believed that we needed to have all of the cabinets of the federal government participating in the preparedness. So he took us all of us as leaders of parts of HHS to every cabinet. And we sat down with every cabinet secretary with the book on the 1918 pandemic. And we went through highlighted sections and asked the question, "What will your cabinet need to do in the context of a serious emergency?" And what that really taught me was that the federal government in every cabinet level has something to contribute, whether it's education and school closures, or commerce and keeping our businesses operational or transportation, whatever the cabinet has authority over, it's relevant in a serious public health crisis. And we need to the whole of government collaborating. The only way to really do that is to bring an uber leader, somebody who really sits above and has the authority of the President. Dr. Gerberdine: (01:12:04) Now I will also acknowledge that there is a Bipartisan Blue Ribbon Panel on biodefense that secretary Ridge, former Governor Ridge and Senator Lieberman have co-chaired for several years. That panel's recommendation, sort of parallel to what CSIS recommended, is that the Vice President should share that whole-of-government process. So I think what that tells you is the idea is the same. You need an empowered person to oversee complex intergovernmental agencies and the government strategy. But how you go about doing that may vary from one administration to another. Ms. Clarke: (01:12:45) Very well. Mr chairman, thank you. My time has run out. I yield back. Mr. Thompson: (01:12:49) Thank you very much. Chair recognizes the gentleman from North Carolina, Mr. Bishop. Mr. Bishop: (01:12:55) Thank you Mr. Chairman. Dr. Ezike, you mentioned in your written and spoken testimony the phrase, " Sentinel surveillance testing." What is that, ma'am? Dr. Ezike: (01:13:04) Thank you for the question. So Sentinel surveillance, once you have the ability to test, involves testing people who don't have a direct connection to a confirmed case, do not have a direct travel to a specific place that would put them in a higher risk to be a Coronavirus suspect. So this is going to your average person with no connection to a case or to a hotbed, if you will. And then them developing a flu-like illness and influenza-like illness and going to their doctor and the doctor identifying that, "Oh you don't have the flu. You don't have any of the other common viruses on the respiratory virus panel. Maybe this is Coronavirus, despite you having no connection." And so testing people with no connection and seeing what the ground percentage of Coronavirus, if it's there and if so how much. And so if you can do that broadly, you can see if there are pockets within your state that have Coronavirus and people that you wouldn't specifically suspect to have. Mr. Bishop: (01:14:21) Thank you ma'am. Dr Gerberding, the CDC, after initially, I understand, in early February releasing test kits, determined that there was a flaw in them. And I've understood from speaking to someone else that those tests are referred to as an RTPCR test and there are three components. And what was flawed was what's called the negative control component. Do you have any information about that or how that came to pass? Because that's sort of alarming if we need to respond quickly. If somewhere in CDCs this test kit was created and then it didn't work because of what I understand to be a very basic error. How does that take place? Do you have any insights about that? Dr. Gerberdine: (01:15:00) I don't have insight into the specifics. I can tell you that long before I was a part of the CDC, the one thing I understood and saw from my front line at San Francisco General Hospital was that that the CDC is the best at testing and their diagnostics are usually gold standard. So this seems to represent a highly unusual and exceptional situation. I'm sure they will get to the bottom of it. And I know they've had a great deal of consternation about their inability to be out there with not just an accurate test, but with the volume of tests that people really need. Mr. Bishop: (01:15:35) Following up that, Dr. Gerberding or whoever else may want to comment. My understanding is that there was a question about who had access to this test, could a line doctor, an emergency room doctor decide to administer this test? And it was limited at some point to public labs perhaps because of supply, but now the Vice President has made it clear that anyone will be allowed to order a test, any doctor. And that there's this distribution going on, like 2,500 or 25,000 kits that will enable a testing of up to a million people, something like that. Can you speak to those details? Dr. Gerberdine: (01:16:07) Yeah. This is not unusual at the very beginning of a situation with a new pathogen that we've never seen before. We don't have a test on the shelf for it. So it's being invented in real time. So it does not surprise me that early on there was a limited number of tests that were available and we typically use what's known as the laboratory response network, because those people are highly trained. They have the standardize equipment, part of our public health system. And they're best able to judge in their own communities who should be tested. Dr. Gerberdine: (01:16:37) The state health officers also contribute to the decisions about what is a case definition and who should be tested. So it's not just an order from above. It's a collaborative process. But when we're sitting in the US and the diseases in China and we're not suspecting large number of cases, it made sense that you would focus your testing, your limited testing on a traveler who had just come back from China. Obviously we're in a very different situation now where we are seeing community spread. So it's normal that we would expand the indications for testing and I completely agree with the notion that if a doctor suspects coronavirus, they to be able to order the test. Mr. Bishop: (01:17:18) Given limited time, my friend, Ms. Clarke made a comment that the President called the Coronavirus a hoax. And I guess since that was said in public, I wanted to say that he didn't say any such thing. And I don't want to alter what I think has been a very good tenor of this hearing. I guess my last question, having said that, is I understand that for the testing to be done rapidly enough, we need to be able to empower or bring in private lab infrastructure into that picture. And I don't know who ... Dr. Gerberding, I'm not trying to pick on you, but just given we've a couple of seconds left, if you could comment on what's needed to make that happen. Dr. Gerberdine: (01:17:53) I think that's well underway. I'm going to be spending some time this afternoon with colleagues, including the CEO of one of the important diagnostic companies in the United States. I'll have a better answer by the end of the day. But I think the first thing is that FDA through the years has really liberalized the process for getting an emergency authorization for new tests to get out there into the community and compared to 20 years ago, our ability to do this fast has significantly improved. Dr. Gerberdine: (01:18:22) Once we know what we're looking for, it's a simple matter for diagnostic companies to pick up on that and they have the scale and the capacity to ultimately build a much larger capacity than the public health system. But they do have to demonstrate the sensitivity and specificity of their tests. And when you don't have the disease, it's a little bit hard to do that because you don't have enough case material to really know if you're accurate in the results that you're receiving. Mr. Bishop: (01:18:49) Thank you ma'am. Mr. Thompson: (01:18:50) Thank you very much. The Chair now recognizes the gentleman from Staten Island, Mr. Rose. Mr. Rose: (01:18:55) Mr. Chairman, thank you. Thank you all so much for being here. I want to start off just with what I'm seeing some business leaders making decisions around employee travel, halting international flights, halting domestic fights, really getting ahead of unnecessarily or necessarily, that's my question here, ahead of guidance from the federal government. So what should our business leaders be doing? People running global companies? Dr. Gerberdine: (01:19:21) I can share what our philosophy has been. We are a global company and we have 8,200 people in China. And many of them were on lockdown for an extended period of time. And I'm so glad that our offices are back open and our systems are operational there. But we recognize that when we have people in several of the hotspots where community transmission is occurring, and we're responsible for essential medicines and vaccines, that we have to keep our supply chain open and running. So people need to become coming to work. And those critical employees are especially cautioned about non-business essential travel and to self quarantine if they have any recent travel to a hot spot and to not come to work if they're sick. So we don't have a decision that you can't travel. We're just simply saying, "While we're working on slowing spread and understanding what's going on here, let's err on the side of caution." Mr. Rose: (01:20:21) What about domestic travel? Dr. Gerberdine: (01:20:24) Minimize unnecessary travel. Mr. Rose: (01:20:24) What about domestic travel? Dr. Gerberdine: (01:20:24) Domestic travel is more in the spirit of slowing down the spread that Dr. Inglesby was talking about, that if we're in a situation where we really can't isolate and quarantine each individual and we're trying to reduce the peak of transmission, it does make sense that we begin to think about avoiding crowds and minimizing our movement and maintaining our distance- Mr. Rose: (01:20:48) Flying as well? Dr. Gerberdine: (01:20:49) Flying as well. So we're just trying to use some common sense. I'm flying, we're on the move when we think it's important to our business. But we're certainly emphasizing now is a good time to be more comfortable using digital communication and being more thoughtful about how we travel. Mr. Rose: (01:21:05) Sure. Anyone else like to speak to that? Dr. Inglesby: (01:21:09) Yeah, I think the CDC guidance on travel at this point seems logical and it's now describing what countries where they think there is elevated risk and making recommendations to Americans about whether they should travel internationally. And that seems sensible. I think one of the challenges is that we've seen things change very rapidly in a week. So 10 days ago, Italy had zero cases. Now it's kind of among the countries with the highest cases. So it's challenging for business leaders to think ahead about a conference in three weeks or four weeks where things can change quite a bit. So at this point, I think the best recommendation is to follow US government guidance, but also be aware that something could change literally in a day or two, as countries begin to start testing. Mr. Rose: (01:21:51) Understood. Would you like to add something ma'am? Dr. Ezike: (01:21:55) I think I echo what these two experts are saying, that this is an emerging situation and advice and counsel given today may not be applicable tomorrow. And so continuing to follow the most recent guidance. Mr. Rose: (01:22:09) So I want to move on to our lower wage, hourly workers. I'm very concerned that they will not, rightfully so, or at least rationally respond to quarantine suggestions because of immediate economic concerns. What can the federal government do to step in to support people so that they respond to quarantines? Dr. Inglesby: (01:22:41) One thing that can be done, which I know is being discussed actively here, is to make sure that there are no barriers to testing or to getting medical care or isolation. And we've already begun to refer to that. And I think that sounds like that's beginning to occur through either CMS or discussions with insurance companies. So that's really important, because we've seen actual evidence of people who have had $3,000 bills after they went in to get a test. And that's been publicized and people will potentially avoid getting tested. I think it's a harder challenge, and maybe Congress and the administration can solve together about workplace- Mr. Rose: (01:23:15) Should we consider expanding unemployment insurance? Dr. Inglesby: (01:23:18) I think if that is a way of helping people in the gig economy or lower wage workers make good decisions, public health decisions, I think that should be considered. Mr. Rose: (01:23:32) Anything else? Dr. Ezike: (01:23:34) I would agree that there should be a mechanism for people who would be economically disadvantaged if they don't have any benefit time. If they don't have any kind of paid leave, that there should be a way for them to be compensated so that they don't have to make the decision between following public health measures that will help the entire community versus being able to pay their next month's rent. Dr. Gerberdine: (01:23:58) I just want to add something because it hasn't come up yet, but in the context of this conversation, we also have to be mindful of stigma. This happened during SARS where the Chinese community was profoundly stigmatized. And I think it's an opportunity for leaders and house members as well to really stand up and make sure that we are including everyone in the benefits that we can provide to help protect Americans. But also that we speak out against the stigmatization that often follows in the wake of an outbreak. Dr. Ezike: (01:24:31) Great. Thank you very much. Mr. Thompson: (01:24:33) Thank you, the Chair recognizes the gentleman from Tennessee, Mr. Green. Mr. Green: (01:24:38) Thank you Mr. Chairman and thank you to all of you guys for being here today. It's greatly appreciated, your involvement in this process. Very quick, my questions, I'm going to try it because I got lots of them. Mortality rate, it appears to be about 3% in China, outside of China, it appears to be about 0.7% is what I saw on a JAMA article that was just published. What are your thoughts about that delta? The journal of American Medical Association seemed to imply that it was attributable to China's smoking rate. Other reasons, but why is their mortality 3% and outside of China it's 0.7. And in South Korea it was 0.12%. So your thoughts on that? Dr. Inglesby: (01:25:26) It's too soon to say because things are changing rapidly in other countries and they don't have as much data being published as there is in China. One of the factors in Wuhan does seem to be the surge in hospitals and it does seem like some of the people who could have used ventilators did not get them because they ran out of ventilators. So that's one possibility. There is a possibility that there's some underlying health conditions or pollution or smoking or something else that will fall out in analysis. But I don't think we have strong understanding of that yet. Mr. Green: (01:25:56) Okay. Dr. Inglesby: (01:25:57) And also, the other thing is important is that there is a time lag from when countries discover cases and begin to see them and the time that people begin to die from this illness, sometimes as long as two weeks. So if it's a country just beginning to report illnesses and deaths, it's really two weeks later when we see better sense of deaths. Mr. Green: (01:26:14) Okay. That makes sense. Sure, that makes sense. I just know the end is well over 3000 now for outside the country. So you would think that would give you some degree of confidence, and there's such a huge delta between 3% and 0.7%. This, obviously based on the way it's hitting the those who have comorbidities and the elderly, probably a very good virus to tackle with a vaccine. But I'm also aware that this attacks the lung tissue directly, so that makes it concerning. We need to be very safe as we develop this vaccine. Mr. Green: (01:26:48) Sort of in the interim time frame, there's Remdesivir and the monoclonal antibodies. And I just wondered if either anyone could comment first on Remdesivir and some of the other antivirals that were developed for Ebola and their usefulness. I know there's a test in Nebraska. And then on monoclonal antibodies because of the ability to blunt the tissue, the lung tissue's damage, with monoclonal antibodies. And they can be spun up so much more quickly than a vaccine. Dr. Gerberdine: (01:27:15) So I'll start with the antiviral question. I'm hopeful, I really want these antivirals to work. But at the same time you got to think about what we've learned about respiratory infections and antivirals so far. And we have several antivirals for influenza and they might mitigate a little bit, but they're not curative. So we need to not over promise on what we might ultimately see. So hope for the best, but I won't be surprised if we were a little bit disappointed. Dr. Gerberdine: (01:27:47) In terms of monoclonals, again, almost every outbreak that I've dealt with, the first thing people do is use serum from recovered people and try to see if it's helpful. So that's the intellectual background for using monoclonals. and they may very well be useful. But on this kind of situation where the severe pulmonary disease is caused by a cytokine storm, which basically means broad inflammation, that's very tissue damaging. You have to test the safety of the monoclonals very carefully because what you wouldn't want to have happen is put an antibody in there and actually make that cytokine storm worse. That's got to be tested. I hope, again, but and I agree with you, these approaches to treatment can happen much faster than a vaccine. So they are definitely a high priority. Mr. Green: (01:28:33) Well, thank you for that. One of the things that concerns me, there's lots of legislation in Congress about price fixing for pharmaceuticals and I know Merck is one of those companies that would be hurt by that. My concern is particularly those smaller companies, the bio companies, biomed companies that when they have an idea, they have to go get capital in order to advance that idea. They're not going to get capital if we price fix. So I wondered if someone, particularly ma'am you, because you are from the industry, could comment about how damaging price fixing might be on some of the innovation that's out there, that could address this issue. Dr. Gerberdine: (01:29:14) Yeah. First of all, as I said earlier, 40 biotech companies have stepped up on Coronavirus, but understandably, the entrepreneurs are very apprehensive about what this will mean to investors. And price fixing is the thing that investors hate the most. And they made that very clear when the subject came up on another topic. I live it in the world of antimicrobial resistance, because we don't have a market for antibiotics. There is no reimbursement appropriate to the danger of multidrug resistant infections. And last year we saw three companies that had new antibiotics that failed and went out of business because their investors pulled back. So it's a real issue and we need to keep our biotech industry alive. Mr. Green: (01:29:56) Thank you for sharing that. Thank you, Mr. chairman. I yield. Mr. Thompson: (01:29:59) Thank you, Chair recognizes the gentle lady from Texas, Ms. Jackson Lee. Chairman Thompson: (01:30:03) Chair recognizes [inaudible 01:30:01] lady from Texas. Ms. Jackson Lee for five minutes. Ms. Jackson Lee: (01:30:09) Mr. Chairman, thank you so very much and thank you very much for your hearing yesterday that was detained in my district for civic matters that occurred on that date in tribute to my constituents and the necessity for America to ensure that people can vote. I was at a college voting precinct at 1:00 AM in the morning where people had remained online to vote at 1:29 because they could not vote because of shortage of machines and broke down machines. I say that because this is the greatest country in the world and I'm disappointed you're not government witnesses. I'm disappointed in the slow response to the coronavirus. We've dealt with Ebola, one of the first cases when the Dallas hospital in Texas dealt with H1N1. Ms. Jackson Lee: (01:31:13) So I'm going to pose the question and I hope I'm straightforward as possible. There were two briefings unclassified. One briefing was complete denial. Everything was fine. Top level leaders about government in health and emergency issues. Shortly [inaudible 01:31:36] I think to do a press conference questioning, everything was fine with airport personnel and others. At that time TSA officers had no gloves, mismatched gloves and mismatched masks and I know there isn't discussion about masks. But I'd like to ask Dr. Ezike. Am I close to the pronunciation? The need for preparedness and awareness when the obvious is occurring. I would like to be prepared months or a year out or regularly having a preparation for this to occur when I say there's an infectious episode to occur. But the fact that China was quite public, they couldn't hold it any longer. Can you comment on the preparedness of this nation? Dr. Ezike: (01:32:29) I think Dr. Gerberding also has eloquently described the situation and has highlighted the importance of having increased surveillance capacity for the CDC. We've been as a state health officer every year we try to come to Washington [inaudible 01:32:48] and encourage increased funding for the CDC to keep up with these surveillance efforts, to keep up with our preparedness and response. All of our preparedness and response- Ms. Jackson Lee: (01:33:01) Do you have an assessment of whether or not we weren't prepared on the federal level for the coronavirus? Dr. Ezike: (01:33:07) I think we can always be more prepared. I think there's levels of preparation and the more prepared we are, the better. Ms. Jackson Lee: (01:33:14) I'm going to go to Mr. Inglesby. forgive me as I watch my time. I appreciate it. Is that Inglesby doctor? I meet regularly with my local health agencies and I appreciate the Director of the Illinois Department of Health and I understand that you're always lobbying to make sure that there's a direct funding to both state and local. This is a particular instance where that would be important to understand our appropriations and something that we've all requested is going to enhance dollars going to state and local entities. How do you translate that into helping you and your local communities be prepared for something that appears now to come from CDC, that it is either an epidemic or pandemic? Now they're willing to say that. How are you doing with the test kits and how would that help you with the test kits? My community does not have them yet, and that's a real problem. Most communities I think do not. Doctor? Dr. Inglesby: (01:34:13) Yeah. I think first of all every year there are public health emergency preparedness grants that are given to states from CDC and they are very important grants for states and locals and need to be supported by Congress and the administration. They are crucial for longterm preparedness. They are separate and distinct from the emergency response funding that we hope will come out through these appropriations. You can't build a firehouse the day before the fire. You have to build it a long time ahead of time. That's what those preparedness grants do. In terms of expanding diagnostic capacity testing, that is now happening over the course of this week and state health labs around the country are going to be able to start testing hopefully within Texas as well. But ultimately to really expand it to clinics and hospitals, we're going to need diagnostic companies to be fully invested. Ms. Jackson Lee: (01:35:02) That's very important, right, in the preparation of our hospitals as well? Dr. Inglesby: (01:35:05) Yes. Ms. Jackson Lee: (01:35:06) Quickly, if we go into a moment in time of a quarantine, closing schools, restaurants, et cetera, do you think we should also be concerned about, in this instance, hourly wage workers who would be caught up in that quarantine who don't get paid and may have a devastating impact on the family? So that would be a part of what we need to do in this moment to be able to provide for people's livelihood and survival if they are quarantined for a period of time. Dr. Inglesby: (01:35:38) I do agree with that. I think people could be. Especially if a quarantine is prolonged, if there are many people in the country who receive a check every week and they need that check that week. If we are telling people they cannot go to work or cannot go to school and have to stay home to take care of their kids, we need to make sure the incentives for doing that are aligned with what we want done and that people aren't having to basically not be able to provide for their families. Ms. Jackson Lee: (01:36:02) I thank the chairman. I thank the witnesses very much for your [crosstalk 00:01:36:05]. Chairman Thompson: (01:36:06) Thank you very much. The chair recognizes [inaudible 01:36:08] from Arizona for five minutes. Mrs. Lesko. Debbie Lesko: (01:36:10) Thank you, Mr. Chairman. Thank you, Mr. Chairman, for having this meeting. Important issue and thank you all of you for being here. Debbie Lesko from Arizona. Our state doctor, Christ, heads up our Arizona Department of Health Services and she's very competent. We just started testing within house ourselves. It's very important obviously that we're prepared, but also we have to balance that with panicking people. I think it may be a little bit too late because you turn on the news and this is all you hear about. My husband went to Sam's club last night and said all of the Purell or whatever brand of the hand sanitizers totally sold out. I mean all of it was sold out. My question is kind of a basic one. So many people die from the flu more than I even realized until just recently. Is this worse than the flu? I mean we need to be concerned, but I'm concerned about people panicking, so I guess I'll ask Dr. Gerberding, if that's how you pronounce your name, is this worse than the flu? Should we be more panicked than the flu? Tell me about that. Dr. Gerberdine: (01:37:34) I think we're learning that this is probably as transmissible as the flu. The rate of transmission seems to vary depending on how much testing goes on in the background to really figure that out. So we still have to learn what the true transmissibility dynamics are, but it's obviously spreading from person to person, especially in families and on cruise ships, in other closed environments with a great degree of efficiency. The question is how fatal is it and who's vulnerable? I think Dr. Inglesby has pointed out earlier that we don't know the true case fatality rate yet. Part of that is because of the differences in medical care that influence that. Part of that is because we don't know the denominator of the less sick people and part of it is because the testing is just not available to sort out who's actually a case. We will learn more about that. But I think what we could say today is that it looks very much like the case fatality rate is significantly greater than the fatality rate for seasonal flu. I think that's the distinguishing issue here that makes me so concerned that it's the death rate that's high and the death rate is highest the older you are and the more underlying disease, particularly respiratory, that you have. This nursing home outbreak, for example, that's a significant concern and we need to prioritize getting infection control precautions and other things to slow down or prevent spread in those settings as one of our highest public health priorities right now. Debbie Lesko: (01:39:14) Thank you very much. My next question has to do with face masks. So anybody can answer this. What is the answer? Should people that don't have a cold or aren't coughing, should they wear face masks? I Googled it and it said, no, you shouldn't wear a face mask unless you're coughing. It won't help. But then why is it that healthcare workers wear it? That's my question to anyone. Dr. Inglesby: (01:39:44) In hospitals, people are exposed to the sickest people and we do see a correlation between level of illness and the ability to spread the disease. Walking around in the community, most of the people are well in the community and even if they are asymptomatic, we don't think they are the fundamental largest drivers of infection. Also when you wear a mask in public, you end up fussing with it a lot, you end up touching your face. Often you're tying the strings, moving it around. It may be that you're actually touching your face even more often than you are normally. The bottom line is that we don't have evidence that face masks in public are going to do any good and we're worried that if everyone goes out and buys a mask, that will diminish the number of masks that are available in the hospital where the people are the sickest and are transmitting at the highest levels. We need our healthcare workers to stay healthy because it's going to be a long period of time, a marathon probably, of high COVID patients in hospitals. Dr. Gerberdine: (01:40:42) Just to real quickly add to that, there are different kinds of masks as well and the masks that are worn in healthcare workers, they're trained and they're fitted to their face so they don't leak air around them. But when people on the streets buy those or buy the regular surgical masks, they're breathing all kinds of air in around the mask and it really doesn't offer the level of protection that health workers need. That's why they have to be trained to use them properly. Debbie Lesko: (01:41:07) What I think I hear is that face masks do help if they're put on properly. They do help from getting it, it's just that you advise against it in community because people don't know how to use it properly. They touch their face a lot because of the mask. Is that what you're saying. Dr. Gerberdine: (01:41:26) Just to add one additional thing is that I've had to wear N95 respirators for many, many, many patient encounters and you can't wear them for very long. They increase your work of breathing. They're incredibly uncomfortable. So you go in the room, you do something, you take the mask off when you come out. To walk around with one of those on all day is impossible. Debbie Lesko: (01:41:45) If you don't mind, one more question on this mask issue. Why do you think it is a lot of the Asian countries, everybody's wearing masks? Is it a cultural thing? Do they think it's going to help? Do they know how to wear it properly? Dr. Gerberdine: (01:42:00) In China right now they're being required. So that's the main reason why you tend to see a lot of people on the streets of China wearing basically usually surgical masks. But I don't think that they're there because they're having a significant impact on disease spread. Debbie Lesko: (01:42:17) Thank you. I yield back. Chairman Thompson: (01:42:18) Thank you very much. A question for the committee is Dr. Gerberding, have you an assessment of how long it will take before we actually will have a vaccine? Dr. Gerberdine: (01:42:36) I'd probably defer to Dr. Fauci's statements on this topic, the head of the NIAID. I think Dr. Fauci has said we will get vaccines into testing in a matter of several weeks to a few months. But that we won't have an approved vaccine for at least a year and probably longer. If I'm not paraphrasing him correctly, I will get back to you for the record. But realistically it's not in a rapid track even with all of the permissions and the energy that we're putting into it. Part of the reason for that is safety. We really need to make sure the vaccine is safe. Chairman Thompson: (01:43:16) Oh, absolutely. Absolutely. Dr. Inglesby, a couple of comments have come up relative to capacity for the virus, whether we were as robust as we need it to be as a federal government. Have you looked at the capacity issue, or are we just basically caught with something that we just wasn't prepared to handle? Dr. Inglesby: (01:43:51) I think it depends on what kind of capacity we're talking about. I think our public health agencies have been training for these kinds of things for a long time, but even as well trained as they are, there are enormous resource challenges and personnel challenges when they're working 24/7 and they're having to create new quarantine sites. So I think in principle there's been a lot of preparedness. There's been a lot of drilling and grants for states and locals around the country, but I still think this is a challenge that they haven't faced before. We do have major capacity challenges ahead in public health and in hospitals. Chairman Thompson: (01:44:29) Thank you very much. The gentleman from Texas, Mr. Crenshaw. Mr. Crenshaw: (01:44:36) Thank you. Mr. Chairman, and thank you all for being here on this important topic. Dr. Gerberding, I'll start with you. Given your lengthy experience in this field, director at CDC who dealt with threats from anthrax, SARS, West Nile, Avian flu, other outbreaks, I'm assuming you all compile constantly and persistently a best practices list and lessons learned. To your knowledge, are those lessons carried over administration to administration even when folks like you leave the administration and are those being implemented now? Dr. Gerberdine: (01:45:17) Thank you. When I was directing the CDC, we implemented very formal after action reviews starting with anthrax. Dr. Jim Hughes, head of the National Center for Infectious Disease at the time, and it was one of the things that we did first was just bring in anybody who we interacted with in the response and learn. What did we do right? What did we do wrong? And what do we need to do better? That mechanism is consistently practiced as far as I know to this very day at CDC. Yes, those lessons are passed forward, but each one of these situations brings in a unique challenge. So it's hard to extrapolate from one after action review to the next one. The constant themes that go through them all are communication, the need for collaboration and the consistency of approach whole of government, but also federal, state level. Those lessons come up. I think we have still opportunities to improve and how we coordinate that as a country. Mr. Crenshaw: (01:46:18) Absolutely. This administration is taking a lot of heat in the media and from politicians. Do you see any big differences in the response that this administration has given compared to say what a previous administration would've done? Dr. Gerberdine: (01:46:37) Since I left the government, I of course watch from the outside in, so I don't really know what's going on in the sausage factory. But I do see that broadly speaking, I think the way the 2009 influenza pandemic was handled quite well. I think Zika was hard, but people did a pretty good job with that. There were lots of missteps in the early days of Ebola. Now here we are with this one. I think many of the people who are acting as leaders of the response here are the same people that I worked with when I was in the government. Secretary Azar was part of the department when we were planning for flu pandemic. [inaudible 01:47:19] was involved with the government in his role and now he's heading as assistant secretary for preparedness response. BARDA has certainly stepped up and funded many things. BARDA funded the Merck Ebola vaccine. So components of the government I think are doing exactly what they've been prepared and designed to do. Mr. Crenshaw: (01:47:41) Do you think the level of outrage over the response is really proportional to any actual shortcomings in the response? Dr. Gerberdine: (01:47:50) Well, earlier I had a chance to talk about trust and what's necessary for people to really trust what's going on. I think the person delivering information is critical at federal, state, and local levels. So that's something that we need to really be mindful of. The consistency of the communication and in my view, that the leading edge of the communication is about science, not politics. So I think that's a really important thing that would help a lot to calm people's criticism and get us on track where people have confidence that their whole government is doing the right thing. Mr. Crenshaw: (01:48:27) Yeah, I would just note that I think a lot of the criticism is not based in science or facts or any of the things that you just noted, but in fact, based in politics, which is the problem. I hope that the goal of that is not to create fear simply for the sake of gaining political points. Although that's what I've seen, frankly, from the media and others. I want to talk, and you hit on this before, about innovation in creating vaccines, in creating treatments and how important the subject of innovation is. But I'm running out of time, aren't I? Can you hit on... With respect to innovation, can you hit on again on the issue of price controls and what that might do to some of these biotech firms that generally rely on investments from venture capitalists or the larger pharmaceutical companies and some of the work they've been doing in the past decade? In fact, Johnson and Johnson for instance, has been looking at a coronavirus vaccine for a decade. Would that research still happen if there were no incentives because of price controls? Dr. Gerberdine: (01:49:45) I am not involved in a small biotech company, but one of the things that I've learned in my role on bio executive committee and I interacted with some of these amazingly creative people is that a lot of times the company is, is based on just one idea or one really good leading approach to a critical innovation. If there isn't the promise of reward to the investors who put their money in what is a really high risk situation, they're gone. If you take away the incentive for the investments to come forward, you have really diminished interest in pushing the envelope on innovation. That's true in coronavirus the same as it is in antibiotics, the same as it is in any of the other things that we wish we had and we don't. Mr. Crenshaw: (01:50:33) Thank you. Thank you, Mr. Chairman. Chairman Thompson: (01:50:35) Thank you very much. I'd like to have entered into the record articles from the Washington Post and National Geographic on the coronavirus subject. Let me recognize Mr. Correa for bringing this hearing forward. He was the first member of the committee to say that we need to bring some experts before the committee so that we can get firsthand knowledge. Mr. Correa, You want to give a- Mr. Correa: (01:51:09) Just have a couple of quick follow up questions. Chairman Thompson: (01:51:12) Go ahead. Mr. Correa: (01:51:12) Incubation period? Dr. Inglesby: (01:51:16) One to 14 days, but on average about five days. Mr. Correa: (01:51:19) One to 14 days, five. Symptoms similar to flu? Dr. Inglesby: (01:51:23) Yes. Mr. Correa: (01:51:25) You don't know if you got the flu. You don't know if you've got corona. Dr. Gerberdine: (01:51:27) Just one thing about symptoms was I think the expectation is that fever is the sentinel system, but a lot of the people end up in the hospital didn't start with fever. So about half of them came to the hospital and hadn't developed fever yet. Mr. Correa: (01:51:42) China. Is the rate going down in China? Infections rate. Dr. Inglesby: (01:51:46) Yeah. The numbers reported by China are going down substantially in the last couple of weeks. Both numbers of cases and deaths. Mr. Correa: (01:51:52) How certain can we be that they're accurate? Dr. Inglesby: (01:51:56) I think the World Health Organization has said that they believe they're accurate. I think it's difficult to know from where we are. Mr. Correa: (01:52:03) Death rate. World Health Organization, just saw an article that said higher than the flu. You're saying, ma'am, that it probably is higher than flu, but yet we don't know the denominator so that we really don't know what the death rate is at this point. We just suspect. Is that correct? Dr. Inglesby: (01:52:22) That is correct. That article that said WHO has concluded that it's a higher case fatality rate, it was really a misquote. WHO hasn't said just that. They have just basically divided the numbers of recognized cases by the deaths and said approximately 3% have died. But we do believe that there are many cases that are unrecognized. We just don't know how many there are. Mr. Correa: (01:52:45) Finally, again, best practices, lesson learned. We have to be consistent. We have to have a system where we continue to invest in an annual basis on the system, research and development, coming up with vaccines and protocols so the next time, this will happen again, that we don't have to scramble and figure out where we get the test kits, the masks, so on and so forth. Dr. Gerberdine: (01:53:08) I would say two things. One is BARDA is good value for Americans. The work that BARDA has done to push the envelope on countermeasure development is something that I hope the committee is aware of and knows about because that is clearly a national asset. The second piece is an ask that's included in the CSIS report and that is that our government needs to contribute to something called CEPI, which is a Coalition for Epidemic Preparedness Innovation. That's a global effort. It includes companies, countries, nonprofits, Gates, Wellcome Trust, et cetera who are saying we some of the bad things like SARS and MERS that may come back. Let's get those vaccines across the finish line or at least into the freezer so that if the problem comes back, we've got something we can pull out and test very quickly. That's an investment [crosstalk 00:24:01]. Mr. Correa: (01:53:59) So here in this committee, you're saying that we've had those challenges. We haven't come up with the vaccines and yet we know they will be back. Dr. Gerberdine: (01:54:07) I think we need to expect they will be back. I hope they don't come back, but they may. Shame on us if we have another situation where we got started on something and we didn't bring it across the finish line. Mr. Correa: (01:54:19) Thank you. Chair. Chairman Thompson: (01:54:22) Thank you. Let me thank the witnesses again. There's no question about what you brought to the committee today. That information will be vital toward ultimate solutions. Some of it obviously is investment over the long haul with respect to detection and others, but I do want to just for the record highlight the fact that we should be providing the public the best information we have. It's not a political issue. It's a health issue. We want to look at it in that respect. Words do matter when politicians get in it. So I caution everyone to govern themselves accordingly as we work through this. But in the interim, I want to again thank you for an absolute excellent sharing of information for the committee. I'd like to also say that the members of the committee may have additional questions for the witnesses and we ask you to respond expeditiously in writing to those questions. Without objections, the committee shall be kept open. Record will be kept open for 10 days. Hearing no further business, the committee stands adjourned. [crosstalk 00:26:06].