Press Briefing Transcript

Anthrax Update:
Telebriefing Transcript

October 29, 2001

CDC MODERATOR: Thank you, Therese.

Welcome to this conference call. I'd like to introduce to you Dr. Bradley Perkins. He is one of our leading anthrax specialists here at CDC. I'll spell the name for you. That was B-r-a-d-l-e-y. Last name Perkins, P-e-r-k-i-n-s. Dr. Perkins is going to be providing a few comments to you, providing an update on where things stand in regards to various anthrax investigations going on around the country, and also is going to be sharing with you his insights as to how an epidemiologic investigation is conducted. Dr. Perkins was one of the first individuals on the ground in Florida from the CDC and is prepared to share with you some pretty useful insight into how we conduct these investigations. And then after his comments, we'll open it up for Q&A to be moderated by Therese.

Dr. Perkins.

DR. PERKINS: Thank you, Tom.

CDC continues to work with state and local health departments and other federal agencies to conduct public health investigations around the recent bioterrorism attacks using Bacillus anthracis spores sent through the mail. CDC has sent dozens of epidemiologists, laboratory scientists and other program staff to Florida, New York City, Washington, D.C., and New Jersey, to assist local health professionals in conducting these investigations.

Currently CDC has more than 50 laboratory scientists in Atlanta, working around the clock to process hundreds of specimens being received in Atlanta by CDC. CDC has set up in Atlanta a 24-hour a day operations center equipped with state-of-the-art communications equipment to help staff coordinate these public health investigations. The operations center includes a public inquiry phone bank, as well as one for health professionals, where staff are receiving hundreds of calls a day.

I'd like to take this opportunity to remind everyone of a few really important points about anthrax. First of all, to remind you that it is not contagious, it cannot be transmitted from person the person. The strain of Bacillus anthracis identified in conjunction with the New York City, Florida, D.C. and New Jersey investigations is a naturally-occurring strain and responds to all antibiotics in a characteristic way for Bacillus anthracis.

CDC continues to work closely with the U.S. Postal Service to better understand the circumstances around the exposure that has led to a number of workers becoming ill, apparently as a result of occupational exposures. CDC has published interim guidelines to help protect postal workers, and the agency continues to provide risk assessment evaluations to the Postal Service.

Based on current scientific information, CDC believes that the risk to the general public of getting anthrax from a piece of mail is very small. If someone receives a suspected package, they should put it down, wash their hands, and call local health and law enforcement officials.

As CDC learns of an emerging situation involving a possible exposure to anthrax, the agency will work with state and local health departments and other federal agencies on an appropriate response.

CDC MODERATOR: And let me just take this opportunity--this is Tom Skinner--to bring everyone up to speed on the case count. We're still at 13 as of this morning, two cases in Florida, three cases in New York City, three cases in New Jersey, and five cases in Washington, D.C. And with that, Dr. Perkins will share with you a few of his insights of what it's like to conduct one of these investigations in the field.

DR. PERKINS: Again, just to clarify my position at CDC, I lead the branch at CDC that has primarily technical responsibility for both epidemiologic and laboratory aspects for Bacillus anthracis and anthrax disease. I led the Florida investigation. And many of the management techniques and the investigatory techniques that are being used in the other investigations are similar to the strategies we used in Florida.

We're being confronted with a number of different and unique situations. In Florida we started with the occurrence of a single sporadic case on inhalational disease without any evidence, at least initially, of transmission through the mail.

In New York City we were presented with a situation where we had a confirmed positive letter in the presence of cutaneous disease.

And in Washington, D.C., that investigation began with a confirmed positive letter, and exposure around that letter in the absence of any disease initially.
However, all of these investigations are being approached with traditional public health strategies, and as soon as people get on the ground, there's a two-pronged effort that is immediately put in place. The first is to completely investigate either the case or the circumstances of a confirmed exposure to Bacillus anthracis. The second strategy is to begin the conduct of intensive surveillance to identify any cases of inhalational or cutaneous anthrax disease.

As those investigations begin, we try to bring information together from both of those arms of the investigation to develop and deliver, as early as possible, appropriate public health intervention. In this setting, in this situation, that intervention has been basically to rapidly characterize at-risk populations and put them on appropriate post-exposure prophylaxis using a variety of antibiotics in an effort to prevent the development of inhalational disease.

As soon as we get to that point, the management and the structure of the investigation usually evolves, and it evolves into at least 5 different teams that coordinate various aspects of the intervention--or of the investigation.

The first team that most of the investigations have used is an intervention team that basically monitors all aspects of the delivery and follow up of the antibiotic that's used in the intervention. These are the people that make sure that the appropriate people are identified, that they get in and they receive antibiotics.

The second team is a surveillance team looking for case.

The third is a clinical team, which has been led by infectious disease specialists. And the function of the clinical team is to go out and rapidly assess any case that's revealed by surveillance activities that has any likelihood of being associated with anthrax.

The fourth team is an environment assessment team, that basically coordinates the sampling of environments associated with the investigation for Bacillus anthracis, and coordinates the movement of those samples to appropriate laboratories.

And then fifth, we've sort of broken off an epidemiology team that tries to pull this all together. The leader of the team, who was myself in the case of Florida, is basically faced with a complicated set of activities that includes management of these teams, communication with local, state, public health authorities, as well as CDC, with media, community and political leaders, with coordinating participates with the FBI and the Postal Service, and also making sure that laboratory testing is going okay and those results are being merged with the investigation in as rapid a time as possible, and that as new information becomes available, it's incorporated into the overall direction of the investigation.

With those comments, I'll go ahead and stop.

CDC MODERATOR: Therese, I think we're ready for questions.

AT&T MODERATOR: Certainly. Ladies and gentlemen, if you wish to ask a question, please depress the "1" on your touch-tone phone at this time. You may hear a tone indicating that you have been placed on queue, and you may remove yourself from that queue at any time by depressing the pound key. If you're on a speaker phone, you may need to pick up your handset before pressing the numbers.

And our first questions come from Megan Garvey from "Los Angeles Times." Please go ahead.

MS. GARVEY: Yes. Dr. Perkins, I wanted to ask you about the possibility of these other letters, which now I think almost everyone believes there must be more letters that have gone undetected. How would these letters be found if they were missing the telltale signs of the letters we already know about, if they did not have the black letters or a threat, an explicit threat in the text?

DR. PERKINS: That's a good question. I mean, obviously, we're using the epidemiologic investigation to generate hypotheses to explain all circumstances of disease and possible exposure. One of the hypotheses that we're working with is that there are letters that went through the mail system that we do not yet know about.

One of the techniques that's being used by FBI and CDC is, in instances where it's possible to recall mail that there's a possibility may have contained a contaminated letter, that that mail is being recalled, and intensively evaluated by FBI.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Thank you. And our next question comes from the line of [inaudible] Borenstein [ph] from Knight-Ridder Newspaper. Please go ahead.

MR. BORENSTEIN: Yes, Dr. Perkins. What I'm trying to understand is if the Post Offices--the mail rooms downstream of Brentwood, such as Justice, State, Supreme Court, have been tested environmentally and have gotten traces, which of course I understand isn't enough for inhalation anthrax, why is there not the theory that there are traces out there in residences who also get their mail from Brentwood? And on the other hand, could these traces be naturally occurring traces that have been there for a long time and we just didn't know it?

DR. PERKINS: We know a fair amount about the epidemiology of anthrax in the United States, you know, over essentially the last hundred years, and we know that throughout the sort of Mississippi River delta that there are foci of environmental contamination with anthrax spores.

There have been several anthrax outbreaks in animals over--just over the last couple of years. Those environments, they're outside environments, do become contaminated with anthrax spores, yet we know that that does not represent a risk to people that live and work daily in those environments.

So there is--there is one example of a safe level of environmental contamination with anthrax spores in those environments. What we don't have very much experience with is--is determining safe levels of anthrax spore contamination in public buildings or office spaces where we traditionally would not recognize, you know, as a place that usually has anthrax spores, although--although that has not been intensively studied, and there may be some normal background level of spores even in those environments.

One of the challenges we're facing currently, when--when new environmental positives are discovered in the absence of any associated disease is trying to describe the risk that those circumstances pose. And while we may understand the extremes of that risk so that heavily contaminated mail rooms, for example, may represent a risk for inhalational disease, and very low levels of contamination, we think, do not represent a risk of disease at all, it's--it's that area, that spectrum in between those two extremes that--that is--is the most challenging aspect of making good public health recommendations currently.

MS. BORENSTEIN: Can I follow up on the first part of those? What about the idea of homes? Why aren't they being tested and people on Cipro if they also get their mail from the same place?

DR. PERKINS: To date the epidemiology suggests that the cases that have occurred have not occurred as a result of exposure in home settings. And that's why we're not focusing on them at the current time. If the epidemiology changes, we will--we will change along with that epidemiology.

CDC OPERATOR: Next question, please.

AT&T OPERATOR: Thank you. And our next question comes from the line of Kyoshi Ondo from Nikkai Newspapers. Please go ahead.

MR. ONDO: Hi. I'd like to ask about, you mentioned about--that we don't have to worry too much at the homes, but in the meantime, in most of the post offices they are recommended to wear gloves and masks, and I think they were saying they were waiting for CDC to show what types of gloves and masks for them to wear, and they are saying the approval is very behind the schedule. I was wondering whether it is really worthwhile doing that at all, first of all, and also whether you are planning to show some sort of approval for certain types of gloves and masks which possibly could be used at residential--at the homes, not only at the post offices.

DR. PERKINS: Yes. We are working intensively with the U.S. postal system in the development of CDC interim recommendations for protecting mail handlers that include a variety of--of--of recommendations, including engineering controls in mail facilities, housekeeping controls, and--and personal protective equipment for workers handling mail. Gloves are included in those recommendations, and a variety of--of masks or respiratory protection strategies are described in that--in that document that basically vary by the kinds of activities the postal workers do. We can get those recommendations to you. They're in the final stages of approval by the--the U.S. postal service.

CDC OPERATOR: Next question, please.

AT&T OPERATOR: Thank you. And our next question comes from the line of Jim Hopkins from NBC News. Please go ahead.

MR. HOPKINS: Thank you very much. Can you hear me okay?

DR. PERKINS: Yes.

MR. HOPKINS: Okay. I want to just follow up on what you said about the FBI attempting to recall the mail. Are there specific pieces of mail that you are aware of that they are trying to bring back? How are they going about that?
And secondly, I wanted to ask you about spore size on the Daschle letter. We've heard all sorts of figures. Do you have an updated figure on how large the spores are?

DR. PERKINS: Yeah. I--I really can't comment on either of those questions as they are part of the active criminal investigation.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Thank you. And our next question comes from the line of Hasta Robertson from "Boston Globe." Please go ahead.

MS. ROBERTSON: Hi, Dr. Perkins. I wanted to ask you what is the impact of so many people in once concentrated area, and that means Washington, D.C., and also New York, on antibiotics, and has there ever been in our history, ever been a time when so many people have been on antibiotics?
And a second part of my question is: what are the side effects of Cipro?

DR. PERKINS: Right. That's a good question. And we have some, I think, some important thoughts on that area.

First of all, all of you recognize that in the October 19th issue of the MMWR, that we recommended the use of ciprofloxacin or doxycycline in this situation as first-line therapies for post-exposure prophylaxis for prevention of inhalational anthrax.

Since that time the number of people given prophylaxis are identified as being at risk for development of disease and recommended for chemo prophylaxis has increased dramatically up through tens of thousands at the present time.

And there's important public health implications of having that large a number of people on particular antibiotics. Our major concern at this point is that ciprofloxacin represents a class of drugs known as floraquinolones [ph]. It's a relatively new class of drug, and it's a class of drug that's used for empiric treatment of a variety of serious and common infections in the United States. And when I say "empiric" I mean that it's used by doctors when they don't yet have information on antimicrobial susceptibility of the organism. It's used frequently for empiric treatment of pneumonia, gastrointestinal infections and urinary tract infections.

The potential consequences of having this large a number of people on a floraquinolone is that we may limit the time that we're able to use the floraquinolones as empiric therapy for these important infections diseases. So that, you know, other bacteria that people are carrying may develop resistance to ciprofloxacin. For that reason we're moving more strongly to use of doxycycline in this particular situation where we know that the strains we've been dealing with are susceptible to doxycycline. We have less concerns about the emergence of new resistance to doxycycline because it's less frequently used as empiric compared to the floraquinolone class of drugs.

DR. : And let me just follow up in saying that both Cipro and doxy are effective first-line drugs for post-exposure prophylaxis, so just want to make sure that we're clear on that.

MS. ROBERTSON: Can you tell me have we ever had--has there ever been a time in history where we've had such a concentrated--so many people in one concentrated area like Washington, 10,000 people, on antibiotics? Has it ever happened before?

DR. PERKINS: There have been examples in the past of large-scale antibiotic use in efforts to try to eliminate infectious diseases, but this is an example--certainly in terms of recent times, this is a unique situation in terms of numbers of people put on antibiotics.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Thank you. And our next question comes from the line of Michael McCarthy from the "Lancet Journal." Please go ahead.

MR. McCARTHY: Hi, Dr. Perkins. I have two questions. Yesterday in your telecast to the Infectious Disease Society of America, Dr. Hughes said there were 19 cases, and that doesn't jive with Tom Skinner's numbers. Is that because Hughes was including suspected cases?

DR. PERKINS: That's correct. He was including suspected and confirmed cases. And the reason for that is that we thought it was important to get out all the information we had to that group of infectious disease clinicians.

MR. McCARTHY: And my second question is: there was a report on CNN and I think in "New York Times" that doxycycline was now being recommended as the drug of choice, but I didn't find any changes in the guidelines on the Web. Is that accurate?

DR. PERKINS: There are compelling public health reasons to consider doxycycline as a better choice in the current situation when we have tens of thousands of people on that drug. And again, the reasons for that is that we would like to preserve the utility of the floraquinolone, ciprofloxacin, for the use in empiric treatment of other infections. We think that's less of an issue with doxycycline, and in terms of the ability to prevent the development of inhalational anthrax, we would consider them equivalent.

CDC MODERATOR: This is Tom Skinner. I think there has been some confusion with the use of the term "drug of choice." And I think it's important that we make clear to you all today that both Cipro and doxy are recommended as first-line drugs for post-exposure prophylaxis. However, Dr. Perkins has alluded to the fact that we have a large number of individuals on Cipro, and that to preserve the use of Cipro in other infections, we're hoping to see more individuals be put on doxy as a first-line--as a first-line defense in a post-exposure prophylactic setting.

MR. McCARTHY: Would it be fair to say that given that caveat in the preference for doxycycline, given the public health concern, that the guidelines in the last MMWR still stand?

CDC MODERATOR: You know, we referred to those as interim recommendations. When those were published, they were referred to as interim recommendations. So that--you know, the term interim means that there is a possibility that they can be, you know, changed or elaborated further on.

DR. PERKINS: I mean in terms of prevention of inhalational anthrax, those guidelines stand. In terms of public health implications on the treatment of other infectious diseases, I would characterize them as evolving as the number of people has increased dramatically since these were published on the 19th, the number of people identified for treatment.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Thank you. And our next question comes from the line of Elizabeth Cohen from CNN. Please go ahead.

MS. COHEN: Hi there. This is actually a follow up to the one that was just asked. I completely understand the theory of doxy and Cipro being just as useful. What I'm having trouble figuring out is the practice. Does this mean that starting today, if someone shows up who's in one of these risk groups and needs to be put on an antibiotic, you'll give them doxy, or you'll give them a choice, or how does that work, the practice of it?

DR. PERKINS: There are a variety of things that are going to go into those decisions. I mean, and the circumstances, the epidemiologic circumstances surrounding that particular incident will be the main driver, as well as individual decisions regarding side effect profile, pregnancy status and so on.

MS. COHEN: So as I understand it--and you tell me if I've got this wrong--but if I understand it, to this day, to this moment in time as we're speaking, the only thing that's being given out has been Cipro. Doxy has not been given out yet? Or if it has, has it been given out 50/50 with Cipro, or 1 out of every 600 people get it, or approximately what would those numbers be?

DR. PERKINS: You know, since we've known the antibiotic susceptibilities of this organism, both ciprofloxacin and doxycycline have been given out. And it's been drive by the circumstances and individual issues at the time the antibiotics are distributed.

MS. COHEN: So would Cipro been--do you folks do the actual handing out or do local authorities do the handing out?

DR. PERKINS: Yeah. It's a combination. In many of these instances the National Pharmaceutical Stockpile has been the source of the antibiotics, and we provide consultation and some support to local and state public health facilities in distributing those antibiotics. Go ahead.

MS. COHEN: So what would be the most accurate way for us to report this? Would it be that you are giving out 50/50 doxy and Cipro, or Cipro except when people have problems with Cipro and then they get doxy, or you want to move to a 50/50 situation? I can't figure out what actually is happening and has happened on the ground.

DR. PERKINS: Let me tell you a couple of things. The stockpile is designed to start with a initial treatment with ciprofloxacin and move to doxycycline as susceptibility of organisms are determined. I mean that's one starting point, and those decisions have been made in the past, and those recommendations stand, and that's the way the stockpile is designed.
In this situation we have information about the susceptibility of the organisms that we've seen to date, so in situations where--new situations where the organism is thought to have or is confirmed to have the same susceptibility, starting with doxycycline, given the number of people that are currently on treatment, would be reasonable and--and, you know, at this point perhaps the preferred way to start. But I would caution--caution you in interpretation of that because if we have a completely new situation where we don't know, where we have reason to suspect that the isolate may be a different isolate and we haven't confirmed susceptibilities yet, we may very well recommend that Ciprofluoxicine be used until we confirm susceptibilities.

CDC OPERATOR: Next question, please.

AT&T OPERATOR: Thank you, and our next question comes from the line of Marcus J. Smith of Postal World. Please go ahead.

MR. SMITH: Yes, Dr. Perkins, I write for those people who handle the mail on receipt at corporations and government and university locations. And it's the question of cross-contamination that's of greatest concern at the moment.
Have you run any tests to isolate what may be causing cross-contamination such as, for instance, the gentleman had asked before about residences. Residents receive actual envelopes, but they generally don't deal with mail trays or sacks. The gentleman who got sick at the State Department, if he was working at the loading dock, would have dealt with both.

Is there a chance that the mailing equipment, the mail transport equipment, because it is larger, or in the case of sacks much more textured, could hold far more spores and therefore be a source of medically significant anthrax spores, whereas envelopes themselves, not being especially charged and therefore attracting more spores, would be less likely, and therefore that's why we haven't had any problems with any residences?

DR. PERKINS: Yeah, I--I think those are all good observations. The--I mean we are working very hard to try to characterize, you know, the distribution of environmental contamination associated with the cases that have occurred, as well as trying to quantitate the amount of contamination, and those are two important aspects. And obviously when you talk about what's done with pieces of equipment and how those pieces of equipment could be involved in generation of an aerosol as a result of contamination, are all critical things that we're looking at and looking for in the epidemiologic investigation.
You brought up, you know, this idea of bags being contaminated and bags being thrown around or handled roughly in a way that spores might be aerosolized and, you know, that's a potential concern and we are actively investigating that sort of thing.

MR. SMITH: Any results at this point, sir?

DR. PERKINS: You know, the--the main result at this time appears to be the association with high speed automated sorting machines in mail handling facilities, and beyond that, it's hard to draw any clear conclusions.

CDC OPERATOR: Next question, please.

AT&T OPERATOR: Thank you. Our next question comes from the line of C.C. Connelly with The Washington Post. Please go ahead.

MS. CONNELLY: Hi. Thank you. I wanted to--two questions. First is could you help clarify a little bit what sort of environmental testing is taking place, and how those decisions are being made? Is that a CDC call to start prioritizing? You've spoken about both upstream and downstream. I'm wondering if you can tell us a little more clearly who's making those decisions and what exactly the testing is, especially with respect to the truckloads of mail that we understand has gone to or is on the way to Ohio? Is that mail also going to be tested by the CDC?

And in Florida, I want to know if you can be certain that Mr. Stevens was indeed your first case, or is it possible that someone may have expired there or elsewhere before you knew you were dealing with anthrax?

DR. PERKINS: The decisions--the first question there. The decisions about environmental sampling are--are complex and, you know, involve a lot of consultation and organization among the involved parties. And the environmental samples are being obtained for different reasons. Just to outline, in the case of the index patient in Florida, environmental sampling was driven purely by the public health--public health investigation in an effort to try to recreate the circumstances of his exposure.

Subsequently, environmental sampling was done by the FBI in the context of a criminal investigation. As we have progressed further in the investigation, not only have samples been obtained, you know, out of--sort of from the public health direction and the criminal direction, now samples are being obtained based on decisions made by the U.S. postal service and the concern for the well being of their employees.

So at this point, a number of groups are trying to make very complex decisions about environmental sampling.

Oh, sort of the other group that I didn't mention that's also, you know, concerned about environmental sampling from another perspective is the Environmental Protection Agency, who is concerned that appropriate sampling was done to direct their clean-up of these facilities and that appropriate sampling gets done after their clean-up to make sure that the facilities have been appropriately decontaminated.

So there's a lot of--there's a lot of consultation and decisions that are being made about environmental sampling in different settings.

MR. SMITH: And then there was something about --

DR. PERKINS: Yeah, can you restate the Ohio mail truck question again?

AT&T OPERATOR: I'm sorry, her line is [inaudible].

SPEAKER: Okay, something about a mail truck in Ohio, and then her last question dealt with the case in Florida, whether we think that was actually the first case.

DR. PERKINS: Yeah, we have--we--in the context of the index case in Florida, we intensively evaluated all deaths as well as admissions to intensive care units that occurred since September 11th, which, you know, predated our arrival in Florida by--by several weeks. We are confident that there were no anthrax-associated deaths or illnesses since October 11th that occurred before the index case. We did not look earlier than September 11th.

CDC OPERATOR: Next question, please.

AT&T OPERATOR: Thank you, and that comes from the line of Kim Dixon from [inaudible]. Please go ahead.

MS. DIXON: Hi. Thanks. I have two questions. First is about the idea of a chemical additive being added to the anthrax, and how, if there was such an additive added, would that affect the number of spores necessary to infect a person? And my second question is just a clarification on what the CDC is doing in terms of getting permission from Bioport to test--to treat civilian workers as part of the investigation.

DR. PERKINS: Okay. Your first question is of interest in terms of explaining some of the epidemiologic phenomena that we have seen, but the responses lie within the realm of the criminal investigation and I can't give you any additional information at this point.

In regard to obtaining vaccine, additional vaccine for use in the civilian sector, we are in active negotiation with the Department of Defense who currently owns all the available anthrax vaccine, trying to obtain enough vaccine to vaccinate laboratory scientists working in the laboratory response network for bioterrorism. This falls with the already established guidelines for the use of these vaccine, and what's changed is that as a result of these bioterrorism attacks, their occupational risk has--has increased, and we would like to see them urgently vaccinated.

MS. DIXON: How many people would that be?

DR. PERKINS: We think that it's about 800 individuals that need to be--need to be vaccinated in that network.

MS. DIXON: And can you just talk about how the idea of a chemical additive would affect infectiousness of spores in sort of a general sense, without commenting on the investigation?

DR. PERKINS: Yeah. Sure. In a general sense we would be concerned about any additive to a powder that would cause irritation or damage to skin that might result in easier--easier entry of anthrax spores into the skin, causing cutaneous disease. So that is of concern.

MS. DIXON: But only of cutaneous? I mean would it make it more infectious in terms of inhalation?

DR. PERKINS: Based on our current understanding, probably not, in that there's other characteristics of the powder that are much more critical for--for inhalational disease. We would be primarily concerned about the effect of additives that would damage the skin and make the kinds of cutaneous disease more likely.

MS. DIXON: Thank you.

CDC OPERATOR: Next question, please.

AT&T OPERATOR: Thank you. Our next question comes from the line of Greg Gordon from [inaudible]. Go ahead.

MR. GORDON: Good morning. Thank you for taking my question. Dr. Perkins, I'm wondering, as you know that the anthrax approximating weapons grade was found in the Daschle letter, and you don't know how many similar letters are being or might be sent, which is a highly potent toxin, or where they might be mailed next, if these mail attacks widen beyond responding to each incident and setting an epidemiological perimeter to establish where these borders, does the CDC have a plan for containing this kind of attack or a recommendation for the postal service?

DR. PERKINS: We--we are working with the U.S. postal service and have developed interim recommendations. In addition to those recommendations, we have a broad range of additional options currently being explored and discuss with the postal service to improve--improve the safety of--of their workers.

You know, that includes a range of things from potential technology to--to sterilized mail. It includes potential future use of vaccination in particular populations, and a variety of other technologies that may be useful.

CDC OPERATOR: Next question?

MR. GORDON: Could I ask a follow-up?

CDC OPERATOR: Yes. Go ahead.

MR. GORDON: Back on an earlier subject, the anthrax vaccine. Is CDC also coming up with a plan for getting--with the understanding that the FDA hasn't approved Bioport's vaccine, is there any kind of a plan for--contingency plan under way now for getting vaccine from Bioport for the general public where needed? You're already talking about using vaccine in conjunction with antibiotics.

DR. PERKINS: There is a--a group of--of combined Federal agencies that are evaluating possible options to increase the production of anthrax vaccine for use in the United States.

CDC OPERATOR: Next question, please.

AT&T OPERATOR: Thank you. That comes from the line of Marilyn Nasjoni from Milwaukee Journal. Please go ahead.

MS. NASJONI: Hi, Doctor. Thank you. I have two questions. Are there any estimates about how many spores it would take to produce cutaneous anthrax versus--we've seen the estimates on inhalation.

And my second question is when is the vaccine protective, at what levels, after how many shots of protection do you get, what percent?

DR. PERKINS: Your first question, there's clearly much better information about the infectious disease for inhalational anthrax than there is for cutaneous, and probably the things that are most important in cutaneous is the--the--the kind of contact or the area of skin that the spores come in contact with, and you know, potentially if there's already damage to the skin barrier, a very small amount of spores may be able to cause disease.
It's also complicated by--by the potential for--for adding, you know, irritants to bacillus anthraces for powders that might promote that kind of injury.
So there's not good data about the number of spores that--that are required. We're--we're working intensively to try to make correlations with the amount of environmental contamination in some of the areas where cutaneous disease has occurred, to try to extrapolate that kind of information.

And the question on the vaccine was?

CDC OPERATOR: Yeah, after how many doses is someone considered, you know, protected.

DR. PERKINS: Right. The current vaccine, as you know, is given in six doses over 18 months with three doses given in the first month, at zero, two and four weeks. There's probably--there's probably reasonable levels of protection after three doses, and--and especially after four doses, but there are no data that demonstrate the effectiveness of the vaccine after abbreviated dosing regimens. And so we are left with--with really the only data that we are confident of, are the data that came from the use of six doses.

CDC OPERATOR: This is our last question, please.

AT&T OPERATOR: And that comes from the line of Joanne Silvernes from National Public Radio. Please go ahead.

MS. SILVERNES: Well, hi, thanks. I understand that in Washington, as far as the mail goes, that there have been no cases of anything, you know, further downstream than the post office. Has there been any environmental checking of people's homes?

DR. PERKINS: To my knowledge, there has not been any environmental checking of people's homes, and--and there has been no evidence that--that anyone has acquired cutaneous or inhalational anthrax associated with this outbreak from exposures that occurred in the home.

CDC OPERATOR: Okay. I'd like to thank everybody for participating. We hope to be doing more of these types of telebriefings, and we will do our best to get word out to you as soon as possible when those briefings are planned.
Thank you very much.

AT&T OPERATOR: Ladies and gentlemen, that does conclude our conference for today. Thank you for your participation and for using AT&T's Executive Teleconference. You may now disconnect.

[End of conference.]

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES