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CDC Telebriefing Transcript

CDC's Response to Severe Acute Respiratory Syndrome

March 17, 2003

CDC MODERATOR: Let me quickly explain how today's briefing will work and our plans for keeping you up to date on this emerging epidemic.

While we have no new developments to announce today, the desire for information about SARS is so pressing that we arranged to combine our typical telebriefing with a news conference format. Following the summary statements, we are going to alternate questions from persons listening by telephone and persons here in the room. Please, if you're in this room, come to the floor mic. We've moved the floor mic. If you're in the room, Dr. Gerberding will repeat your question so that we will have that for the record. Our usual telebriefing rules will stand. That means whether you're in the room or on the phone line, you will have one question and a follow-up, and then we'll move to the next questioner.

We'll try to reserve an early afternoon time every day this week, and we'll advise you daily by means of a media advisory if we intend to conduct a briefing that day what the time will be. If we don't currently have your e-mail address, you may forward that information to pet4@cdc.gov. That's P as in peter, E as in elephant, T as in tiger, 4@cdc.gov. The media advisory will contain confirmation of the call-in number. We anticipate these updates will last approximately 30 minutes. Since this is the first one, we'll have a little more time today as needed.

We're very privileged today to have the Secretary of the Department of Health and Human Services joining us by telephone. Following Secretary Thompson's remarks, Dr. Julie Gerberding, Director of the Centers for Disease Control and Prevention, will provide information about our response to the epidemic. Then we'll open to your questions.

Secretary Thompson, welcome to the briefing, sir.

SECRETARY THOMPSON: Thank you so very much, and let me just thank everybody for being here today, and thank CDC for doing such a wonderful job. I know how many of the doctors and researchers spent all week working on this because I was in communication on almost an hourly basis with Dr. Gerberding, who is just doing an outstanding job, and I want to publicly thank her for what she's doing.

I would just like to say that the Department is working with CDC as well as the World Health Organization. We are having a teleconference with the World Health Organization tomorrow morning, and we're all aggressively responding to and we're trying to monitor all the cases of SARS.

Experts at their labs, not only at our own CDC but also at the World Health Organization, are actively analyzing specimens to identify the cause for this illness. To date, however, we have not been able to identify any agent that could be linked to the outbreak, and none has been identified as such.

First and foremost, I want to reiterate that I, as well as all of us here at HHS and CDC are taking the situation very seriously. I just left a representative of the Vice President of the White House and discussed this issue with them. We're all taking the prudent steps needed to ensure the maximum safety and the health of all Americans. The current outbreak of this unknown infectious agent is of concern to everybody.

I met with the Chinese officials about 10 days ago, and I asked them at that time to allow CDC to go in and work with them. We were not able to successfully negotiate that at that time, but subsequently we have been able to, and we have been working with the CDC in China along with our CDC, and we're making some progress.

The staff at the CDC have been doing a fantastic job of working around the clock to monitor this situation and marshaling all the resources necessary to deal with the outbreak as it unfolds. Our experts at CDC are keeping me and my staff here at HHS informed throughout the day, and I thank them for that, and I appreciate that very much.

As you all know, the centers of this outbreak so far have been in Hong Kong and in Hanoi, and it was started in the Guangdong Province in China. The individuals who have been infected all have recently traveled in these areas or had contact with individuals who had traveled there. There have been no cases reported to date that have not followed this pattern. However, with the ease of international travel, it is a possibility that there may be some cases that appear in the United States, most likely in individuals who probably fall into the pattern of transmission that we've seen so far.

Officials at CDC are working very closely with the State Department, the Defense Department, which we had a meeting with yesterday afternoon and this morning, the Transportation Security Agency, and other federal and state partners to monitor the situation.

CDC has regular conference calls with state and local public health officials, and earlier this afternoon CDC had a call with major U.S. health organizations to share the latest information we have on the outbreak. We're also in constant communication with the World Health Organization, and we'll have a teleconference with them tomorrow morning.

All I would like to say is thank you for the press for covering this issue. It's very important to get the information out. And also I want to thank CDC and Julie Gerberding for the great job they're doing.

With that, I'll turn it over to Dr. Gerberding to give you her statement and also to answer your questions.

Thank you, Julie.

DR. GERBERDING: Thank you, sir. Very glad you could join us for this.

And thank you for taking time out of a busy afternoon to be here and cover this situation. What I wanted to do was first tell you a little bit about what we know is going on, tell you some of the things that we still have to work out, and then describe for you the steps we're taking and the kind of operating procedure we've instigated here to deal with this situation.

The Severe Acute Respiratory Syndrome is an emerging infection, primarily in Asia, but we do see evidence that it can spread to other countries, in particular we already know there are cases in Canada, and we're evaluating individuals who are currently present in Germany and in other parts of the country. It will not be surprising to us if we identify cases in the United States, but we have not identified cases here yet. We have received reports of at least 14 persons who meet some of the WHO criteria for a diagnosis. These individuals are in active investigation by state and local health agencies, and if any of them does turn out to actually have this syndrome, we will be issuing an update.

We know that the disease is so far limited to people who have had very close contact with cases. Most of the individuals are health care personnel who have been in direct contact with either the patient or body fluids from the patient. We also know that household contacts are at risk, particularly if they've had direct and sustained contact with sick individuals.

So far the cases are limited, as Secretary Thompson said, to individuals who have either lived in parts of Asia that are affected, or who have recently traveled from those areas.

We believe the incubation period is approximately 2 to 7 days, although as new information unfolds, that may be updated. So the travel advisories that have been issued stipulate that individuals returning from those areas with fever and respiratory symptoms within 7 days of their departure should seek medical attention to be sure that they are not in the early stages of this syndrome.

We also know that there is no evidence so far that persons not in direct contact with suspect cases are at risk. We have not identified any people with casual contact or indirect contact. I think we were reassured by the investigation here in Georgia, where there was an individual who acquired this infection presumably from family members, was here in this city while sick, was involved in activities that involved exposure to others in a workplace setting, and there is no evidence of spread from that kind of contact in the workplace.

Nevertheless, I stress again this is an ongoing investigation. We certainly don't have all the information we need to know to have certainty about any of these issues, and we will just simply have to update you as we go forward.

The most important thing that we need to do is to prevent spread of this infection, and I'll tell you some of the things we're doing about that right now. But the second most important thing is to figure out what's causing. This appears to be a contagious infectious disease, and as I said, limited to health care personnel and close household contacts. That suggests spread by the droplet route, and that's why our infection control precautions emphasize prevention of droplet spread through the use of face shields and gowns and gloves.

But since we can't be 100 percent sure that there isn't an airborne component, at least in close quarters, we're also recommending that masks be worn to protect health care personnel who are treating these individuals.

Our laboratories here at CDC are literally working around the clock on the specimens that we've received. They're working in collaboration with WHO and reference laboratories internationally to try to identify the pathogen.

We are not suspicious that this is a common organism, or we would have found it by now. So that leads us to conclude that it's either a difficult-to-grow organism or one that we have less experience with. But here at CDC we have reference laboratories that really have the wealth of the world's reagents and technologies and capacities, and we are confident that we will be able to identify the cause.

The rate-limiting step for us at this point has been access to specimens from the patients that are affected with the illness in Asia, and I'm very pleased to say that we now have taken important strides toward getting those specimens here. Some are en route and we expect others to follow this week. So that will be helpful to all of the laboratories internationally who are collaborating on identifying this agent.

Some of the things that we're doing right now are probably obvious to you. We're making a huge effort to communicate about what we know and what we don't know to the public. But we're also taking steps to communicate with the involved stakeholders, particularly here in the United States, where we have yet to identify a case, but we want to make sure we don't miss one.

We have established a website that contains all of the information that we have available to us, and the WHO will be issuing morning updates on the number of cases that have been identified around the world. You may see some wobble in numbers over time. The case definition here is very broad: fever, respiratory symptoms in someone who's been in Asia. And as these cases are investigated, many individuals may turn out to have other conditions, and they will be taken off the list. So be prepared for some uncertainties in the actual number as we go forward one day at a time.

We have activated our emergency response center here to manage this international outbreak that allows us to have the expert logistic support for our teams. Right now we have 12 individuals deployed to various locations internationally to support this, but also it allows us to take information in real time and transform it into guidance, isolation recommendations, and public information to help ensure that we've got the information out in a timely manner.

I just got off the telephone with a number of clinician organizations from around the country to make sure that they have the updated information. Dr. John Jernigan, who's here, is leading our clinician team. We are making 24-hour-a-day services available to clinicians who have questions about this illness so that they can get state-of-the-art information, and you can also follow up with us because we have a public information hotline to help provide people information as well.

Finally, we really appreciate the efforts of our state and local health partners across the country who have also been briefed by telephone and are participating in ongoing updates about this illness. They, too, along with clinicians, are the front line of detecting initial cases here, and we know that they will be called to investigate suspicious patients as they come forward and will be the first to take steps to prevent further spread.

We have issued guidance to clinicians that says one very important thing, and that is, when an individual presents to medical care with fever and respiratory symptoms, it's important to take a travel history and know if that person has recently left, within the last seven days, one of the countries in Asia where these cases are being reported; and if so, the individual should be isolated until additional information is available to be sure that we're not dealing with a case patient. And that means that people who have fever and this travel history and are developing respiratory symptoms, when they go to the doctor it's very important to let the clinicians know that you have this travel history and that you've been in this area so that the appropriate precautions can be taken.

With that, let me just stop and open this up for questions and answers.

QUESTION: [inaudible].

DR. GERBERDING: The question is what can I say about the 14 reports we've received in the United States where there's a suspicion of this syndrome.

Our initial information that of the 14,10 are almost certainly not people with the syndrome. They don't meet any of the relevant history, and four are under a little bit more scrutiny just because they have at least some of the characteristics of the illness that WHO has defined. But we haven't confirmed any cases here, and so we'll update you as we go forward.

CDC MODERATOR: The next question will come from the phone line.

DR. GERBERDING: Can we have the first question from the phone, please?

AT&T OPERATOR: We have a question from Robert Bazell (ph) with NBC News. Please go ahead.

QUESTION: Dr. Gerberding, you have had some samples from the Canadian cases, I believe, for several days now, and you mentioned the difficulty you're having. Can you tell us a bit more about what that means, the fact that some of these things you've had in your lab there for three or four days now and you haven't been able to culture out anything. Isn't that highly unusual?

DR. GERBERDING: Let's say that, first of all, in looking at specimens, the quality of the specimen is important, but also the time in the illness when the specimen was obtained matters. The specimen we received from Canada was an autopsy specimen. It was derived from the patient more than 14 days after the onset of illness, and it's not uncommon at all for us not to be able to isolate an organism in a specimen that that's far into the clinical course. That's why we're putting so much emphasis on trying to obtain early specimens or respiratory specimens from patients who are recently developing the signs and symptoms of the disease.

We do look forward to being able to provide more of an update on that as we go forward. I would also add that the evaluation of the Canadian specimen is not complete, and whenever we have to do virus culturing, we expect results to take several days, and sometimes weeks.

[Inaudible comment.]

QUESTION: [inaudible].

AT&T OPERATOR: Ladies and gentleman, for the phone participants, if you have a question, press 1. You will be allowed only one question. Thank you.

DR. GERBERDING: The question is: What is the validity of reports that we've ruled out bacteria and that the Hong Kong laboratories have excluded influenza in the diagnosis?

First of all, at this point we have not ruled out anything. We simply have insufficient material to draw firm conclusions about any of this. We do know that the laboratories in Hong Kong, where a large proportion of the patients are receiving care, are very good at diagnosing influenza. They developed this capacity and experience in the context of the previous avian influenza outbreaks there, and the fact that they haven't been able to diagnose influenza in the patients is a strong argument against that being the etiology, at least in those individuals, but it's really too soon to draw firm conclusions.

We are looking at bacteria. We're looking at viruses. We're looking at atypical bacteria. We are checking for absolutely everything.

A question from the radio, please?

AT&T MODERATOR: We have a question from Bill McLaughlin with (?) Business Magazine. Please go ahead.

QUESTION: Good afternoon. In terms of the method of transmission, you mentioned droplets. Is there any possibility that droplets on an inanimate surface, in other words, if someone were to sneeze on something and someone else down the road at some point would come in contact with that particular object, is that of any concern? Or is that really not likely at this point?

DR. GERBERDING: Droplets almost always are infectious when they're fresh, and so we are most concerned about recent exposure to fresh body fluids, and the epidemiologic pattern that we understand so far is very consistent with that. This is sort of a face-to-face transmission pattern. We're learning that when we look at the patients in Hanoi and the patients in Hong Kong and the cluster in Canada. But we are using infection control precautions that go beyond that in health care settings where there's likely to be concentrated exposure just to be absolutely certain. We are not seeing, as I said, spread within the general population by casual contact, and there's no suggestion that inanimate objects of any sort are playing a role in transmission at this point in time.

QUESTION: [inaudible].

DR. GERBERDING: The question is: Are there any commonalities among the people who have acquired the infection other than being in that part of the world?

The answer is that these kinds of epidemiologic investigations are ongoing as we speak. The WHO has teams of investigators in all of the locations, and they are doing exactly what you said. They are trying to look for clustering in person, place, and time and see if they can find any additional clues about where the exposures that led to infection might have occurred. But we don't have any information at this point to draw conclusions.

A phone question, please?

AT&T MODERATOR: We have a question from Tom Watkins with CNN. Please go ahead.

QUESTION: Can you update the numbers you gave over the weekend? How many cases are there so far? How many deaths? What are the--what is the status of the survivors? Are they getting better? How many are on ventilators? And do you know anything about the status of the WHO health worker who was sickened?

DR. GERBERDING: The WHO has reported an update this morning of 167 cases and four deaths. Keep in mind, as I said before, these numbers are apt to change as additional information becomes available or additional cases are detected.

In terms of the clinical status of these individuals that are surviving this illness, we don't have line-by-line information. There's a great deal of variability in the presentation and outcome. We have reports of people who are improving. We have not yet documented that someone who's been on a ventilator has recovered and gotten off the ventilator, but we're hopeful that that will be the case.

QUESTION: And any idea how many of them are on ventilators?

DR. GERBERDING: At this point I don't have an update on that.

QUESTION: Okay. Thanks.

[Inaudible comment and question.]

DR. GERBERDING: With respect to the reports of patients that are under active investigation, I'm going to defer that question until state and local health offices have had a chance to provide their own individual updates.

With respect to what does the WHO number mean, 167 cases are cases that have been diagnosed since the syndrome was recognized following the index patient, so this is the cumulative total of cases. Of course, that does not include the cases that have been described coming out of Guangdong Province in China where we have much less information and cannot say at this time whether they are related or unrelated to this current outbreak situation.

I would just like to emphasize that what we're dealing with here is an emerging infection, and the fact that we live in this global village makes our need to be able to identify and respond to these infections so critical. The fact that Hong Kong has a surveillance system and is very alert to infectious diseases that could be flu has certainly helped us identify the early cases there. We need that kind of capacity in every corner of the world.

Can we take a phone question, please?

AT&T MODERATOR: We have a question from Lori Good(?) with Newsday. Please go ahead.

QUESTION: Yes, this is Lori Good. Is Secretary Thompson still on the line?

DR. GERBERDING: No, he's not on the line.

QUESTION: Okay. Then my question concerns China and the status of cooperation with China. Clearly they've been sitting on information for a very long time, and they've been reluctant to cooperate. I wonder, are we sending a team in? Do we have an actual firm agreement that would allow the CDC to go to Guangdong? And as a follow-up, what's the latest from Switzerland and the U.K. on those suspect cases?

DR. GERBERDING: This morning the WHO reports that the Minister of Health of China has requested support from an international team and that the team is being assembled. That's very good news, and I anticipate that means that we'll be able to get into China very soon, as soon as folks on the ground get coordinated.

Lori, I forgot your last--the last part of your question.

QUESTION: What's the latest on the suspect cases in the Switzerland and the U.K.?

DR. GERBERDING: I have no specific information on the suspect cases in Switzerland other than there are two that are under evaluation. They are alive and there are no reports of secondary transmission yet. And in terms of Britain, that was a breaking news item this morning, and I do not have the follow-up at this point in time.

QUESTION: Thank you.

[Inaudible comment and question.]

DR. GERBERDING: The question is: Why is it difficult to get specimens?

First of all, this is an international effort, and CDC is not the only partner who has a role to play here. WHO has a whole network of laboratories that have great expertise and great capacity in this area. So we are partnering with a number of different agencies, and if we don't have specimens, some of the other labs in the consortium certainly do. And we're very respectful of that partnership.

But, in addition, as a problem emerges in a new area, there are issues of patient consent, family considerations, then as well as scientific considerations. Just as in this country we defer to state health departments when there's evolving a problem internationally, we defer to the Ministers of Health in the implicated country and we also defer to WHO in countries that are part of the World Health Organization. So all of those things mean that there are channels and processes that we follow when we need to acquire specimens.

Secretary Thompson was very helpful in working with Dr. Bruntdland at WHO and other Ministers of Health in the affected areas to open the doors to receiving specimens, and I think that's why we have the optimism we do that we will be able to have more materials here at CDC to work with in our laboratories.

AT&T MODERATOR: We have a question from John Sattrack (ph) with Washington (?) . Please go ahead.

QUESTION: Dr. Gerberding, taking note of the previous comments you made regarding the unlikelihood of this being influenza, we've nevertheless heard for some time from influenza experts that the world is overdue for a large-scale pandemic. I'm wondering--they've called for pre-event and post-event strategies similar to what's going on right now with smallpox, and I'm wondering if this is going to change the long-term thinking in terms of the cost/benefit of any kind of pre- or post-event strategies, either for influenza or whatever this SARS might turn out to be.

DR. GERBERDING: Thank you. I believe that most people in the health community recognize the danger that pandemic flu would place in our society and have been advocating for some time to speed up and scale up efforts for preparation. This current emerging threat is a wake-up call. We right now don't believe that it represents influenza, but it has many of the same characteristics that we would be concerned about with an emerging influenza illness. That is, it appears to be contagious with a high degree of efficiency in at least close quarters. It's emerging in a part of the world where there are great conditions of crowding and a great deal of international travel. And certainly it reminds us that we really do live in a global village and that an emerging problem in one corner of the world will soon be an emerging problem for all of us.

[Inaudible comment and question.]

DR. GERBERDING: When is the last time we've dealt with a global emerging infection? We deal with global emerging infections all the time. For example, we just are in the midst of an Ebola outbreak in the Congo.

[Inaudible comment and question.]

DR. GERBERDING: Of an unknown agent? I'd have to defer that to Dr. Hughes, who's the Director of the National Center for Infectious Diseases and has the historical perspective.

DR. HUGHES: Thank you. The most dramatic recent example perhaps would be hantavirus pulmonary syndrome back in 1993. Now, that was not initially a global problem. It appeared to be local. But subsequently we've learned about hantaviruses present throughout the Western Hemisphere that were previously unrecognized. You can go back to Legionnaire's disease in 1976.

I'd remind you, you know, in terms of dealing with an unexplained illness, those of you who were around in 1976 might recall it took six months to identify the cause, and that was a bacterium that caused Legionnaire's disease. We think we'll get to the bottom of this more quickly, but there are substantial challenges ahead.

DR. GERBERDING: From the phone?

AT&T MODERATOR: We have a question from Seth Bornstein with Knight Ridder. Please go ahead.

QUESTION: Yes, can you tell us, are you--you've looked at obviously bacteria and viruses. What about the co-infection, especially with bacteria that has--allows virus to invade, I know which is something (?) an issue in the labs but never in the wild. Is that something that this is a possibility and you are examining that possibility?

DR. GERBERDING: We're not ruling out any possibilities, but right now I think the pattern of transmission implies fairly direct contact with an individual infectious agent. We will certainly be looking for DNA for a whole host of organisms, and if we're dealing with a dual infection or something that's complicated of that nature, our probes should be able to figure that out.

[Inaudible comment and question.]

DR. GERBERDING: I will follow up what the Georgia State Health Department is reporting about the situation here in Georgia. The person who visited Georgia was a family member of the family in Canada that has two individuals who have died from this syndrome. This individual traveled here on business. She was here for a few days, a relatively short period of time. She was involved in a business activity, and the health department has done an outstanding job of investigating the individuals she had contact with in the workplace, in the place where she stayed, and the restaurants where she ate, and I think has done an amazing job of tracking back to make sure that there was no secondary transmission. She was here much earlier in the month, and it's past that seven-day period that we're defining as, you know, the best guess of the incubation period. So as time goes on, I think it's less and less likely that we'll discover that there's been any transmission. But the health department is vigilant, and certainly we'll continue to monitor that situation.

AT&T MODERATOR: We have a question from Kevin Finnegan with CBS News. Please go ahead.

QUESTION: Actually, it's Elizabeth Kaladin (ph). Dr. Gerberding, I'm just wondering what, if anything, you've learned from the four deaths. Were these people people who received no therapy or no hospitalization? Were they a certain age group? Is there anything in common in the four people who didn't survive?

DR. GERBERDING: We are deferring to the investigators in the field to pull together the clinical information. Dr. Jernigan is here with us, who heads our clinical team, and I don't believe we have specific information on all of the deaths. But right now we cannot draw any conclusions about benefits of any treatments. A few empiric treatments have been provided. Most of the patients were treated with conventional antibiotics that you would use for a community-onset pneumonia. But, you know, even with common garden-variety pneumococcal pneumonia, and if you treat with penicillin, you don't always cure the infection.

So we really can't draw any conclusions on that at this point in time, and we don't want to wish to have bad outcomes for any of our patients, but I think the numbers right now are just simply too small for us to make any conclusions about that.

[Inaudible comment and question.]

DR. GERBERDING: Let me emphasize again the timing of the testing is highly variable depending on the specific test. We have rapid tests that screen for families of viruses and bacteria. Bacterial cultures for common-variety bacteria often become positive very quickly. But some of the viruses that we're looking for either cannot be grown in culture or take very long times to grow in culture, and some of them we still are dependent on probes of the DNA to really identify the agent.

When we have a situation where we can't actually grow the organism and get a lot of genetic material, we often have to resort to the most sensitive DNA technology that we have, and if there is not a dense infection, sometimes we get a false negative from those tests.

So the rapid tests are being completed very quickly. We're doing special staining of tissue and immunohistochemical staining to really look at the location of any potential antigens in tissue, and, believe me, we've got laboratories all over the center working on this around the clock.

So in terms of when we'll be able to draw any firm conclusions about what's going on, I can't predict that. I'd just tell you that we're doing it as fast as we humanly can, and we're prepared to scale up as we get more specimens.

AT&T MODERATOR: We have a question from Jennifer Colman with KYW-TV. Please go ahead.

QUESTION: Yes, hi. With respect to the 14 cases, you mentioned that four of them were more--you know, were more suspicious. Which areas of the United States are they in?

DR. GERBERDING: I'm not going to comment on the specifics of those cases right now in deference to state and local health agencies. But I think that--I checked with Dr. Jernigan just before I came into this meeting, and we're not highly suspicious of any of these cases, but under the circumstances, we want to be absolutely certain that we're not missing the first patient, and so we are giving them a very careful follow-up and working with the health authorities in those areas to provide any technical assistance that we can.

We're also working to obtain specimens from the patients so that we don't miss the opportunity to make a diagnosis if it turns out that they do, in fact, represent a case.

A last question from the phone?

AT&T MODERATOR: We have a question from Erica Needowsky (ph) with the Baltimore Sun. Please go ahead.

QUESTION: Hi. Can you explain what it was specifically about this illness that raised a flag in the first place, perhaps something to suggest that it was behaving differently?

DR. GERBERDING: There are, I think, two things that sounded the alarm in this illness. One is that the first patient that was initially in Hanoi and then transferred back to Hong Kong, in that particular cluster, seemed to be the source of many health care worker infections, much more transmission in the health care environment than we typically see with most infectious diseases.

Now, in that particular hospital, barrier precautions were not in place so that's somewhat confusing because they're using a different approach to infection control than we use here.

So one issue was the high degree of contagion to health care workers, and the other was the rapidity and severity of the pneumonia in the case patients. Even in influenza, most people have sort of the systemic fever illness, and it's quite unusual to develop pneumonia. Here we had a very high proportion of individuals developing pneumonia. That signaled something unusual, and I'm sure that was one of the reasons why they took a closer look at what was going on.

CDC MODERATOR: Thank you, Dr. Gerberding, and thank you also, Secretary Thompson, for joining us today. That concludes our briefing. We will keep you up to date on the progress that we're making here, and we will notify you if we're going to be briefing tomorrow or again this week.

Thank you.

AT&T MODERATOR: Ladies and gentlemen, that does conclude your conference for today. Thank you for your participation and for using AT&T Executive Teleconference. You may now disconnect.

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