CDC update on Ebola Response, 10-13-2014
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Press Briefing Transcript
Monday, October 13, 2014, Noon ET
OPERATOR: Welcome and thank you for standing by. At this time all participant are in a listen-only mode. After the presentation, there will be a question and answer session. Please limit your question to one question per person. To ask a question, you may press star 1 on your touch tone phone and record your name when prompted. Today's conference is being recorded. If you have any objections you may disconnect at this time. I would now like to turn the meeting over to Miss Barbara Reynolds. Go ahead; you may begin at any time.
BARBARA REYNOLDS: Good afternoon. You're joining CDC's update on the Ebola response. I'm Barbara Reynolds, the director of CDC's public affairs. We'll have two speakers today and then we'll go to questions. For those of you in the room asking questions, would you please wait for the microphone and give your name and affiliation. Our first speaker today is CDC director, Dr. Tom Frieden.
TOM FRIEDEN: Good afternoon, everyone, and thank you very much for joining us. Stopping Ebola is hard. We're working together to make it safer and easier. Yesterday we confirmed the first case of Ebola contracted in the United States in a health care worker who cared for what we refer to — who we refer to as the index patient in Dallas, Texas. Our thoughts are with this health care worker. She is now being cared for, and we understand that she is clinically stable. Please refer any questions on her care to the hospital where she is being cared for so that only information that she and her family want released is released. The existence of the first case of Ebola spread within the U.S. changes some things and it doesn't change other things. It doesn't change the fact that we know how Ebola spreads. It doesn't change the fact that it's possible to take care of Ebola safely. But it does change substantially how we approach it. We have to rethink the way we address Ebola infection control, because even a single infection is unacceptable. I'll get into some details of what we're thinking about with regard to how to make care even safer in a minute, but i want to just step back first and outline what we're doing and what the current status is. First, before the index patient in Dallas was hospitalized and isolated, there were 48 potential contacts. Ten known to have contact with him, 38 who may have had contact with him. All of those 48 contacts have been monitored daily. None of them have developed fever or other symptoms as of now. This is consistent with what we know about Ebola. That people aren't sick when they don't have symptoms and the sicker they get, the more infectious they may become because the amount of virus in their body increases. Second, for the health care worker who was diagnosed yesterday, we have been discussing with her, our team lead in Texas has spoken with her on multiple occasions. She's been extremely helpful, and we have identified one and only one contact who had contact with her during a period when she was potentially, although likely not infectious, because it was at the very onset of her symptoms. That individual is also being monitored and as of now has no symptoms suggestive of Ebola and no fever. Third, is to identify the health care workers who also cared for the index patient and ensure that they are actively monitored for development of symptoms or fever. And if they develop either symptoms or fever, that they're immediately isolated, assessed and tested. That process is still under way. The team worked hard through the day yesterday, into the night yesterday and are still actively working today to interview each one of the large number of health care workers who might potentially have had contact with the index patient when he was hospitalized. And the thinking here is straightforward. If this one individual was infected and we don't know how within the isolation unit, then it is possible that other individuals could have been infected as well, so we consider them to potentially be at risk and we're doing an in-depth review and investigation. So these are the three categories of contacts. Contacts with the index patient before he was hospitalized, contacts with the health care worker who was diagnosed yesterday, and contacts who may have also had contact with the index patient after he was hospitalized. All of them will be actively monitored, and that's how we break the chain of transmission. We prevent another generation of spread of Ebola. In addition, as i indicated yesterday, we are doing a detailed investigation to better understand what might have happened with the infection of the health care worker. We look at what happens before people go into isolation, what happens in isolation and what happens when they come out of isolation. And we're particularly concerned with that third process, taking off the isolation personal protective equipment, because if it is contaminated, there's a possibility that a worker will contaminate themselves and become infected in that process. From day one we've had a team on the ground in Dallas working closely with the hospital, the state and the local health officials. When the additional patient was diagnosed, we doubled down and sent an additional team in place. That team has been at the hospital just about continuously since. They have been working through the night. We're not just doing an investigation, we're immediately addressing anything that could potentially make it safer and easier to care for people who have or may have Ebola. We're not going to wait for the final results of that investigation, and i can go in some detail later, to what we are doing in the short run, but each time we identify a process or training or equipment or protocol that can be improved there, we are improving it right there on the site. I want to clarify something I said yesterday. I spoke about a breach in protocol, and that's what we speak about in public health when we're talking about what needs to happen. And our focus is to say would this protocol have prevented the infection, and we believe it would have. But some interpreted that as finding fault with the hospital or the health care worker. I'm sorry if that was the impression given. That was certainly not my intention. People on the front lines are really protecting all of us. People on the front lines are fighting Ebola. The enemy here is a virus, Ebola. It's not a person, it's not a country, it's not a place, it's not a hospital, it's a virus. It's a virus that's tough to fight. But together I’m confident that we will stop it. What we need to do is all take responsibility for improving the safety of those on the front lines. I feel awful that a health care worker became infected in the care of an Ebola patient. She was there trying to help the first patient survive, and now she has become infected. All of us have to work together to do whatever is possible to reduce the risk that any other health care worker becomes infected. When we think about hospitals where Ebola care can be given, really there are two different steps. The first is diagnosis. And every hospital in this country needs to think about the possibility of Ebola in anyone with a fever or other symptoms that might be consistent with Ebola who's traveled to any of the three countries, Liberia, Sierra Leone and guinea in the previous 21 days. Whatever else we do that's critical so that patients are rapidly diagnosed if additional patients become ill in this country. Second is the issue of care of Ebola once the diagnosis has been made. I think what we recognize is that that care is complex, and we're now working very closely with the hospital to make that care simpler and easier with hands-on training, hands-on oversight and monitoring and that's something that we will do any time there is a case of Ebola. Now I want to just end, before I turn it over to commissioner Lakey with thinking a bit about what comes next. What's going to be happening in the coming days and weeks. Well first is the safe and effective care of the health care worker in Dallas, and we will do everything to make sure that those who are taking care of that individual are doing so while protecting themselves and that that individual gets the best possible care. Second, as i said yesterday, we need to consider the possibility that there could be additional cases, particularly among the health care workers who cared for the index patient when he was so ill. That's when this health care worker became infected, and we're concerned and would unfortunately not be surprised if we did see additional cases in the health care workers who also provided care to the index patient. Third, we will continue to track all contacts. All of the 48 from the initial patients, exposures before he was hospitalized. The one individual who was exposed to the health care worker who is hospitalized now and all of the health care workers who may have been exposed during the initial care of the index patient. Fourth, we'll work with hospitals throughout the country to think Ebola in someone with a fever or other symptoms who has had travel to any of the three affected countries in the previous 21 days. And fifth, we will double down on training, outreach, education and assistance throughout the health care system, through professional associations, through hospitals, through group organizations and individuals reaching out to health departments at the state and county levels in cities and elsewhere so that we can increase the awareness of Ebola and increase the ability to respond rapidly. We wish the situation in Dallas were different than it is today. We wish this individual had not been infected and we're concerned there could be other infections in the coming days. But what we're doing now is implementing an immediate set of steps that will ensure that the care of that individual is safe and effective while we look longer term at what this implies for what we should be doing to care for Ebola as safely and effectively as possible, wherever it may arise. And with that I’ll turn it over to Dr. David Lakey, who is commissioner of the Texas department of state health services.
DAVID LAKEY: Thank you, Dr. Frieden. Thanks, everyone, for being part of this briefing today. Obviously it's been a very tough several days here in Dallas. Very tough day the last several days for the hospital staff. We knew it was a possibility that one of the health care workers could become infected, but it's still very disappointing. I know the family is possibly listening and so i want them to know that our thoughts and prayers are with them, with the health care worker and with the staff that are working hard on her care right now. There's many components to our response here in Dallas. Dr. Frieden talked about many of those components. Our top priority right now is the contact investigation. It's hard work. A lot of work is taking place. We pulled in additional staff from throughout the state of Texas complementing the work of the CDC and the Dallas health department's staff, so we're bringing in the resources to do the contact investigation from many different levels of government to identify those individuals and contact them as quickly as possible. Dr. Frieden talked about infection control. Obviously a critical component of this response. Looking hard at the infection control practices and making sure that they're even more stringent than what they are right now and have CDC experts, the best in the field here in Dallas working with us to make sure that we are as stringent as possible with infection control. The health care worker's apartment, the initial cleaning has been done. Additional evaluation and cleaning will be accomplished today. We're doing this with local leaders, but also with other state agencies to make sure that we do that in accordance with the best guidance that's out there. One issue related to the final cleaning is the health care worker had a dog. We want to make sure that we respond appropriately and so we're working hard to find a location to care for the dog and a location where we can have the proper monitoring of the dog. The final leg of the work that we're doing is contingency planning. Again, we know the possibilities that can occur and we want to be prepared, so a lot of work is taking place right now with a variety of health care providers, emergency managers, EMS, to make sure that we are ready for whatever needs to take place and at the same time following the folks that we know have been contacted and the 48 individuals that we've been monitoring so far and the additional individuals that Dr. Frieden has discussed today, making sure that all of them know what needs to happen if any of them start having symptoms. And so, again, a lot of work is taking place here in Dallas and we continue to be grateful for the support from the CDC and our many other partners in this response. With that, Dr. Frieden, I’ll hand the line back over to you. Thanks.
TOM FRIEDEN: Thank you very much, Dr. Lakey, and thank you for all that the team is doing there in Texas. It's an excellent working relationship and we value it greatly. Before turning to questions i will comment that the situation is fluid and we will continue to update you as we get more information. In the room.
NICOLE ESTAPHAN: Doctor, you spoke about the possibility of further infections. Is that because there's a known safety procedure or protocol that perhaps was not followed? And my follow-up question to that is if you cannot pinpoint the breach in protocol, how do you move forward with education?
TOM FRIEDEN: If we knew that there was a specific incident, such as a needle stick, that would indicate that we could narrow down the health care workers at risk to those who had that specific exposure. Since we don't know what the exposure was but we know there was an exposure, then we have to cast the net more widely and see in terms of monitoring, monitor a larger portion of the health care workers. And in terms of infection control protocols or procedures, improve every aspect of those procedures every time we see something that could be improved. So, for example, our staff there now are watching as patients put on and take off all of their protective garb. They're retraining staff in how to do that safely. They're looking at the types of personal protective equipment that are used to see if there are some types that may be easier to put on or take off and thereby reduce the risk that someone would unintentionally contaminate themselves. We look at what we do when someone comes out of the isolation unit and possibly spraying them down with a product that would kill the virus if there is contamination. That was already in our guidelines for gloves, but we're looking at that more broadly. We're also looking at things that can be done within the isolation facility to reduce the risk that individuals personal protective equipment could become contaminated with the Ebola virus. So there are a series of things that are already implemented in the past 24 hours and we will continue to look at that in terms of how can we make care easier and safer.
MIRIAM FALCO: Miriam Falco from CNN. You have been telling us about what needs to be done and how prepared we are for months now. You've been telling us for a long time about the risks and all the things that can be done but you just said that you're working at making care simpler and you're providing hands-on training. It seems like there's a gap in what you may have thought was happening at the nation's happen hospitals and what actually is happening. Have you thought about bringing in somebody like doctors without borders who has been successfully treating patients in Africa for years to learn about how they do it? And then the second question i have is regarding the travel. You have said multiple times that a travel ban is not helpful for many reasons, but many people still think why not keep those people who may be sick from coming into this country. Can you better explain why you don't think a travel ban is a good idea?
TOM FRIEDEN: Sorry, your first question again?
MIRIAM FALCO: Training?
TOM FRIEDEN: Thank you. We've worked very closely with doctors without borders, MSF, in fact we have replicated their training course, and we have dozens and hundreds of U.S. doctors and other health care workers who are going to Africa to fight the outbreak at the source, going through a CDC-run training program that replicates the training that MSF has done. The same team at CDC who created that training course is training physicians throughout the U.S. but definitely we will be looking over the coming days in how we can increase training and increase training materials and availability most urgently for the health care workers caring for the patient in Dallas, but also more generally throughout our health care system. It is worth highlighting that the single most important thing for every other hospital in the country to know is the importance of taking a history of travel. That if someone has fever or other symptoms that could be Ebola, ask where they have been in the previous 21 days. And if it's to Liberia, Sierra Leone or guinea, then immediately place them in isolation, consult with us, the state and local health department, and we'll go from there. But that's what the health care system in general needs to really focus on. In terms of travel, we're looking at multiple levels of protection. The first is screening of people on departure from these three countries. All are screened with a questionnaire. All have their temperature taken. 77 people in the last two months were not allowed to board, not allowed to enter the airport even because they had fever or other symptoms. None of those were diagnosed with Ebola. Many of them had malaria. In addition, starting yesterday at JFK international airport in New York City we began screening people who came from these countries, these three countries also with a detailed questionnaire and temperature check. Since that was implemented, 91 such individuals were identified. None of them had fever. Five of them were referred for additional evaluation by CDC. None were determined to have exposure to Ebola. So this is in place at JFK. Thursday of this week we anticipate having this in place at four additional airports in the U.S. and we'll learn from that experience. Also making sure that doctors throughout the health care system diagnose Ebola promptly is very important. On the issue of banning travel, i understand that there are calls to do this. I really try to focus on the bottom line here. The bottom line here is reducing risk to Americans. The way we're going to reduce risk to Americans is do the steps of protection i just went through and stop it at the source in Africa. Today CDC has 150 of our top disease detectives throughout the three countries and many of the counties, districts and prefectures within the three countries helping to turn the outbreak around, working along with the department of defense, with USAID, with the world health organization and with many other governments which are surging in to help stop it at the source. If we do things that unintentionally make it harder to get that response in, to get supplies in, that make it harder for those governments to manage, to get everything from economic activity to travel going, it's going to become much harder to stop the outbreak at the source. If that were to happen, it would spread for more months and potentially to other countries, and that would increase rather than decrease the risk to Americans. Above all, do no harm, and that's why we want to focus on stopping the outbreak at the source and protecting Americans wherever Ebola may arise, even though we know that that can be challenging.
MISTY SHOWALTER: Misty Showalter with CBS news. Texas Presbyterian is a relatively large hospital and still had a breach like this. Do you still feel confident that smaller hospitals can handle an isolated patient with people that have symptoms?
TOM FRIEDEN: We're going to look carefully at the issue of what's the optimal say to safely carefully care for people with Ebola but I would reiterate whatever we do on that issue, it's very important that every hospital be prepared to diagnose someone with Ebola. Remember, there may be Americans who have deployed or traveled to the area who come back, so whatever we do, we're not going to eliminate travel from these countries.
MICHELE MARILL: Thank you, Dr. Frieden. I'm Michele Marill with hospital employee health newsletter. We mentioned doing everything possible to protect health care workers, and I was wondering if you feel that you could be certain that in the presence of a patient with projectile vomiting and coughing that there could not be inhalation and whether or not you're considering changing the CDC recommendations to include respiratory protection, which I understand is what doctors without borders uses in West Africa?
TOM FRIEDEN: Actually the hospitals that have treated patients with Ebola in this country have all used what are called positive air pressure respirators. That is clearly not how the individual in Texas became infected. So I don't think we have concerns about the potential route of transmission, but our guidelines already say that if there's any concern for aerosol-generating procedures, such as intubation of a patient or suctioning, then absolutely we recommend respiratory protection.
ARIEL HART: Ariel Hart with Atlanta Journal Constitution, Two questions. First of all, can you clarify about the breach in protocol? Are you deducing that a breach in protocol must have happened because of the result or have you identified any particular breach in protocol? And second of all, back in august the CDC held a conference call helping clinicians prepare for Ebola and your folks were pressed again and again by the clinicians about negative air pressure rooms and about what kind of garb to use. They seemed to think that, you know, shouldn't there be some indication for leg protection and again and again the CDC folks came back with up to hospital policy, stuff like as for head coverings we do not specifically call this out. Do you still stand by that guidance or is there anything you would change?
TOM FRIEDEN: And again your first question was?
ARIEL HART: The first question was about the breach in protocol.
TOM FRIEDEN: We have not identified a specific problem that led to this infection. We have identified a series of things where we can make the care safer and easier for the health care workers who are providing it. One of the things that's very important is that we have practical solutions that are workable. When you're taking care of a patient with Ebola, you need to go in and come out multiple times, doing that in a way that works for you is very important. We're looking at what are the ways to do this most safely and most easily. One of the things that we found is that sometimes health care workers may think that more is better, so may put on additional sets of gloves or additional coverings and that may actually end up paradoxically making things less rather than more safe because it may be so difficult to remove those levels or layers that it inadvertently increases risk. We don't know that that happened here but that's one of the things that we've been addressing. Even before the individual's infection, we had improved some of the infection control practices at the hospital. Over the past 24 hours, we have undertaken a series of improvements and we'll continue to look at as we investigate every possible way to increase safety for health care workers.
ELIZABETH TAYLOR: Elizabeth Taylor, CBS 46. My question is regarding the screenings that you mentioned are going to start Thursday at Hartsfield Jackson. Do those work? If someone is non-symptomatic like Duncan or the index patient as you call him was when he gets here, how are we going to stop him? And we're kind of relying on, you know, everyone being honest to say that they ran into someone or they didn't.
TOM FRIEDEN: The airport screenings will identify people with fever. They will undergo a detailed questionnaire about contacts. And if there's any possible contact, secondary or tertiary screening by the CDC specialized public health officers at the airports. But we recognize that until we stop the outbreak in West Africa, there is no way to get the risk in the U.S. to zero. What we can do is stop its spread within the U.S. and minimize the possibility that we have other cases here, and that's exactly what we're doing. We'll go to the phones for the first question.
OPERATOR: Again, if you would like to ask a question on the phones, please press star 1 and record your name when prompted. Please limit your question to one question. Our first question comes from Eben Brown of Fox News Radio. Go ahead, sir, your line is open.
EBEN BROWN: Good afternoon and thank you for doing this. Is there any type of either federal standard or state level standards for hospital employees, nurses, doctors, respiratory technicians, lab technicians to work in an isolation unit? I mean we do have those folks and even some lay people that get certified for things like CPR and whatnot and they do that through special training and they have to take exams and they have to renew them. Do they do this for isolation ward care? And would that be one of the things going forward that might be helpful?
TOM FRIEDEN: I'll begin and turn it over to Dr. Lakey for further comment. There are a series of specialties in the health care field, infection control preventist, critical care nursing, there are many specialties in which infection control is an integral part. But in terms of specific qualifications or certifications for isolation treatment, no, there's nothing there. However, what we will be doing in the coming days and weeks is doubling down on the amount of education, training, outreach and support we provide not just to this hospital but to other hospitals and other health care settings that are concerned appropriately about the possibility of detecting Ebola and safely caring for it. Dr. Lakey?
DAVID LAKEY: Thanks, Dr. Frieden. I don't have much to add besides what you just discussed. Licensure of hospitals, they look at the rooms and the negative pressure rooms to make sure that they're up to standards. There's general education that takes place with infection control practitioners and a lot of education that takes place in the hospital itself. But we don't — we do not have a specific regulatory certification for individuals that work in these types of environments. A lot of that education takes place at the hospital. And those hospitals have licensure with the state that they perform at the standards that they need to perform at. Thank you.
TOM FRIEDEN: On the phone.
OPERATOR: Our next question comes from Sharon Bagley of Reuters. Go ahead, your line is open.
SHARON BAGLEY: Hi, thank you, everyone. A question for either Dr. Lakey or Dr. Frieden or perhaps both of you. Late last night the Louisiana attorney general announced that he would seek a temporary restraining order so that the incinerated waste from the apartment where Mr. Duncan stayed could not ultimately be disposed of in a Louisiana landfill. I wondered if you could speak to any scientific basis for that, and then practically how you think, DR. Frieden, that might impact the care of Ebola patients at the other hospitals around the country.
TOM FRIEDEN: Well, we certainly know how to inactivate and destroy the Ebola virus. It's readily destroyed by incineration, destroyed by chemical means. It's not a particularly hearty virus environmentally. Dr. Lakey, do you have anything more you'd like to comment?
DAVID LAKEY: Thanks, Dr. Frieden. I don't think I have much more to comment on. We feel very comfortable that with the procedure, with incineration, with total inactivation of any virus, we believe that the ash would pose absolutely no risk. That's basically kind of where we are right now. Thank you.
TOM FRIEDEN: In the room.
ERICA BYFIELD: Yes, WSB right here in Atlanta. You mentioned that there were several other staff members that you guys were interviewing who had contact with the index patient. Do you have a number of the people and exactly what you're talking to them about, those kind of details?
TOM FRIEDEN: The teams on the ground are going through in great detail what kind of contact people had, what kind of care they gave, on which days, so we can really develop a map of what the potential exposures are. We do not today have a number of such exposed people or potentially exposed health care workers. It's a relatively large number, we think in the end. What portion of them will actually have contact we will know after we complete that. We cast a wide net and narrow that down. We're hopeful by Tomorrow we'll be able to provide that number to you. In the room.
MIRIAM FALCO: Miriam from CNN. You talked about how more training needs to be happening and there are a lot of hospitals in this country. We thought that — at least the hospitals thought in Dallas that they had prepared well. They had an Ebola training session the week before Mr. Duncan was admitted. So is there any consideration to choose certain hospitals in certain areas as Ebola designated hospitals so that you know that hospital has been up to par or improved training until all hospitals have that opportunity?
TOM FRIEDEN: We're certainly looking at all of the possibilities and all of the opportunities. We want to make sure that when patients are cared for, they're cared for safely. I think the events in Dallas this week really reiterate how hard it is to do that. Care for a patient with Ebola requires meticulous attention to detail, and we're looking at every aspect to see how we can make it safer and easier. We'll go back to the phone for just one more question on the phone and one more in the room and then we'll be done.
OPERATOR: Thank you. Our next question comes from Marilyn Marchione of the Associated Press. Go ahead, ma'am, your line is open.
MARILYN MARCHIONE: Thank you. Could you please tell us the steps that the health care workers in Texas were taking to decontaminate? How did it work, what did they do? You mentioned something about starting a buddy system now. If you could walk us through what had been done up to now.
TOM FRIEDEN: What we're doing at this point is looking at every aspect of prevention of infection in the Dallas hospital. That includes what's done when people put on their personal protective equipment. That may mean looking at the different equipment that's used and see if there's equipment that's easier to put on or more protective. What they do when they're in the isolation facility. Whether there's things to reduce the risk that the virus gets on their protective equipment. And what they do when they come out is the area we're most concerned because that's the area where you may have virus on your protective equipment and how do you take it off, making sure that there's a buddy there watching you do it, that there's someone who's monitoring and providing oversight and supervision, looking at ways to decontaminate any potential contamination. And really it's an ongoing process. We worked through the night with staff there. We're already today implementing some new procedures to make it safer and easier, and we'll continue to do that in the coming days. Last question.
ELIZABETH TAYLOR: Thank you. You mentioned that you were going to rethink patient care possibly. Could one of that be — one way to do that be considering end of life care such as intubation or other things that are sort of more invasive for health care workers?
TOM FRIEDEN: We will look at all aspects of care, but we want to make sure that patients who have Ebola are cared for both safely and effectively. That's so important for them and it's important for all of us. Because when Ebola patients are cared for safely, it's more likely that people will come in for care. It's more likely the health care workers will have the confidence that in the what we hope will be extremely unlikely event that they will become infected, they will get the best possible care so that's where our focus is. Dr. Lakey, is there anything that you'd like to say in concluding?
DAVID LAKEY: Well, thank you, Dr. Frieden. Again, I appreciate the support from the CDC and our many other partners as we do everything we can to stop the spread of Ebola here in Dallas. I feel confident that we are going to do that. We're bringing in the staff we need to do the contact tracing. We are working with it, as you've noted many times, working to make sure the infection control is as stringent as possible. Doing everything else we can to make sure that we have a coordinated response. So again, appreciate the work from the CDC and our many partners as we do this. And again, right now we're concentrated on the care of this individual and making sure that no other Texans are exposed. Thank you.
TOM FRIEDEN: Thank you very much, Dr. Lakey, Bottom line here is that the care of Ebola is hard. We're working to make it safer and easier. The control of Ebola is something we know how to do. Already we've seen that the contacts of the index patient so far have not had illness. We've had one case and hope we have no additional cases among health care workers who cared for him, but that one case does tell us that there were risks to that individual and potentially to others, so we're intensively monitoring that so that we can break the chain of transmission there. And we're assessing what more we can do, what more we all can do to improve the care of people with Ebola so that we can not only stop it at the source but also reduce the risk to any health care workers going forward. Thank you very much.
TOM FRIEDEN: Let's go back. The question was should the public be confident that we know how to deal with this. Let's identify what "this" is. If "this" is stopping Ebola, absolutely. We know how to do it. We know how to break the chains of transmission by making sure that people that develop symptoms are rapidly isolated and effectively cared for. We know how to do it by making sure that the care of patients is safe and effective. Right now we have to make sure that that care is done safely and effectively everywhere, particularly in Dallas where there is a patient today. We've already cared for other patients with Ebola in this country without infections. Doctors without borders and others, including ourselves, have cared for patients for decades without infections. So we know how to stop Ebola. For the general public, the key message here is if you're a health care worker, see what you can do to help stop it by detecting it sooner or helping out if you volunteer to do so. For the individuals who are potentially exposed to either of the two patients in Dallas, you need to monitor intensively for that 21-day period. For everyone else, there's no risk of exposure to Ebola unless you go to West Africa. That's why we're going to West Africa to stop that risk there. We need to do everything we can, and we are doing everything we can to both protect Americans and protect Americans effectively by stopping it at the source as well as stopping it here. Thank you.
BARBARA REYNOLDS: Thank you. This concludes CDC's Ebola response update. For any media who have additional questions, you can call us at 404-639-3286. Thank you.
OPERATOR: This concludes today's conference. Thank you for your participation. You may now disconnect.
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