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CDC Prepared For U.S. Ebola Cases; Nina Pham Will Be Transferred To NIH; House Panel Grills CDC Chief On Ebola; CDC May Ban 76 Texas Hospitals From Working
Aired October 16, 2014 - 13:00 ET
THIS IS A RUSH TRANSCRIPT. THIS COPY MAY NOT BE IN ITS FINAL FORM AND MAY BE UPDATED.
UNIDENTIFIED MALE: -- Texas Health Presbyterian Dallas emergency department with a fever of 100.1, abdominal pain, dizziness, nausea and headache. Symptoms that could be associated with many other illnesses. He was examined and underwent numerous tests over a period of four hours. During his time in the E.D., his temperature spiked to 103 degrees Fahrenheit but later dropped to 101.2. He was discharged early on the morning of September 26th, and we have provided a timeline on the notable events of Mr. Duncan's initial emergency department visit. On September 28th, Mr. Duncan was transported to the hospital by ambulance. Once he arrived at the hospital, he met several of the criteria of the Ebola algorithm. At that time --
WOLF BLITZER, CNN ANCHOR: Hello, I'm Wolf Blitzer in Washington. And we're going to continue to monitor this hearing and get back to it. It's 1:00 p.m. in Washington, 7:00 p.m. in Brussels, 8:00 p.m. in Damascus, 2:00 a.m. Friday in Tokyo. Wherever you're watching from around the world, thanks very much for joining us.
The Ebola crisis certainly the top priority today for so many leaders here in the United States as well as elsewhere around the world, especially in Africa and Europe. This is the scene right now on Capitol Hill where members of Congress are holding a hearing on the U.S. response to the Ebola outbreak and cases here in the United States.
Several lawmakers are particularly outraged at how the Centers for Disease Control and Prevention in Atlanta has handled the infections at Texas Health Presbyterian Hospital in Dallas, and they're demanding answers from the CDC director, Tom Frieden, who is testifying today. There you see him it on the left-hand part of your screen.
Frieden admits his agency should have sent a larger response team to Dallas when the first Ebola diagnosis was made there. But today, he insisted the CDC is prepared to deal with the crisis and is protecting Americans' health. That's the number one priority.
(BEGIN VIDEO CLIP)
DR. THOMAS FRIEDEN, DIRECTOR, CENTERS FOR DISEASE CONTROL AND PREVENTION: There is a lot of fear of Ebola. And I will tell you, as the director of CDC, one of the things I fear about Ebola is that it could spread more widely in Africa. If this were to happen, it could become a threat to our health system and the health care we give for a long time to come. Our top priority, our focus, is to work 24-7 to protect Americans. That's our mission.
(END VIDEO CLIP)
BLITZER: There are other major developments in the Ebola crisis that we're following as well. Here's what we know. Right now, two sources tell CNN, Nina Pham, the first nurse to come down with Ebola after caring for a man who died from the disease, is now being transferred from Texas Health Presbyterian Hospital in Dallas to a National Institutes of Health Facility outside of Washington, D.C. and nearby Maryland. That transfer order comes just a day after Pham's colleague, Amber Vinson, was transferred from Dallas to Emory University Hospital in Atlanta, Georgia. Both the NIH Facility and Emory are two of the four hospitals with specialized Ebola isolation units.
Meantime, there are growing concerns of how Vinson was able to board a flight from Cleveland to Dallas only a day before being diagnosed with Ebola. A federal official tells CNN Vinson called the CDC to report she had a fever of 99.5 before she took the flight, but she was not told to stay off the plane.
We've also learned that the CDC is considering putting 76 health care workers at Texas Health Presbyterian Hospital on a list banning them from flying while being monitored for Ebola symptoms.
And in Washington, President Obama, once again, canceling travel plans, this for a second straight day to hold meetings on the Ebola response over at the White House.
Meanwhile, leaders in Belgium, France, Great Britain and Africa, they are also holding briefings on the crisis, clearly deep concern in Europe as well.
We're covering all angles of the story. Dr. Sanjay Gupta is outside Emory University Hospital in Atlanta, Elizabeth Cohen is in Dallas, Rene Marsh is at Dulles International Airport outside of Washington, D.C.
Sanjay, let's start with you. This -- the news, at least right now, is that the first nurse to contract Ebola, Nina Pham, she is now being flown to an NIH facility right outside of Washington National Institutes of Health facility. We heard Dr. Anthony Fauci make that announcement at this hearing just a little while ago. Why do you believe she's being transferred?
DR. SANJAY GUPTA, CNN CHIEF MEDICAL CORRESPONDENT: Well, it was interesting, I'm looking at my notes here when Dr. Vargas was talking about her, he said that her care was evolving, was how he described this in reference to the fact she was being transferred over to the NIH. It's a vague term. I'm not sure what she means by that -- what he means by that, I apologize.
It's -- we know that Amber Vinson, perhaps, came here to Emory in this building behind me because they were concerned about whether or not they would have the staff to be able to care for her, even though there's obviously 76 staff members who are staying home. There are others that have been furloughed. There's a question -- there's been concerns of nurses may walk out. So, this may fall into that same category, is there enough staff to actually be able to take care of her? Good news, it sounds like she's doing well. It doesn't sound like she's taken a decline, in terms of her health, that's prompting this decision -- Wolf.
BLITZER: And, clearly, a concern that maybe the Texas hospital not up to the challenge. That's why they're moving both of these nurses. One has already been moved to Atlanta. The other one here to Washington, D.C.
I want everyone to stand by. I want to go back to the hearing, the Q and A with these witnesses is beginning.
REP. TIM MURPHY (R), PENNSYLVANIA, CHAIRMAN, HOUSE ENERGY AND COMMERCE COMMITTEE (live): -- with yourself, somebody else advised you that's a position we need to protect fledgling democracies.
FRIEDEN: My recollection of that conversation is that that discussion was in the context of our ability to stop the epidemic at the source.
WRIGLEY: Well, but we can get supplies and medical personnel into the Ebola hot zones and so stopping planes. And I've heard you say this on multiple occasions that we have a thousand plus persons per week coming to the United States from hot zones, am I correct on that? Coming from those areas?
FRIEDEN: There are approximately 100 to 150 per day.
WRIGLEY: A day, OK. Now, I mean, the Duncan case has seriously impacted Dallas and northern Ohio. But what I don't understand is if the administration insists on bringing Ebola cases into the United States, clearly, you've determined how many Ebola infectious cases the U.S. public can handle. I mean, we are -- NIH can handle two of these beds. Do you know the number overall in this country, how many we can handle?
FRIEDEN: Our goal is for no patients.
WRIGLEY: I understand. But as long as we don't restrict travel and we're not quarantining people and we're not limiting their travel, we still have a risk. And so, these issues of surveillance and containment, I don't understand. And this is the question the American public is asking, why are we still allowing folks to come over here? And why, once they're over here, is there no quarantine?
FRIEDEN: Our fundamental mission is to protect Americans. Right now, we're able to track everyone who comes in.
WRIGLEY: But you're not stopping them from being around other people, doctor. I understand that and I have a high respect for you. But my concern is that the American people says that even so, they're not limited from travel, they're not quarantined for 21 days because they could still show up with symptoms. They could still bypass other questions Mr. Wagner referred to in the thermometers on there. So, -- and I'm -- and this is what happened with the nurse who went to Cleveland. So, I'm concerned here. Is this going to be your maintaining position of the administration, that there will be no travel restrictions?
FRIEDEN: We will consider any options to better protect Americans.
WRIGLEY: Thank you. I now give five minutes to Miss DeGette.
REP. DIANA DEGETTE (D), COLORADO, RANKING MEMBER, HOUSE ENERGY AND COMMERCE COMMITTEE: Thank you, Mr. Chairman. Dr. Frieden, I've got some questions for you and Dr. Vargas for you and I'd appreciate yes or no answers, because I have a lot to move through and only a short amount of time.
Dr. Frieden, in the spring of 2014, Ebola began spreading through West Africa causing increasing concern within the international public health community, correct?
DEGETTE: Ebola has an incubation period of about 21 days and is not contagious until the person with the virus begins to be symptomatic, beginning often with a fever, correct?
FRIEDEN: Between two and 21 days, yes.
DEGETTE: Ebola is transmitted through contact with a patient's bodily fluids including vomit, blood, feces and saliva and the virus concentrates more heavily as the patient becomes sicker presenting increasingly greater risk to those who may come in contact with them, correct?
DEGETTE: Now, the CDC has developed guidance for hospitals to follow if patients present with symptoms consistent with Ebola and it distributed them to hospitals around the country in the summer of 2014, correct?
DEGETTE: Now, Dr. Varga, can you hear me?
DR. DANIEL VARGA, CHIEF CLINICAL OFFICER, TEXAS HEALTH RESOURCES: Yes, ma'am.
DEGETTE: Your hospital received the first CDC health advisory about Ebola on July 28th, and this advisory was given to the directors of your emergency departments and signage was posted in your emergency room. Is that right?
VARGA: Yes, ma'am.
DEGETTE: Now, was this information given to your emergency room personnel and was there any actual person-to-person training at Texas Presbyterian for the staff at that time? Yes or no.
VARGA: It was given to the emergency department.
DEGETTE: Was there actual training?
DEGETTE: On August 1st, your hospital received an e-mail from the CDC specifying how to care for Ebola patients and advising intake personnel to ask a question about travel history from West Africa. Is that right?
VARGA: That's correct.
DEGETTE: Now, on September 25th, almost two months after the first advisory received by the hospital, Thomas Eric Duncan showed up at Texas Presbyterian with a fever that spiked up to 103, and he told the personnel that he had come from Liberia. Despite this, the hospital sent him home. Is that right?
VARGA: That's not completely correct.
DEGETTE: Well, they did send him home, right?
VARGA: That's correct.
DEGETTE: Now, three days later, on September 28th, he took a severe turn for the worse and was brought back by ambulance. The hospital staff nurses and everybody else wore protective equipment. Is that right?
VARGA: That's correct.
DEGETTE: And then, eventually, shoe covers were put on too. Do you know how long that took them to put the shoe covers on?
VARGA: I don't.
DEGETTE: Now, because Ebola is highly contagious when the patient's symptomatic, the protective gear has to shield them from any contact with bodily fluids. Is that right, Dr. Frieden?
DEGETTE: Now, I have a slide I'd like to put up and I got it from "The New York Times" today. It's the photo of the people in the various protective gear. So, the first one, on the left, shows what they're supposed to wear when they come in contact with -- when they're not having contact with the bodily fluids. The second one shows what they're supposed to have with the bodily fluids. So, I want to ask you, Dr. Varga, is what they were wearing at first, before the Ebola was diagnosed, that first set of protective gear?
VARGA: I'm sorry, I can't see the picture right now.
DEGETTE: OK. I was told you would be able to.
Dr. Frieden, what should they have been wearing, of that protective gear, before the Ebola was diagnosed?
FRIEDEN: I can't make out the details but the recommendations vary as to the risk, including whether the patient is having diarrhea or vomiting and may expose health care workers to fluids.
DEGETTE: Well, this guy, he had diarrhea and vomiting. So, in your testimony, people should have been completely covered. Is that right?
FRIEDEN: I would have to look at the exact details to know what the answer to that question would be.
DEGETTE: So, you don't know whether they should have been completely covered if the patient had diarrhea and vomiting and he had come from West Africa?
FRIEDEN: If the patient had diarrhea or vomiting, then additional covering is recommended under the CDC recommendations, yes.
DEGETTE: Now, my other question that I want to ask, and I'm going to have to get -- Dr. Varga, I'm going to have to get your testimony since you can't see my chart. Now, subsequently a number of people, health care workers, were put into this group, this protective work. Is that right, Dr. Frieden? People who were being monitored.
FRIEDEN: So, health care --
DEGETTE: And on October 10th, Nina Pham, presented with a fever and she was admitted to the hospital. Is that right?
DEGETTE: And then, on October 13th, Amber Vinson, who was self- monitoring, she presented with a fever and she was told by your agency, she could board the plane. Is that right? I just have one more question.
FRIEDEN: That is my understanding.
DEGETTE: Now, your protocols --
FRIEDEN: I need to correct that.
FRIEDEN: I have not reviewed exactly what was said but she did contact our agency and she did board the plane.
DEGETTE: And she says she was told to board the plane.
FRIEDEN: That may --
DEGETTE: Now, your August --
FRIEDEN: --that may well be correct.
DEGETTE: Your August 22nd protocols say people who are being monitored should not travel by commercial conveyances, don't they?
WRIGLEY: Time's expired. You can answer the question.
DEGETTE: That's what they say.
FRIEDEN: People who are in what's called controlled movement should not board commercial airlines.
DEGETTE: Right. And that's people who have had close contact with these patients, right?
FRIEDEN: The --
DEGETTE: That's what your guidelines say.
FRIEDEN: -- guidelines say that people -- health care workers with appropriate personal protective equipment don't need to be but people without appropriate personal protective equipment do need to travel by controlled transfer.
WRIGLEY: (INAUDIBLE) --
DEGETTE: Chairman, I just ask --
WRIGLEY: -- but you need to --
DEGETTE: -- I just ask, for the record, the interim guidance dated October 22nd, the interim guidance dated October 21st and interim guide -- or the CDC Health Advisory dated July 28th to be included in the record.
WRIGLEY: Without objection, we'll include it in the record. Dr. Frieden, I need you and also the doctors in Texas to get back to the committee as a follow-up to her questions because your comments you made to us was that if she was wearing appropriate protective gear, she's OK to travel. If she was not, she should not have traveled. And you just told us, we don't know. We need to find that out. It's an important question. Now, recognize the chairman of the committee, Mr. Upton, for five minutes.
FRED UPTON (R), MICHIGAN, CHAIRMAN, HOUSE ENERGY AND COMMERCE COMMITTEE: Thank you, again, Mr. Chairman. I think most Americans realize that it is -- if you're exposed, that you have 21 days. If you -- if you -- if you go beyond 21 days, you're at virtually no risk of Ebola if you go that far. But it's conceivable then that after 14 or 15 days, you, in fact, can still get Ebola. Is that correct?
UPTON: So I want to go back to the restricting of travel, particularly by non-U.S. citizens, 150 folks a day into the U.S. from West Africa. So it's -- the conditions, as you talked about, exit screening, all folks from there are exit-screened, so it's perfectly conceivable that someone, even after 14 days, can exit-screen, they're OK, no fever, and in fact, get to their destination, perhaps in the United States, and have the worst; is that right? FRIEDEN: Yes.
UPTON: So if our fundamental job is to protect the American public, the administration, as I understand it, as I've looked at the legal language, does the president -- does have the legal authority to impose a travel ban because of health reasons, including Ebola; is that not correct?
FRIEDEN: I don't have the legal expertise to answer that question.
UPTON: I saw language earlier today. We can share that with you. But he does, from what we understand, not only an executive order that former President Bush issued when he was president, but also legal standing as well.
So if you have the authority -- and it's my understanding, again, that a number of African countries around West Africa, around particularly these three nations, in fact have imposed a travel ban from those three countries into their country; is that not true?
FRIEDEN: I don't know the details of the restrictions. There are some restrictions.
UPTON: It's my understanding that they've said no, and including even Jamaica, as I read in the press earlier this week, has issued a travel ban from folks coming from West Africa. Are you aware of that?
FRIEDEN: I don't know the details of what other countries have done. I know some of the details, and some of them have been in flux.
UPTON: Well, I guess the question that I have is if other countries are doing the same, and as you said, the fundamental job of the U.S. now is to protect American citizens, why cannot we move to a similar ban for folks who may or may not have a fever, knowing in fact that the exposure rate, 14 days or 15 days, is well within the 21 days, and in fact, knowing that 150 folks coming a day, not 100 percent -- it's 94 percent in terms of screening from U.S. airports, it seems to me that this is not a failsafe system that's been put into place at this point.
FRIEDEN: Mr. Chairman, may I give a full answer?
UPTON: I look forward to it.
FRIEDEN: Right now, we know who's coming in. If we try to eliminate travel, the possibility that some will travel over land, will come from other places, and we don't know that they're coming in, will mean that we won't be able to do multiple things. We won't be able to check them for fever when they leave.
UPTON: Do we not have -- again, to interrupt you just for a second. Do we not have a record of where they've been before, i.e., a passport, or travel status, as they travel from one country to another? FRIEDEN: Borders can be porous -- may I finish? -- especially in this part of the world. We won't be able to check them for fever when they leave, we won't be able to check them for fever when they arrive. We won't be able, as we do currently, to take a detailed history to see if they were exposed when they arrive.
When they arrive, we wouldn't be able to impose (ph) quarantine as we now can if they have high-risk contact. We wouldn't be able to obtain detailed locating information, which we do now, including not only name and date of birth, but e-mail addresses, cell phone numbers, address, addresses of friends, so that we could identify and locate them.
We wouldn't be able to provide all of that information, as we do now, to state and local health departments, so that they can monitor them under supervision. We wouldn't be able to impose controlled release, conditional release on them, or active monitoring, if they're exposed, or to, in other ways...
UPTON: My time is expiring. I know I've got a swift gavel over here to my left. But I just -- I just don't understand if we -- if we have a system in place that requires any airline passenger to -- from coming in overseas with a date of birth to make sure they're not on the anti- terrorist list, that we can't look at one's travel history and say "No, you're not coming here," not until this situation -- you're right, it needs to be solved in Africa. But until it is, we should not be allowing these folks in, period.
MURPHY: Gentleman's time is expired. Recognize Mr. Waxman for five minutes.
WAXMAN: Thank you. Thank you, Mr. Chairman. Dr. Frieden, you have a difficult job. In fact, all of the -- your colleagues who are involved from the different agencies have a difficult job, because this is a fast-moving issue.
And you're trying to -- you're trying to explain things to people and educate them with limited information and partial authority. In fact, the CDC can't even do anything in a state. They have to be invited in by the state. You can't tell the states to follow your guidelines. You can give them guidelines.
So you're dealing with a fast-moving situation, and you have to strike a balance about informing the public on the one hand, and keeping it from panicking on the other. So let's -- let's go to basics.
If people are frightened about getting Ebola, what assurances can we give them that this is not going to be a widespread epidemic in the United States, as you've said on numerous occasions?
FRIEDEN: The concern for Ebola is, first and foremost, among those caring for people with Ebola. That's why we're so concerned about infection control anywhere patients with Ebola are being cared for.
Second, in the health care system as a whole, to think about travel, because someone who has a fever, or other signs of infection, needs to be asked, "Where have you been in the past 21 days?" And if they've been in West Africa, immediately isolated, assessed, and cared for.
WAXMAN: So we have to make sure that we monitor health care workers, because they're exposed to people who have Ebola. The questions have been raised, well, what about all these people coming in from Africa from the countries where the Ebola epidemic is taking place?
And you've been asked, why don't we just restrict the travel, either directly or indirectly, from anybody coming in from those countries?
I'd like to put up on the screen a map to show the passenger flows from those countries. That map shows that if you hold it up here, if you're looking at those particular countries in Africa, they can go to any country in Europe. They can go to Turkey, Egypt, Saudi Arabia. They can go to China, India. They can go to other countries in Africa, and then from those other countries, come to the United States.
So I suppose we can set up a whole bureaucratic apparatus to be sure that somebody didn't really travel from Nigeria, or Cameroon, or Senegal, or Guinea, or Sierra Leone, to be sure they didn't really get here from any of those countries. That could be our emphasis, but it seems to me what you're saying is that we want to monitor people before they leave those countries to see whether they have this infection, and we want to monitor them when they come into these countries to see whether they have this infection. Is that what you're proposing to do?
FRIEDEN: That's what we're actually doing. We're able to screen on entry. We're able to get detailed locating information. We're able to determine the risk level.
If people were to come in by -- for example, going overland to another country, and then entering without our knowing that they were from these three countries, we would actually lose that information. Currently, we have detailed locating information. We're taking detailed histories, and we're sharing information with state and local health departments, so that they can do the follow-up they decide to do.
WAXMAN: Dr. Fauci, do you agree with Dr. Frieden on this point?
FAUCI: I do.
WAXMAN: You wouldn't put a travel ban. It sounds like -- we always say, "Seal off our borders, don't let those people come in."
Now, that's usually referenced to the immigration matter, not public health, particularly. It might be a tangential issue. But we know certain countries where the epidemic is originating. Why not stop them coming here?
FAUCI: I believe that Dr. Frieden and yourself just articulated very clearly. It's certainly understandable how someone might come to a conclusion that the best approach would be to just seal off the border from those countries. But we're dealing with something now that we know what we're dealing with. If you have the possibility of doing all of those lines that you showed, that's a big web of things that we don't know what we're dealing with.
WAXMAN: So what we know is this epidemic can spread if there's contact with body fluids from somebody who's showing the symptoms of Ebola, or someone who's been exposed to that individual. If we had a traveler ban, wouldn't we just force these people to hide their origin, and wouldn't we also not know where they're coming from if they're going out of their way to hide it? Ban or quarantine would hinder efforts to fight the epidemic in West Africa. And the worse the epidemic becomes in West Africa, the greater it's going to be a problem all over the world, including the United States. MURPHY: Gentleman's time is expired.
WAXMAN: Is that your position? Dr. Fauci, is that your position?
FAUCI: (OFF-MIKE) Yes.
MURPHY: Gentleman's time's expired. Now we recognize the vice chair of the full committee for five minutes.
BLACKBURN: Thank you, Mr. Chairman. Dr. Frieden, I want to be sure I heard you right. You just said to Chairman Upton that we cannot have flight restrictions because of a porous border. So do we need to worry about having an unsecure Southern and Northern border? Is that a big part of this problem?
FRIEDEN: I was referring to the border of the three countries in Africa, Liberia...
BLACKBURN: So you're referring to that border, not our porous border?
FRIEDEN: ... Guinea and Sierra Leone.
BLACKBURN: Mr. Wagner, would it help you all, the Border Patrol, if we secured the Southern border and eliminated illegal entry?
WAGNER: Well, travelers coming across the Southern border, like the Northern border, we're going to, you know, query their information in our databases. We're going to ask them their travel history; where they're coming from, how they arrived in the country they're coming from. So...
BLACKBURN: OK, yes or no is sufficient. I need to -- I need to move on.
Dr. Frieden, I want to come back to you. I would remind you that a week before last when I was at the CDC -- and I thank you for letting me come down to follow up with you all on some of our committee work -- that I recommended a quarantine in the affected region, and hold people there. And I still think that that is something that we should consider; quarantine people for 21 days before they leave that region, it helps every country.
I want to go back to an issue that you and I talked about at the CDC and the subsequent phone call, and that is the medical waste. And you assured me that standard protocols were being followed for disposal of this waste. And we know that 20, 25 years ago, hospitals could incinerate their waste.
EPA regulations now prohibit that, and the waste has to be trucked, and they outsource the care of this medical waste. And it results in that going to central processing centers.
So let me ask you this: Is Ebola waste as contagious as a patient with Ebola?
FRIEDEN: Ebola waste -- waste from Ebola patients -- can be readily decontaminated. The virus itself is not particularly hearty. It's killed by bleach, by autoclaving, by a variety of chemicals.
BLACKBURN: OK. Is Ebola medical waste more dangerous than other medical waste?
FRIEDEN: The severity of Ebola infection is higher, so you want to be certain when you're getting rid of it that you handle it...
BLACKBURN: OK. Is the CDC assessing the capabilities of hospital to manage the medical waste of Ebola patients? And does the CDC allow offsite disposal of Ebola medical waste?
FRIEDEN: My understanding is to the latter question, yes, we worked very closely with both the Department of Transportation, as well as the commercial waste management companies, to ensure that capability.
BLACKBURN: So we have an added danger in having to truck this waste and move it to facilities. Are the employees at the processing centers being trained in how to dispose of Ebola waste?
FRIEDEN: We have detailed guidelines for the disposal of medical waste from care of Ebola patients.
BLACKBURN: All right. You and I talked a little bit about my troops from Fort Campbell that are going to be over there. And I have some questions from some of my constituents.
Are the American troops going to come in contact with any Ebola patients, or with those exposed to Ebola, or included in any of these controlled movement groups?
FRIEDEN: The -- as I understand it from the Department of Defense, their plans do not include any care for patients with Ebola, or any direct contact with Ebola.
That said, we would always be careful in country, because there is the possibility of coming in contact with someone with symptoms, and being exposed to their body fluids. And that's why the Department of Defense is being extremely careful to avoid that possibility.
BLACKBURN: We're still going to rely on self-reporting?
FRIEDEN: No. We're taking temperatures at many locations within the country. We are having handwashing stations...
BLACKBURN: So you're moving away from self-reporting, because originally, it was -- you said our structure was built on self- reporting when I visited with you earlier.
And I found a quote from you from December 2011 at the George Comstock lecture in TB research. And I'm quoting you, "Hippocrates was right, patients lie. About a third of patients don't take medication as prescribed, and a third don't take them at all. You can either delude yourself and think that patients are taking their medications or not. In TB control, it's a simple model. If we see people take their meds, we believe they took their meds.