Open Letter to the CDC on Ebola Preparedness


The Honorable Darrell Issa
House Oversight and Government Reform Committee
Washington, DC 20515

Dear Representative Issa:

The U.S. was initially unprepared for clinical cases of Ebola virus disease. Former Surgeon General Richard Carmona tells the news media that with updated CDC guidelines and current precautions, properly used, there is “zero risk” of infection to workers who transport or care for these patients.

We are concerned that the CDC Guidelines have not taken into account all the published scientific literature. One main assertion is the CDC’s statement that Ebola cannot be transmitted “in the air” or by aerosol.

AAPS calls your attention to the following facts:

Airborne transmission of Ebola virus is experimentally demonstrated.

Aerosols are generated by coughing, sneezing, invasive procedures, vomiting, diarrhea, flushing a toilet, and common laboratory equipment. Aerosol droplet transmission has been demonstrated in animal models.

  1. Jaax N, et al. Transmission of Ebola virus Zaire strain to uninfected control monkeys in a biocontainment laboratory. Lancet 1995;346:1669-1671.
  2. Jaax NK, et al. Lethal experimental infection of rhesus monkeys with Ebola-Zaire (Mayinga) virus by the oral and conjunctival route of exposure. Arch Pathol Lab Med 1996;120:140-155.
  3. Twenhafel NA, et al. Experimental aerosolized guinea pig-adapted Zaire ebolavirus (variant: Mayinga) causes lethal pneumonia in guinea pigs. Vet Pathol 2014(May 14).
  4. Zumbrun EE, et al. Development of a murine model for aerosolized ebolavirus infection. Viruses 2012;4:258-275.
  5. Jahrling PB, et al. Experimental infection of cynomolgus macaques with Ebola-Reston Filovirus from 1989-1990 epizootic. Arch Virol Suppl 1996;11:115-134.
  6. Formenty P, et al. Detection of Ebola virus in oral fluid specimens during outbreaks of Ebola virus hemorrhagic fever in the Republic of Congo. Clin Infect Dis 2006;42:521-1526.
  7. Leffel EK, et al. Marburg and Ebola viruses as aerosol threats. Biosecur Bioterror 2004;2,186-191.
  8. Bausch DG, Towner JS, Dowell SF, et al. Assessment of the risk of Ebola virus transmission from bodily fluids and fomites. J Infect Dis 2007;196(Suppl 2):S142-S147.
  9. Kobinger GP, Leung A, Neufeld J, et al. Replication, pathogenicity, shedding, and transmission of Zaire ebolavirus in pigs. J Infect Dis 2011;204:200-208.

Replication of the Ebola virus occurs in the skin.

One of the target organs for infection by the Ebola virus is the skin. The clinical possibility of transmission via skin shedding was suggested in 1995 during an Ebola outbreak in the Democratic Republic of the Congo (DRC). The timing of the appearance of Ebola viral particles in the skin and the onset of viral shedding into the environment has not been well defined to date.

  1. Zaki SR, et al. A novel immunohistochemical assay for the detection of Ebola virus in skin: implications for diagnosis, spread, and surveillance of Ebola hemorrhagic fever. Commission de Lutte contre les Epidémies à Kikwit. J Infect Dis 1999;179(Suppl 1):S36-S47.

Much remains unknown about Ebola.

In contrast to repeated public statements by national health leaders, much remains unknown about the filoviruses and their survival in the environment.

  1. Piercy TJ, et al.The survival of filoviruses in liquids, on solid substrates, and in a dynamic aerosol. J Applied Microbiol 2010;109, 1531-1539.

Fever is not always an early presenting sign of Ebola virus infection.

In approximately 12% of cases, Ebola can present without fever, and the absence of fever is not a reliable indication that an individual is not infected.

  1. WHO Ebola Response Team. Ebola virus disease in West Africa—the first 9 months of the epidemic and forward projections. NEJM 2014;371:1481-1495.

First responders and physicians need clear guidance supported by scientific data. AAPS requests the Committee to call for an urgent investigation by the Government Accountability Office (GAO), to be completed within 30 days, to determine the following:

  • Has the CDC incorporated published scientific evidence pertaining to the above in its guidance?
  • What is the scientific evidence for the CDC’s assertion that “airborne” transmission of the Ebola virus does not occur, and that this should not be a concern for first responders and medical workers?
  • The CDC website transiently acknowledged the danger of transmission by aerosol, in a posting captured at, but this material was quickly removed. Who is responsible for the material on the website and its removal?
  • How much has been expended for pandemic preparedness? What supplies are available in the Strategic National Stockpile (SNS), and how can they be accessed? Have they been tested for efficacy against Ebola? Note that Kimberly Clark is being sued for alleged flaws in its protective surgical gowns. (
  • Ebola is a biosafety level 4 (BSL-4) classified disease. What procedure did CDC follow in developing guidance for workers who are forced by circumstances to work under a lower grade BSL-3 condition?

This information is critical before any decisions are made to bring additional Ebola patients into this country, as the lives of transportation and medical personnel are at risk, as well as their families and other patients.

The Association of American Physicians and Surgeons (AAPS) is a national organization representing physicians in all specialties, founded in 1943 to preserve private medicine and the patient-physician relationship.


Jane M. Orient, M.D., Executive Director

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