oversight

DHS' Ebola Response Needs Better Coordination, Training, and Execution

Published by the Department of Homeland Security, Office of Inspector General on 2016-01-06.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

DHS' Ebola Response Needs
Better Coordination, Training,
and Execution




                      January 6, 2016
                           OIG-16-18
                                       DHS OIG HIGHLIGHTS

                              DHS’ Ebola Response Needs Better 

                            Coordination, Training, and Execution



  January 6, 2016                            What We Found
                                             Although the Department responded quickly to
  Why We Did                                 implement domestic Ebola screening with the
  This Audit                                 Department of Health and Human Services (HHS), it
                                             did not ensure sufficient coordination, adequate
                                             training, and consistent screening of people arriving
  In 2014, West African countries            at U.S. ports of entry. Coordination between DHS,
  experienced the largest Ebola              HHS, and other DHS components was not sufficient
  virus disease (Ebola) outbreak to          to ensure all passengers received full screening.
  date. As part of the Department of         Components did not ensure all personnel received
  Homeland Security’s (DHS)                  adequate training on the screening process or the
  response to prevent the spread of          use of certain protective equipment. Component
  Ebola in the United States, DHS            personnel also did not always follow established
  instituted additional screening at         Ebola procedures and ensure all identified
  U.S. ports of entry for passengers         passengers completed required screening. As a
  traveling from Ebola-affected              result, some passengers with potential risk of Ebola
  countries. We conducted this               exposure may have entered the United States
  audit to determine whether DHS             without having their temperatures taken or
  has effectively implemented its            otherwise cleared by health professionals, and the
  enhanced screening measures to             DHS workforce performing the response was not
  respond to an Ebola outbreak.              always appropriately protected.

  What We                                    DHS Response
  Recommend                                  The Department concurred with all 10
                                             recommendations and has initiated corrective
  We made 10 recommendations to              actions that should improve the effectiveness of the
  address the coordination,                  Department’s response to Ebola when implemented.
  guidance, and training involved            We consider seven recommendations resolved and
  with DHS’ response to Ebola.               open. However, for three recommendations, the
  These recommendations, when                Department needs to identify additional steps to
  implemented, should improve the            address the findings and resolve these
  efficiency and effectiveness of the        recommendations.
  program.

  For Further Information:
  Contact our Office of Public Affairs at
  (202) 254-4100, or email us at
  DHS-OIG.OfficePublicAffairs@oig.dhs.gov


www.oig.dhs.gov                                                                     OIG-16-18
January 6, 2016

                   OFFICE OF INSPECTOR GENERAL
                       Department of Homeland Security



is received and evaluated, the recommendations will be considered open and
unresolved. We consider recommendations 1, 3, 4, 5, 6, 8, and 9 open and
resolved. Once your office has fully implemented the recommendations, please
submit a formal closeout letter to us within 30 days so that we may close the
recommendations. The memorandum should be accompanied by evidence of
completion of agreed-upon corrective actions and of the disposition of any
monetary amounts.


Please send your response or closure request to
OIGAuditsFollowup@}oig.dhs.gov.


Consistent with our responsibility under the Inspector General Act, we will
provide copies of our report to congressional committees with oversight and
appropriation responsibility over the Department of Homeland Security. We will
post the report on our website for public dissemination.


Please call me with any questions, or your staff may contact Mark Bell,
Assistant Inspector General for Audits, at (202) 254-4100.


Attachment




www.oig.dhs.gov                        2
                            OFFICE OF INSPECTOR GENERAL
                                Department of Homeland Security

Table of Contents

Background .................................................................................................... 1 


Results of Audit .............................................................................................. 3 


        DHS Ebola Response Coordination ........................................................ 3 

        Training for Ebola Response .................................................................. 6 

        Implementation of Ebola Response ...................................................... 10 


Recommendations ......................................................................................... 13 


Appendixes

        Appendix       A:   Objective, Scope, and Methodology ................................. 22                

        Appendix       B:   DHS Comments to the Draft Report ................................. 25                 

        Appendix       C:   Office of Audits Major Contributors to This Report ........... 33                     

        Appendix       D:   Report Distribution .......................................................... 34     


Abbreviations

        CBP          U.S. Customs and Border Protection 

        CBRN         Chemical, Biological, Radiological, and Nuclear 

        CDC          Centers for Disease Control and Prevention 

        DHS          Department of Homeland Security 

        FEMA         Federal Emergency Management Agency 

        HHS          Department of Health and Human Services 

        HQ           Headquarters         

        HRM          Human Resources Management 

        ILSP         Integrated Logistics Support Plan 

        MOU          memorandum of understanding 

        OFO          CBP Office of Field Operations 

        OHA          Office of Health Affairs 

        OIG          Office of Inspector General 

        OSC          USCG Office of Specialized Capabilities 

        OSHA         Occupational Safety and Health Administration 

        PPE          personal protective equipment 

        PSC          Port State Control 

        TSA          Transportation Security Administration 

        USCG         U.S. Coast Guard 





www.oig.dhs.gov                                                                                     OIG-16-18
                   OFFICE OF INSPECTOR GENERAL
                       Department of Homeland Security

                                 Background

This audit is one of a series related to Department of Homeland Security’s
(DHS) pandemic preparedness and response. We previously reported on DHS’
management of pandemic supply of personal protective equipment and
antiviral countermeasures. We conducted this audit on DHS’ response to the
Ebola virus disease (Ebola) outbreak to determine whether it effectively
implemented DHS’ screening measures.

In 2014, West African countries experienced the largest Ebola outbreak to date.
In response, the Centers for Disease Control and Prevention (CDC) initiated exit
screening in countries experiencing the Ebola outbreak. As part of the domestic
response, DHS partnered with the CDC to prevent the spread of Ebola by
instituting additional screening at U.S. ports of entry for passengers traveling
from Ebola-affected countries.

In September 2014, the CDC, which is part of the Department of Health and
Human Services (HHS), confirmed the first case of Ebola in the United States.
DHS coordinated with Federal agencies, including HHS and the National
Security Council, to develop strategies for DHS’ domestic response to Ebola.
DHS’ Office of Health Affairs (OHA) led the Department’s Ebola response
activities and coordination efforts.

Within approximately 2 weeks of the first identified Ebola case in the United
States, DHS, in coordination with the CDC, began screening for Ebola at the
following five U.S. airports:

   x   John F. Kennedy International Airport (JFK) in New York;
   x   Washington-Dulles International Airport (IAD) in Virginia;
   x   Newark Liberty International Airport (EWR) in New Jersey;
   x   Chicago O’Hare International Airport (ORD) in Illinois; and
   x   Hartsfield-Jackson Atlanta International Airport (ATL) in Georgia.

Authorities selected these five airports because DHS identified that more than
94 percent of travelers from the Ebola-affected countries arrived in the United
States at these airports. OHA provided guidance to DHS personnel on
implementing screening and provided training at the five airports. Once the
screening began at these airports, DHS quickly expanded screening for Ebola
to all ports of entry. DHS identified U.S. Customs and Border Protection (CBP)
as the component to perform screening for Ebola at U.S. ports of entry. CBP
reported screening more than 20,000 people between October 2014 and June
2015.


www.oig.dhs.gov                         1                               OIG-16-18
                    OFFICE OF INSPECTOR GENERAL
                        Department of Homeland Security

The Ebola screening process began by identifying travelers who had been to an
Ebola-affected country within the previous 21 days, or had other links to one of
the countries, such as a passport or visa. Identified travelers were then referred
for additional Ebola screening. CBP officers reviewed travel documents,
conducted health-screening interviews, and documented the traveler’s
temperature. In cases where an Ebola risk was identified or where travelers
were exhibiting Ebola-like symptoms, CBP officers referred the traveler to the
CDC for screening.

The CDC screening consisted of an in-depth public health assessment. If no
CDC personnel were on site, the CBP officer was supposed to contact the CDC
Emergency Operation Center for further instruction. The CDC maintained
jurisdiction to determine whether to isolate, quarantine, or issue monitoring
orders for a person entering the United States from an Ebola-affected country.
CBP officers could have been called upon to help enforce such orders or to
provide law enforcement support, if necessary, when transporting a person to a
medical facility. In addition to screening passengers at airports, CBP also
conducted screening at land ports of entry and seaports.

Other DHS components were involved during the Ebola response efforts in
2014 and 2015, including the Federal Emergency Management Agency (FEMA),
the U.S. Coast Guard (USCG), and the Transportation Security Administration
(TSA).

   x   FEMA assisted HHS in interagency planning and facilitated the
       implementation of Ebola screening at the five airports.

   x   The USCG initially assisted CBP with the temperature screening of
       passengers at the five airports previously discussed, until contractors
       were put in place. Additionally, the USCG monitored vessels en route
       from Ebola-affected countries. This monitoring was done by email and
       radio prior to the vessel reaching a U.S. port of entry. If there were
       suspected cases of Ebola onboard maritime vessels, the USCG could
       have been asked to provide transportation for medical personnel or
       perform evacuations. Once in port, the USCG conducted its normal
       inspections for vessels.

   x   TSA coordinated with the CDC to restrict individuals with communicable
       diseases from boarding an aircraft through the “Do Not Board List”
       program. The “Do Not Board List” prevents travelers from purchasing a
       ticket or obtaining a boarding pass. TSA used this list to restrict travel of
       suspected or confirmed Ebola cases. TSA was also responsible for issuing


www.oig.dhs.gov                          2                                OIG-16-18
                   OFFICE OF INSPECTOR GENERAL
                        Department of Homeland Security

      Ebola awareness information with recommended precautionary
      measures to airline carriers.

The final audit in this series will focus on reviewing DHS pandemic
preparedness plans. Results from that audit will appear in a separate report.

                               Results of Audit

Overall, DHS did not ensure sufficient coordination, adequate training, and
consistent screening of people arriving at U.S. ports of entry during its response to
Ebola. Coordination between DHS, HHS, and other DHS components was not
sufficient to ensure all passengers received full screening. Components did not
ensure all personnel received adequate training on the screening process or on
the use of certain protective equipment. Component personnel also did not
always follow established Ebola procedures and ensure all identified
passengers completed required screening.

   x	 For example, CBP officers did not always refer passengers to Ebola
      screening, even when the travelers had self-declared their travel to an
      Ebola-affected country.
   x	 Diplomats, United Nations workers, U.S. Government employees, or
      other dignitaries were not thoroughly scrutinized or were incorrectly
      assumed to be exempt from Ebola screening.
   x	 Passengers with known travel to an Ebola-affected country were not
      properly escorted to Ebola screening when required and departed into
      the U.S. without completing Ebola screening.
   x	 CBP officers did not always receive proper medical clearance from CDC,
      when required, before releasing the traveler.

As a result, some passengers with potential risk of Ebola exposure may have
entered the United States without thorough screening, and the DHS workforce
performing the response was not always appropriately protected.

DHS Ebola Response Coordination

Coordination between DHS and HHS

DHS and HHS did not establish documented roles and responsibilities for
domestic Ebola screening. The memorandum of understanding (MOU) between
DHS and HHS, dated October 2005, established specific cooperation
mechanisms to enhance the Nation’s preparedness against quarantinable and
serious communicable diseases. The MOU was specific to an HHS-initiated


www.oig.dhs.gov                          3	                                OIG-16-18
                   OFFICE OF INSPECTOR GENERAL
                       Department of Homeland Security

response to an influenza threat. However, it did not identify response roles for
initiating the DHS Ebola screening process.

The MOU required DHS to assist HHS during an influenza outbreak, but the
MOU did not include specific operational guidelines for a response to Ebola.
During the Ebola response in 2014 and 2015, the MOU was not updated and
no other formal agreement was documented that explained the roles of DHS
and HHS. The Assistant Secretary for Health Affairs and Chief Medical Officer
reported that although Ebola screening began after consultation and
agreement at the highest levels of government, no formalized agreement was
documented.

DHS established procedures to screen passengers for Ebola at U.S. ports of
entry. These procedures contained roles for CBP and CDC, including obtaining
passengers’ temperatures and transporting sick passengers. Although CBP’s
procedures outlined CDC’s responsibility for arranging transportation, this was
not included in the formal MOU between the agencies. By not determining and
documenting these responsibilities beforehand, the agencies risk missing
necessary precautions or delaying agencies’ response.

Furthermore, CBP headquarters arranged for only contracted personnel to take
temperatures at the five airports where the majority of passengers from Ebola-
affected countries entered the United States. From October 2014 through July
2015, CBP spent more than $4 million for these contractors. Yet, CBP did not
always have contractors in place at other ports of entry to take passengers’
temperatures and did not allow CBP officers to perform the procedure. CBP
released 169 passengers with recent travel to an Ebola-affected country into
the public from October 2014 through June 2015, without ensuring
passengers had their temperatures taken, or were otherwise cleared by health
professionals.

CBP reported 100 percent of travelers it identified as flying directly from the
affected countries went through Ebola screening. While we agree with CBP’s
focus on passengers posing the greatest risk, the 169 passengers identified
above, traveled from one of the affected countries and were not fully screened.
DHS asserted that these passengers presented no overt risk factors and were
released after consultation with CDC or local public health officials. However,
CBP was unable to provide sufficient documentation to substantiate these
passengers were not a risk to the public and should have been excluded from
screening. CBP also conducted a separate review and reported instances where
full screening did not take place and passengers were released without
receiving medical clearance by CDC. Without documentation, we cannot verify
how CBP determined these 169 passengers were not a risk to public health.

www.oig.dhs.gov                         4                               OIG-16-18
                       OFFICE OF INSPECTOR GENERAL
                         Department of Homeland Security

In addition, CBP reported the discovery of multiple errors in CBP Ebola
screening data. CBP attributed these errors to inconsistent understanding,
variances in data entry, and differences in activity summarized by CBP
personnel. As a result, the data is unreliable and CBP cannot determine how
many passengers were not fully screened.

As part of the Ebola screening process, CBP’s procedures required CBP to
depend on local medical personnel to take temperatures at ports where
contractors were not hired. In these instances, CBP officials stated they would
have relied on the CDC to take temperatures. However, CDC officials stated
they did not have sufficient personnel to respond to CBP’s request. The CDC
recommended having passengers take their own temperatures at these
locations, but CBP did not include this in its procedures.

As screening of passengers continued, CBP did not update its screening
procedures to ensure temperatures were taken at locations where CDC would
not respond and contractors were not stationed. Instead, CBP provided
guidance to all ports of entry that allowed passengers to be released without
temperatures being taken. This increased the risk of an infected individual
entering the country.

According to the Assistant Secretary for Health Affairs and the Chief Medical
Officer, “DHS and HHS (including the Centers for Disease Control and
Prevention) are in the process of further clarifying cooperative mechanisms,
which will be memorialized in either annexes to the 2005 MOU or stand-alone
MOUs.”

Coordination between DHS Components

DHS did not establish policies and procedures to ensure coordination between
CBP and USCG for boarding vessels from Ebola-affected countries. CBP
boarded these vessels to conduct Ebola screening, as well as to complete its
normal customs inspections. The USCG also boarded vessels from Ebola-
affected countries to perform inspections as part of enforcing port safety,
security, and environmental regulations. 1 However, the USCG did not require
employees to ensure CBP completed its Ebola screening prior to them boarding
these vessels. At three USCG locations we visited, officials indicated they did
not coordinate with CBP prior to USCG performing their on-vessel work. In its
formal response, the USCG reported CBP did not screen all vessels,
passengers, or crew prior to most USCG boardings. Rather, the USCG relied on
regulations that require vessel operators to report ill passengers.

1   33 CFR § 1.01–30

www.oig.dhs.gov                         5                              OIG-16-18
                     OFFICE OF INSPECTOR GENERAL
                          Department of Homeland Security


In addition, CBP and USCG personal protective equipment (PPE) usage
requirements when boarding vessels from Ebola-affected countries were
inconsistent. The CBP maritime standard operating procedure for Ebola
screening required mandatory use of PPE for all CBP personnel who process
travelers from Ebola-affected countries in accordance with DHS guidance. 2
USCG issued a planning order for Ebola preparedness and response, which
included a risk assessment for PPE usage. 3 For a vessel entering from an
Ebola-affected country, USCG members were not required to wear PPE unless
there was a suspected or known Ebola case. However, according to the USCG,
PPE use depended on the situation and was the responsibility of the
operational commander to make the determination. Unlike CBP, the USCG did
not base the level of PPE protection solely on the vessel’s country of origin.

DHS or component headquarters did not review the level of PPE required for
boarding a vessel from an Ebola-affected country for consistency. As a result,
USCG personnel may not have been equally protected when boarding these
vessels if they boarded prior to CBP completing its Ebola screening. By not
coordinating with CBP to ensure Ebola screening had been completed, the
USCG may have been at a higher risk of exposure to Ebola from either
unreported or unknown sick persons.

Training for Ebola Response

CBP Training on Ebola Screening

CBP did not ensure that all officers conducting Ebola screening received timely
and adequate training on established procedures and use of PPE. Given the
increased risk of potential close contact with those infected with Ebola, training
was needed to protect frontline personnel.

The Department of Labor Occupational Safety and Health Administration
(OSHA) recommended workers show competency in hands-on donning (putting
on) and doffing (removing) of PPE for Ebola response. All CBP officers were
required to take an online Ebola PPE training; however, it did not involve
demonstrating competency in donning and doffing per OSHA’s
recommendation. CBP headquarters identified it had provided hands-on
training for donning and doffing of PPE to 19 ports of entry. However, not all of
the remaining ports that conducted Ebola screening received this training.

2
  CBP, Maritime Environment Standard Operating Procedures – Enhanced Screening of
Passengers with Travel Nexus to Ebola Affected Countries.
3
  Ebola Virus Disease Planning Order Change 1

www.oig.dhs.gov                              6                                      OIG-16-18
                   OFFICE OF INSPECTOR GENERAL
                       Department of Homeland Security


In addition, the training that was provided was not always timely. CBP began
screening for Ebola at five airports in early October 2014, without ensuring
personnel at these airports received sufficient training. Only two of the five
initial airports received in-person training prior to beginning Ebola screening. It
took another month to complete the training at the three remaining airports.
Additional ports did not begin in-person training until 2 months later and, as
previously stated, not all of those personnel received the training. These lapses
put CBP personnel at increased risk of Ebola exposure.

USCG Chemical, Biological, Radiological, and Nuclear Training Oversight

The USCG did not ensure that all applicable employees completed training for
Chemical, Biological, Radiological, and Nuclear (CBRN) protective equipment
needed to safely respond to Ebola. CBRN is specialized PPE used by USCG
members to prevent exposure from potential deadly hazards. USCG determined
that CBRN equipment was the only PPE sufficient to protect members from
Ebola exposure in the maritime environment. The CBRN training was meant to
ensure members could safely use the equipment, including how to properly
don, doff, and decontaminate in a hazardous environment. Without sufficient
training on CBRN equipment, USCG members may not have been adequately
protected when performing USCG’s missions.

USCG headquarters established a requirement for members to complete CBRN
training and delegated oversight of this requirement to local offices. In response
to the 2014 Ebola epidemic, local offices were required to perform audits to
confirm members completed CBRN training. Only one of the three offices we
visited reported having met this requirement; however, the office could not
provide documentation. In addition, USCG headquarters did not verify
completion of these audits and did not perform its own review to determine
whether members met CBRN qualifications. Without overseeing members’
CBRN training qualifications, USCG cannot be sure of its true readiness to
respond to chemical, biological, radiological, or nuclear events, including
Ebola. Table 1 illustrates the number of members lacking CBRN training at the
three Sectors we visited. The records we reviewed also included CBRN training
records from the Sectors’ supporting units. Of the training records we reviewed,
69 percent of USCG members were not current with required CBRN training.




www.oig.dhs.gov                         7                                OIG-16-18
                     OFFICE OF INSPECTOR GENERAL
                          Department of Homeland Security

Table 1: USCG CBRN Training at Local Offices and Supporting Units
       Local Offices      Members Not Current with CBRN Training
 New Orleans                              68/140 (49%)
 Corpus Christi                            92/95 (97%)
 Houston                                   51/70 (73%)
 Overall                                 211/305 (69%)
Source: Office of Inspector General (OIG) analysis of USCG data

USCG provides three types of CBRN training, and members should receive
training on the type of CBRN equipment used at their local office. However, the
USCG training records system did not differentiate between the types of CBRN
training members received. Due to this limitation, USCG could not determine
whether members received the specific training for the type of CBRN equipment
used at each local office. USCG identified this issue as a capability gap and
reported that it is working to better track the type of CBRN training completed.

In response to CBRN training needs, USCG headquarters hired contractors to
provide training at local offices. However, this contract did not provide
sufficient training capacity to ensure all members received the required CBRN
training. Specifically, 450 units were required to receive the Domestic Egress
CBRN training every 2 years. However, USCG’s contract capacity cannot
ensure they meet this requirement. As a result, not all local units will be
adequately trained to use CBRN equipment during a response.

USCG also did not conduct training exercises while using CBRN equipment in
a maritime setting. The CBRN training available to USCG members was limited
to a classroom setting. As a result, members may have been unfamiliar with
the challenges encountered when using CBRN equipment because training did
not occur in conditions experienced when performing missions.

USCG personnel at a port we visited performed a live demonstration of CBRN
in which members had difficulty using the equipment. During the
demonstration, pieces of a CBRN suit fell into the water instead of being
properly disposed. Additionally, a USCG member improperly discarded a mask
rather than following decontamination procedures. Figure 1 shows USCG
members demonstrating the decontamination process for CBRN equipment,
and Figure 2 shows the removal of decontaminated equipment.




www.oig.dhs.gov                               8                        OIG-16-18
                    OFFICE OF INSPECTOR GENERAL
                           Department of Homeland Security

Figure 1: CBRN Decontamination Demonstration




 Source: OIG photographs

 Figure 2: CBRN Removal




 Source: OIG photographs

The USCG identified improvements for its CBRN training program, including
updating its policy to require local offices demonstrate the proper use of CBRN.
Additionally, the USCG is considering incorporating exercises using CBRN in
scenario-based training simulating the real-world environment.



www.oig.dhs.gov                           9                            OIG-16-18
                   OFFICE OF INSPECTOR GENERAL
                        Department of Homeland Security

Implementation of Ebola Response

CBP Compliance with Screening Requirements

CBP officers did not always follow established requirements for Ebola
screening, such as maintaining the recommended distance, wearing required
PPE, and ensuring all necessary passengers completed required screening. CBP
headquarters also did not provide sufficient oversight to ensure screening
requirement compliance. Without sufficient guidance, training, and oversight,
CBP cannot be sure its employees are adequately prepared to protect
themselves from exposure to Ebola.

The DHS Ebola Entry Screening Guidance advises that to the extent feasible,
CBP officers should maintain a distance of not less than 3 feet between
themselves and travelers, absent a physical barrier. In addition, the DHS
guidance outlines the PPE requirements for the Ebola screening intended to
ensure personal protection and minimize risk. Figure 3 shows some of the PPE
used during the CBP Ebola screening process.

     Figure 3: PPE Used During Ebola Screening




     Source: Medscape and CDC websites

During our site visits, CBP officers did not always maintain the distance
recommended by DHS between themselves and travelers from Ebola-affected
countries. Specifically, at three of the airports we visited, CBP officers did not

www.oig.dhs.gov                          10                                OIG-16-18
                   OFFICE OF INSPECTOR GENERAL
                          Department of Homeland Security

keep 3 feet of distance or wear additional PPE when conducting Ebola
screening. According to CBP, although it understands the importance of “safe-
distancing” to minimize potential exposure to a communicable disease,
operational application of a standardized procedure is subject to “real-world”
environmental constraints. The result being that the officer must close the
recommended safe-distance to accomplish the mission objective of escorting
the traveler to an area for isolation. Although CBP Ebola screening procedures
referred to DHS guidance, it did not specify the 3-foot requirement. As a result,
CBP officers may have overlooked this requirement and did not always
maintain the recommended distance or wear additional PPE as required. Figure
4 illustrates the use of PPE during the Ebola screening process.

Figure 4: Ebola Screening Process




Source: CBP photographs

www.oig.dhs.gov                         11                              OIG-16-18
                   OFFICE OF INSPECTOR GENERAL
                       Department of Homeland Security

CBP’s procedures for Ebola screening required mandatory use of PPE for all
CBP personnel who process travelers from Ebola-affected countries. During our
site visits, we found CBP officers did not always use the PPE required for
protection. For example, at two airports, when CBP officers did not maintain 3
feet of distance they were not wearing all the additional PPE required. At
another airport, a CBP officer escorted a passenger to the CDC for additional
screening without wearing the required face shield or non-ventilated goggles. At
several other airports, CBP officers indicated they might not wear the surgical
masks, face shields, or non-ventilated goggles when conducting Ebola
screening unless the passenger appeared symptomatic.

CBP headquarters implemented a Crisis Action Team to lead in the Ebola
response that was in charge of reporting, answering requests for information,
and CDC follow-up. However, CBP headquarters did not provide sufficient
oversight to ensure correct implementation of screening as intended. CBP
headquarters also identified instances where personnel did not always follow
procedures to ensure passengers received Ebola screening when required.
Examples included:

   x   CBP officers did not always refer passengers to Ebola screening, even
       when the travelers had self-declared their travel to an Ebola-affected
       country.
   x   Diplomats, United Nations workers, U.S. Government employees, or
       other dignitaries were not thoroughly scrutinized or were incorrectly
       assumed to be exempt from Ebola screening.
   x   Passengers with known travel to an Ebola-affected country were not
       properly escorted to Ebola screening when required and departed into
       the United States without completing Ebola screening.
   x   CBP officers did not always receive proper medical clearance from CDC,
       when required, before releasing the traveler.

Once CBP headquarters identified these issues, it required field offices to take
corrective actions, including retraining personnel and reviewing and updating
local standard operating procedures to ensure they included requirements for
Ebola screening. However, as previously noted, deficiencies in the Ebola
screening process still existed at the time of our audit field work.

TSA’s Inventory/Purchases of Ebola Response Equipment

In responding to the Ebola threat, TSA made PPE purchases that were
unnecessary. Specifically, TSA made the decision to purchase 500 face shields
at a cost of $1,350 for TSA officers at the five airports where CBP established
Ebola screening. However, TSA was not involved in the screening of travelers

www.oig.dhs.gov                        12                               OIG-16-18
                   OFFICE OF INSPECTOR GENERAL
                       Department of Homeland Security

from the Ebola-affected countries. Therefore, their risk level was essentially the
same as any government employee in a customer service role dealing with the
U.S. public. Furthermore, TSA’s Ebola Screening PPE Assessment determined
that its screening procedures were appropriate for the Ebola response and
personnel did not need additional PPE beyond nitrile gloves. However, the
purchase still occurred and, as a result, TSA has stored the 500 face shields at
airports without an identified need.

                             Recommendations

Recommendation 1: We recommend that the Deputy Secretary of DHS ensure
DHS coordinates with HHS to update the current infectious disease MOU or
create a new formalized document between the Departments that:
   a. is applicable to more infectious diseases than influenza, and
   b. fully outlines the agreed upon roles and responsibilities of each 

      Department and component in the infectious disease response. 


Recommendation 2: We recommend that the Deputy Secretary of DHS ensure
CBP provides all ports of entry with the necessary guidance and resources to
complete required infectious disease screenings, including Ebola.

Recommendation 3: We recommend that the Deputy Secretary of DHS ensure
USCG update its Ebola Virus Disease Planning Order to include coordination
with CBP, specifically ensuring CBP completes its Ebola screening before USCG
boards vessels within 21 days of visiting Ebola-affected countries.

Recommendation 4: We recommend that the Deputy Secretary of DHS ensure
USCG revises training requirements to ensure its required members train in
the use of CBRN equipment within conditions they may experience while
performing missions.

Recommendation 5: We recommend that the Deputy Secretary of DHS ensure
USCG updates its training capacity to meet its CBRN equipment training
requirements within the required timeframes.

Recommendation 6: We recommend that the Deputy Secretary of DHS ensure
USCG establishes CBRN training oversight to ensure all designated members
have met CBRN equipment training requirements.




www.oig.dhs.gov                         13                               OIG-16-18
                  OFFICE OF INSPECTOR GENERAL
                       Department of Homeland Security


Recommendation 7: We recommend that the Deputy Secretary of DHS ensure
CBP updates guidance and screening procedures to consistently outline the
distance recommendations and PPE usage when necessary distance cannot be
maintained during Ebola screening.

Recommendation 8: We recommend that the Deputy Secretary of DHS ensure
CBP enhances its oversight process to ensure that reporting on Ebola
screening is accurate and complete to meet screening requirements.

Recommendation 9: We recommend that the Deputy Secretary of DHS ensure
CBP completes in-person PPE donning and doffing training at the remaining
ports meeting CBP’s risk-based criteria.
Recommendation 10: We recommend that the Deputy Secretary of DHS
ensure components make PPE purchases based on component risks.

Management Comments and OIG Analysis

In its response to our draft report, the Department concurred with all 10
recommendations. The Department identified issues it believed were not
appropriately characterized in the report, which we have addressed below.
During the audit, we reviewed DHS’ response to the Ebola outbreak and the
implementation of Ebola screening. DHS quickly mobilized its response to
Ebola; however, it did not ensure all DHS staff conducting screening had the
necessary training prior to the commencement of the Ebola screening.
Although the screening and monitoring of passengers from Ebola-affected
countries has declined, this report outlines deficiencies within the DHS Ebola
screening process conducted during the Ebola outbreak. These deficiencies
allowed passengers to enter the country without being fully screened and put
DHS screening employees at a higher risk of exposure to Ebola.

DHS worked with the airline carriers and implemented a targeting system to
funnel at-risk passengers from one of the Ebola-affected countries to five
designated airports for Ebola screening. DHS protocols also required Ebola
screening at all other ports of entry, not just those five airports. More than
2,000 passengers arrived at ports other than the five designated airports and
were identified by CBP’s targeting system or other referrals. However, not all
ports received the enhanced Ebola training to conduct such screenings. DHS
identified Ebola screening as the final check in a multi-layered approach in its
response to Ebola. DHS invested significant resources for medical personnel to
take temperatures, PPE, and other expenses. Yet the agency did so without
ensuring adequate and timely training for necessary personnel, consistent
guidance, and appropriate oversight. Although it is not DHS’ mission to

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perform medical screening, it took on the responsibility to assist CDC and
implement Ebola screening procedures as part of the United States domestic
response. DHS should ensure it has provided sufficient training, guidance, and
oversight to the employees involved in the screening process in order to protect
themselves and the United States against the spread of Ebola.

DHS also criticized the OIG’s identification of 169 passengers who did not
undergo full Ebola screening. CBP provided information regarding these
passengers, but could not provide sufficient documentation for us to verify that
the passengers went through full Ebola screening. In addition, CBP identified
inconsistencies and errors in the information entered into CBP’s Ebola
screening reporting tool. As a result, CBP cannot be assured its reporting of
completed Ebola screening is accurate. Furthermore, in a separate review
conducted by CBP, it identified several instances where full screening did not
take place as required.

Recommendation 1: We recommend that the Deputy Secretary of DHS ensure
DHS coordinates with HHS to update the current infectious disease MOU or
create a new formalized document between the Departments that:
   a. is applicable to more infectious diseases than influenza, and
   b. fully outlines the agreed upon roles and responsibilities of each 

      Department and component in the infectious disease response. 


DHS Response: Concur. DHS Headquarters Office of General Counsel, in
coordination with relevant Department components, including the Office of
Health Affairs and CBP's Office of Field Operations (OFO), is working with HHS
to update or replace the current infectious disease MOU, as appropriate.
Estimated Completion Date (ECD): January 31, 2016.

OIG Analysis: The Department’s response to this recommendation addresses
the intent of the recommendation. This recommendation is resolved and will
remain open until the Department provides evidence that DHS and HHS have
updated or replaced the current infectious disease MOU. The Department
should also provide a copy of the new agreement, once implemented.

Recommendation 2: We recommend that the Deputy Secretary of DHS ensure
CBP provides all ports of entry with the necessary guidance and resources to
complete required infectious disease screenings, including Ebola.

DHS Response: Concur. As part of its preparations for the Ebola response,
CBP OFO, in coordination with the CDC, began sending guidelines to CBP
officers in the field regarding the Ebola crisis in West Africa and what to look
for months before Ebola became a significant event in the United States. As the

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outbreak evolved, so did CDC and DHS guidance and training to CBP officers.
The guidance and training information is available via an electronic reference
library and online tutorials for application in current and future infectious
disease response planning and implementation. Supporting documentation
substantiating these actions was previously provided to the OIG. We request
that OIG consider this recommendation resolved and closed.

OIG Analysis: The Department’s response to this recommendation does not
address the intent of the recommendation. This recommendation is unresolved
and will remain open until the Department provides evidence that it has
consolidated and integrated its guidance to ensure consistency and has
provided the guidance to all ports of entry for Ebola screening.

Recommendation 3: We recommend that the Deputy Secretary of DHS ensure
USCG update its Ebola Virus Disease Planning Order to include coordination
with CBP, specifically ensuring CBP completes its Ebola screening before USCG
boards vessels within 21 days of visiting Ebola-affected countries.

DHS Response: Concur. The USCG Deputy Commandant for Operations and
Deputy Commandant for Mission Support have already initiated an update to
the Ebola Virus Disease Planning Order and established a February 2016 target
to review, update, and promulgate a revised planning order. In the interim
period before the revised planning order is released to the field, the USCG will
continue to exercise its proven risk-based assessment methodology to protect
its workforce.

The August 2015 USCG Office of Commercial Vessel Compliance monthly Port
State Control (PSC) message recommended that USCG PSC examiners
coordinate with CBP prior to conducting any PSC examination on a vessel that
visited an Ebola-affected country within its last five ports of call prior to
arriving to the United States.

In 2014, more than 79,000 foreign vessels arrived in the United States. During
the West African Ebola outbreak, less than 1 percent (200) of those vessels
arriving in the United States had visited an Ebola-affected country within its
last five ports of call.

Additionally, the majority of these arrivals were made after an oceanic voyage
greater than the 21-day monitoring period as established by the CDC. USCG
agrees that DHS should continually improve on unity of effort across the
Department’s components. DHS has established a "Unity of Effort" initiative in
its 5-year strategic plan. The initiative is designed to improve overall


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cooperation to best identify, investigate, and interdict any threat as early as
possible.

The USCG has already implemented a significant framework of collaboration
with other DHS Components to support key areas of effort to ensure the safety
and security of the maritime transportation system. This effort also supports
state, local, tribal, territorial, and regional governments while working closely
with non-governmental organizations and the private sector to help leverage
the resources they can bring to bear. The USCG will continue to leverage its
Command Centers, Area Maritime Security Committees, Area Committees
Intelligence community, liaison officers, and a contingent of skilled,
professional, and dedicated uniformed service members to ensure the highest
level of inter-department collaboration. ECD: March 31, 2016.

OIG Analysis: The Department’s response to this recommendation addresses
the intent of the recommendation. This recommendation is resolved and will
remain open until the Department provides evidence that the USCG has
revised its Ebola Virus Disease Planning Order and a copy of the new planning
order, once implemented.

Recommendation 4: We recommend that the Deputy Secretary of DHS ensure
USCG revises training requirements to ensure its required members train in
the use of CBRN equipment within conditions they may experience while
performing missions.

DHS Response: Concur. The USCG Office of Specialized Capabilities (OSC) will
include revised training and exercise requirements in a pending major revision
of USCG CBRN Policy. USCG has already developed specific competencies and
tasks related to CBRN PPE training. ECD: November 30, 2016.

OIG Analysis: The Department’s response to this recommendation addresses
the intent of the recommendation. This recommendation is resolved and will
remain open until the Department provides evidence that the USCG has
revised and implemented its USCG CBRN Policy to allow USCG personnel to
train in CBRN equipment within the conditions they may experience while
performing missions.

Recommendation 5: We recommend that the Deputy Secretary of DHS ensure
USCG updates its training capacity to meet its CBRN equipment training
requirements within the required timeframes.

DHS Response: Concur. The USCG Maritime Law Enforcement Academy’s
Force Command will assess and modify training support contracts to increase

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the output in response to the Ebola Virus Disease Planning Order, as
appropriate. USCG has already developed specific competencies and tasks
related to CBRN PPE training. ECD: November 30, 2016.

OIG Analysis: The Department’s response to this recommendation addresses
the intent of the recommendation. This recommendation is resolved and will
remain open until the Department provides evidence that the USCG has
modified its support contracts to increase training capacity to meet CBRN
training requirements.

Recommendation 6: We recommend that the Deputy Secretary of DHS ensure
USCG establishes CBRN training oversight to ensure all designated members
have met CBRN equipment training requirements.

DHS Response: Concur. The USCG OSC has already developed specific
competencies and tasks related to CBRN PPE training and individual personal
competencies are documented in USCG's new training management system in
order to track individual and unit readiness. ECD: February 29, 2016.

OIG Analysis: The Department’s response to this recommendation addresses
the intent of the recommendation. This recommendation is resolved and will
remain open until the Department provides evidence that the USCG has
implemented revisions to its training management system in order to track
individual and unit CBRN training requirements.

Recommendation 7: We recommend that the Deputy Secretary of DHS ensure
CBP updates guidance and screening procedures to consistently outline the
distance recommendations and PPE usage when necessary distance cannot be
maintained during Ebola screening.

DHS Response: Concur. CBP OFO has already provided sufficient guidance to
officers regarding the screening protocols, as well as scientifically factual
information on Ebola. DHS guidance does not mandate a single distance
requirement for all operational biological threat situations. DHS and CBP
Ebola-specific guidance recommends a distance of 3 feet, if feasible, between
employee and traveler, which aligns with CBP's Standard Operating Procedures
for Serious Communicable and Quarantinable Diseases guidance of 6 feet or as
directed, based on CDC guidance. The risk of infection for Ebola was low in the
non-febrile individuals, and there was interagency support for CBP’s decisions
on distancing in the airports. Supporting documentation substantiating these
actions was previously provided to OIG. We request that OIG consider this
recommendation resolved and closed.


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OIG Analysis: The Department’s response to this recommendation does not
address the intent of the recommendation. This recommendation is unresolved
and will remain open until the Department provides evidence that CBP has
updated guidance and screening procedures to consistently outline the
distance recommendations and PPE usage when necessary distance cannot be
maintained during Ebola screening.

Recommendation 8: We recommend that the Deputy Secretary of DHS ensure
CBP enhances its oversight process to ensure that reporting on Ebola
screening is accurate and complete to meet screening requirements.

DHS Response: Concur. In November 2015, CBP OFO established a working
group to create the oversight procedures described in this recommendation.
According to the draft report, data provided by CBP indicate that 169
passengers with recent travel to an Ebola-affected country, who had arrived at
outlying ports, were admitted into the United States without ensuring their
temperatures were taken or otherwise being cleared by health professionals.
CBP conducted an internal review of source documentation from the ports of
entry for each of the passengers the audit team identified and established that
these 169 travelers had been properly admitted after being evaluated by CBP
officers and categorized as having:

      ‡	 no identifiable risk under CDC policy,
      ‡	 already been entered in CDC’s health monitoring system,
      ‡	 been deemed by CDC as not needing to have their temperature
         recorded, or
      ‡	 been declined by the host nation public health authority to have their
         temperature taken at a preclearance site.

The review also found there were inconsistencies and errors in the manual
transcription of source traveler admission data into CBP’s data reporting tool,
which may have contributed to a lack of clarity regarding the evaluation of
these passengers, and CBP is making changes to improve the quality of this
data through more robust collection processes. Specifically, OFO will
implement a monthly data quality review to assure data integrity and accuracy
of reporting. This data review will assist OFO with identifying any screening
requirement deficiencies and establishing corrective actions as needed. ECD:
December 31, 2015.

OIG Analysis: The Department’s response to this recommendation addresses
the intent of the recommendation. This recommendation is resolved and will
remain open until the Department provides evidence that CBP has enhanced
its oversight process to ensure that reporting on

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Ebola screening is accurate and complete to meet screening requirements.

Recommendation 9: We recommend that the Deputy Secretary of DHS ensure
CBP completes in-person PPE donning and doffing training at the remaining
ports meeting CBP’s risk-based criteria.

DHS Response: Concur. CBP OFO provided detailed training and appropriate
protective equipment to its officers conducting enhanced Ebola screening, and
developed additional online training resources for all CBP employees. CBP
worked closely with the CDC to ensure appropriate guidelines and PPE were
distributed to the field. CBP delivered hands-on enhanced screening training to
approximately 4,500 officers at 25 airports and distributed screening guidance
to all domestic and preclearance ports of entry. More than 36,000 CBP officers,
agents and employees completed formal Ebola screening and PPE training.
Additionally, all officers have standard “universal precautions” infection control
training. As a result, not a single DHS employee contracted Ebola in the course
of their duties.

In November 2015, CBP OFO conducted a review of all ports of entry using
CBP “risk based criteria” as defined in the Ebola Training Plan dated November
20, 2014. CBP has determined its risk-based criteria to be those port of entry
airports that have had three or more travelers who entered a U.S. port of entry
airport from an Ebola-affected country within the past 21 days would require
hands-on training. This “risk-based criteria” was defined by the CBP Office of
Human Resources Management (HRM), Office of Safety and Health, the CBP
Medical Advisor, and OFO.

Additionally, per the training, PPE needs to be donned and doffed when:
      ‡ a 21-day nexus has been established with a traveler,
      ‡ a traveler is symptomatic, and
      ‡ the officer is within 3 feet of the traveler during the traveler’s
      examination by medical personnel.

CBP identified nine airports that meet the “risk based criteria” threshold as
defined by the Ebola Training Plan, and an HRM Occupational Safety and
Health safety specialist will provide hands-on training at each of those nine
locations. ECD: June 30, 2016

OIG Analysis: The Department’s response to this recommendation addresses
the intent of the recommendation. This recommendation is resolved and will
remain open until the Department provides evidence that the CBP has
completed in-person PPE donning and doffing training at the remaining ports
meeting CBP’s risk-based criteria.

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Recommendation 10: We recommend that the Deputy Secretary of DHS
ensure components make PPE purchases based on component risks.

DHS Response: Concur. As required by the DHS Pandemic Workforce
Protection Plan, Component and Headquarters (HQ) Occupational Safety and
Health Managers, and where available, Medical Officers, will coordinate to
perform a mission-based pandemic risk assessment once the overarching
disease-specific risk assessment guidance is received from the DHS HQ Office
of the Chief Human Capital Officer. Subsequent purchases of PPE will be based
on the results of the risk assessments across the Department and will reflect
the unique environments in which the components operate. To further
strengthen this requirement and clearly state the need to base PPE purchases
on risk assessments, the requirement was specifically highlighted in the DHS
Integrated Logistics Support Plan (ILSP), published by the HQ Office of the
Chief Readiness Support Office in July 2015.

The ILSP represents the specific pandemic PPE purchasing guidance that all
components are now required to follow. Supporting documentation
substantiating these actions was previously provided to OIG. We request that
OIG consider this recommendation resolved and closed.

OIG Analysis: The Department’s response to this recommendation does not
address the intent of the recommendation. This recommendation is unresolved
and will remain open until the Department provides evidence that components
will make purchases based on component risks. The Department implemented
component risk assessments; however, there is no assurance that components
make purchases based upon the risks identified. Once the Department can
provide evidence that it has implemented assurances to ensure components
have implemented purchase plans aligned with risk assessments, OIG will
review this recommendation for resolution and closure.




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Appendix A
Objective, Scope, and Methodology

The Department of Homeland Security Office of Inspector General was
established by the Homeland Security Act of 2002 (Public Law 107ï296) by
amendment to the Inspector General Act of 1978. This is one of a series of
audit, inspection, and special reports prepared as part of our oversight
responsibilities to promote economy, efficiency, and effectiveness within the
Department.

The objective of our review was to determine whether DHS has effectively
implemented DHS’ screening measures for a response to the Ebola outbreak.
To achieve our objective, we reviewed applicable Federal laws, regulations,
guidance, and the DHS memorandum of understanding with HHS. In addition,
we reviewed applicable DHS policies and procedures for Ebola screening and
identified the specific screening requirements. We identified the offices and
components responsible for the Ebola response coordination, planning, and
implementation. The audit covered DHS’ Ebola response planning and
screening efforts from April 2014 through June 2015.

We interviewed DHS officials within the Directorate for Management, the Office
of Health Affairs, and the eight operational components to determine their role
in the Ebola response. Specifically, we met with component officials from CBP,
FEMA, U.S. Immigration and Customs Enforcement, TSA, USCG, National
Protection and Programs Directorate, U.S. Citizenship and Immigration
Services, and U.S. Secret Service. We met with component officials at field
locations for CBP, TSA, and USCG. We also met with personnel from HHS.

To determine whether the Ebola screening requirements were always met, we
reviewed CBP’s guidance and created a data collection instrument to assist in
documenting compliance at airports where screening was observed. We visited
and met with CBP at the five airports first set up to conduct Ebola screening
and observed screening at three of the five:

   x   John F. Kennedy International Airport (JFK) in New York;
   x   Washington-Dulles International Airport (IAD) in Virginia;
   x   Newark Liberty International Airport (EWR) in New Jersey;
   x   Chicago O’Hare International Airport (ORD) in Illinois; and
   x   Hartsfield-Jackson Atlanta International Airport (ATL) in Georgia.

In addition, we met with CBP and USCG at other ports of entry to determine
how personnel were implementing Ebola screening at those locations. We


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selected these additional locations based on the number of travelers from an
Ebola-affected country and concerns identified by CBP. We met with CBP at the
following domestic and international preclearance airport locations:

   x   Philadelphia International Airport, Philadelphia, PA;
   x   Miami International Airport, Miami, FL;
   x   Los Angeles International Airport, Los Angeles, CA;
   x   San Francisco International Airport, San Francisco, CA;
   x   Montreal Trudeau International Airport, Dorval, Quebec, Canada; and
   x   Toronto Pearson International Airport, Toronto, Ontario, Canada.

We also met with CBP at the Champlain, NY, land border station.

To determine whether DHS established procedures to ensure coordination
between components for maritime activities involving vessels from Ebola-
affected countries, we met with CBP and USCG at the following seaport
locations:

   x   New Orleans, LA;
   x   Houston, TX;
   x   Corpus Christi, TX; and
   x   Point Comfort, TX.

To determine whether DHS employees received timely and adequate training,
we assessed whether components had created training plans. We evaluated the
guidance issued on Ebola screening and reviewed training records. We
assessed component oversight by determining how component headquarters
tracked and monitored training. Finally, we evaluated the effectiveness of the
trainings by observing DHS employees perform the skills covered by trainings.

TSA does not have a primary role in the DHS Ebola response efforts; however,
we met with TSA during our site visits to determine its role in Ebola response
and as part of our ongoing audit of DHS pandemic workforce protection plans.

We relied on components to provide data regarding data on travelers from
Ebola-affected countries and the data on training records. We determined these
data were sufficient and adequate for the purposes of meeting our audit
objective.

We conducted this performance audit between November 2014 and July 2015
pursuant to the Inspector General Act of 1978, as amended, and according to
generally accepted government auditing standards. Those standards require


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that we plan and perform the audit to obtain sufficient, appropriate evidence to
provide a reasonable basis for our findings and conclusions based upon our
audit objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based upon our audit objectives.




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Appendix B
DHS Comments to the Draft Report




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Appendix C
Office of Audits Major Contributors to This Report

Brooke Bebow, Director
Stephanie Christian, Audit Manager
Ruth Gonzalez, Auditor-in-Charge
Gary Crownover, Program Analyst
Megan McNulty, Program Analyst
Matthew Noll, Program Analyst
Sabrina Paul, Program Analyst
Melissa Woolson Prunchak, Program Analyst
Kevin Dolloson, Communications Analyst
April Evans, Referencer
Priscilla Cast, Referencer




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Appendix D
Report Distribution

Department of Homeland Security

Secretary
Deputy Secretary
Chief of Staff
General Counsel
Executive Secretary
Director, GAO/OIG Liaison Office
Assistant Secretary for Office of Policy
Assistant Secretary for Office of Public Affairs
Assistant Secretary for Office of Legislative Affairs

Office of Management and Budget

Chief, Homeland Security Branch
DHS OIG Budget Examiner

Congress

Congressional Oversight and Appropriations Committees




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