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CDC Telebriefing Transcript

SARS: Travellers Health Alert Notices

March 19, 2003

CDC MODERATOR: I am pleased, very pleased indeed, that Dr. Julie Gerberding has time today to join us and to give you a personal update on CDC's response to severe acute respiratory syndrome and assistance to the World Health Organization and the global investigations. Dr. Gerberding.

DR. GERBERDING: Good afternoon. Thank you for taking time to be here for this update.

I'd like to just start by putting the situation in perspective. The WHO, as of just a few minutes ago, provided updated information about the total numbers of cases reported. Today they're reporting a total of 264 cases of severe acute respiratory syndrome and nine deaths internationally.

In the United States, we are reporting to WHO 11 suspected cases that are currently under investigation. I'm not going to be able to provide you details about those cases, but information will be made available by the relevant health departments in the state or local areas as information becomes available.

I want to also emphasize that there is a lot we still don't know about this problem. It's unfolding, and the investigation is still unraveling. But today the Hong Kong Health Department did announce that at least seven of the initial patients were residents in a hotel in Kowloon during the month of February. This is an epidemiologic clue that suggests to us that close contact in that hotel may have been a common source of exposure for at least some of the initial cases, but we still know that the majority of individuals with this infection were either health care personnel or close family contacts of cases.

So the investigation to understand the types of contact that occurred in the hotel is actively in progress. Right now the floor of the hotel is closed and local health officials are taking steps to make sure that there is no additional transmission there. But we're very reassured by the fact that none of the hotel staff are ill. This is the same situation we've seen in both New York and Georgia, where we've done similar investigations of ill individuals staying in hotels and have not found a risk to hotel employees, suggesting again that close contact is the most likely mode of transmission in these environments. As we learn more, we will update you with additional information from the Hong Kong investigation. You can find this information on their Web page.

CDC will be providing additional information about suspected cases in evaluation in this country on our Web page as it becomes available for release, and so you can check there later tonight or tomorrow to get the facts that you need.

Also, know that the paramyxo virus, a common virus, family of viruses that has many different subtypes, has been identified in two of the patients that are being evaluated in Germany and also a patient in Hong Kong. The laboratories that have identified this virus are very good laboratories. They're excellent investigators, and we've put a lot of credibility in their report of identifying paramyxo virus, but we don't at this point know what it means because the virus was detected from the nasal pharynx of these infected patients and it hasn't yet been identified from any tissues or lung material or other specimens that would directly implicate it as the cause of the infection.

So there's a lot more work to go on before we can draw any inferences about the relationship between this virus in the nose and the disease in the patients at hand. But we regard this as an encouraging step forward and certainly will help us focus in on our initial laboratory investigations.

At CDC, we are also extremely pleased that we have a larger number of specimens arriving today and a great number that will be arriving tomorrow, and this will help us get our laboratory investigations into a more rapid phase so that we can work in collaboration with the other scientists around the world to try to get to the bottom of this situation as quickly as we can.

We are also expanding our safety net to returning passengers. We are currently issuing health alerts to passengers arriving on direct flights from Hong Kong and will be expanding that to include passengers arriving from indirect routes of travel from the relevant areas of Asia, and also people who are coming in on cruise liners and passenger ships and commercial shipping vehicles, to be sure that anyone who's been in the implicated area knows that if they develop symptoms of a respiratory illness and a fever within seven days of leaving the countries that are involved, they should seek medical attention and make sure that they're not involved in these outbreak situations.

So that is really the update on where we are today, from both an international and a CDC perspective. We'd like to also say that we understand and appreciate that this investigation is very stressful for recent travelers, in particular for the families of the people who are being evaluated as potential suspect cases. We recognize and empathize with how difficult and challenging this is for everyone involved and will do our very best to assist in whatever way we can.

Let me take some questions now.

QUESTION: [Off-microphone] On Monday you characterized the 14 U.S. cases that, you know, a certain number that probably weren't and a certain number was somewhat suspicious. How would you describe now these [inaudible]?

DR. : On Monday I described the number of calls we had received from clinicians who were describing patients that they had some concern about. But when we interview the clinician who was calling in, we often can discover very quickly no, this person hasn't traveled to Asia or no, this person doesn't actually doesn't have any respiratory symptoms or signs at all. So I count them as a contact with a concerned clinician, but we didn't consider them suspected cases.

The 11 people that we're talking about today have a travel history, a fever, and respiratory symptoms that makes them fall into the case definition for a suspect case. And as the clinicians taking care of them do more evaluation, they may find a completely unrelated cause, but for now they're still on the active evaluation list so that we're sure we've thoroughly looked at everything.

QUESTION: [Off-microphone] One follow-up question. Does that number 11 come from [inaudible]?

DR. : Well, since Monday I think we've had over 40 calls about individuals that clinicians are concerned about. So this is 11 out of 40. On Monday it was four out of 14 that we were concerned about, if that helps you. We will also be able to see this on our Web site as we go forward, as new cases come and go from the list.

Question from the telephone?

AT&T MODERATOR: As a reminder, for questions press the 1. One question, one follow-up, and then re-queue for further questions. Our first question will come from the line of Maggie Fox, with Reuters. Please go ahead.

QUESTION: Hi, Dr. Gerberding. Thanks again for doing this. I'd like to ask you about how common these kind of symptoms are. I know that you're making the travel history part of the case definition, but can we have some context about how common the other symptoms are?

DR. GERBERDING: Well, the symptoms of concern are fever, cough, difficulty breathing or chest discomfort. And during flu season these are extremely common symptoms. They are common even in non-flu season. So the travel history is extremely important here. We are recognizing the very close association with the defined geographic regions in Asia, and recent travel is the common denominator. So we don't want people who haven't traveled to those regions to be concerned about this problem, at least at this point in time. If that changes, we will of course advise people through our Health Alert Network and through press briefings and our Web site.

QUESTION: And can I just clarify, please, Dr. Gerberding, nobody at CDC has identified this paramyxo virus? It's just been identified in Hong Kong and Germany?

DR. GERBERDING: Investigations in the CDC laboratories are ongoing. As I mentioned, we are just receiving now the specimens that we've been waiting for, and so we'll be working very hard to look at this particular family of virus as well as a host of many, many, many other pathogens that could potentially be involved.

A question here?

QUESTION: [Off-microphone] [Inaudible.]

DR. GERBERDING: The paramyxo virus family is very broad. It contains the viruses that cause mumps and measles and canine distemper and a lot of other illnesses. And maybe I would ask Dr. Anderson, who's our expert on paramyxo viruses to respond specifically to the question.

DR. ANDERSON: There certainly have been paramyxo viruses that have infected humans from animals. The nipah-hendra group is in this family of virus, so it's possible until we know more about the virus, that's one possibility. But we really can't say more than that.

CDC MODERATOR: Question from the telephone, please?

AT&T MODERATOR: Yes, we'll next go to the line of Dan Vergano with USA Today. Please go ahead.

QUESTION: Hi, Dr. Gerberding. I'm wondering if you could sort of put in perspective or tell people in the U.S. what they should take away from cases in the U.S. suddenly being announced today. Obviously you don't want to panic people, but what does this mean to people in the U.S. if cases have suddenly appeared here?

DR. GERBERDING: Well, as we know, there is a great deal of international travel to Asia. We live in a global community, and we are not surprised to see that there are individuals in this country who may be cases. But I think it's very preliminary to definitively say that any of these individuals are a case of SARS because it's a very early in the investigation. Any patient with a travel history and an unexplained pneumonia is basically going to be under investigation. And there are so many causes with common garden-variety pneumonia this time of year that it is going to take some days to really know for sure. Because we don't have criteria to exclude someone as being a case until we have other identified diagnoses, this will take some time.

QUESTION: [Off-microphone.] [Inaudible.]

DR. GERBERDING: Okay, what we have learned so far from the Hong Kong Health Department is that these individuals included three visitors from Singapore, two visitors from Canada, one visitor from Mainland China, and a local resident of Hong Kong. And they've had some, at least two of the individuals visited each other in the hotel, but the details about how the others interacted with each other are still sketchy. We really look forward to getting those details from the investigators in Hong Kong.

QUESTION: [Off-microphone] follow-up. [Inaudible.]

DR. GERBERDING: What we are doing in our experience here in the States is using the WHO case definitions, but what I'm just describing to you is the broadest group of people. These are people that we either don't have enough information to characterize it as being suspect or probable or not a case or people who meet some of the case-definition criteria, but the evaluation is incomplete.

So, unfortunately, the case definition is, as I said, very broad: fever, respiratory symptoms and a travel to Hong Kong or Hanoi or the affected areas is just going to include a very, very large number of people in this country, and so we have decided to err on the side of including anyone who falls into that broad definition up front, and we will go forward, and the health agencies involved will investigate to understand when they traveled, was this within the period of time where we think the incubation falls, which right now is still about two to seven days.

If the travel was remote, they will come off the list. If we find out they have pneumococcal pneumonia instead, they will come off the list.

So we just need to get both clinical details, as well as a lot of exposure details before we can really say that they're definitely in or they're definitely out, and we will be updating that as we go forward in time. It just takes a little bit of time to get that information together.

QUESTION: [Off microphone.] [Inaudible.]

DR. GERBERDING: In general, the state health departments will be providing that information initially, but we are working on agreements to make sure that we can, whatever means, get it out to you as quickly as possible because we know there is a great deal of interest in this, and we want to push it out quickly.

A question from the phone?

AT&T OPERATOR: Yes, next question on the phone comes from the line of John Boswell with ABC News. Please go ahead.

QUESTION: Dr. Gerberding, we have heard reports--unconfirmed and, in fact, possibly denied--that there may even be one case in Bahrain. Given the close quarters of the troops in the Gulf area does SARS endanger the troops at all, and are there any plans to deal with it?

DR. GERBERDING: I'm looking at the WHO report that is timed just this afternoon, and Bahrain is not one of the countries listed on the report, and I really can't comment on the safety of the troops. You can be sure that the DOD is well up-to-date on the status of this outbreak and investigation, and they are doing what is necessary to protect the troops.

QUESTION: Thank you.

QUESTION: [Off microphone.] [Inaudible.]

DR. GERBERDING: I think we still don't have complete information about the outbreak of a typical pneumonia that was reported by the Chinese Ministry of Health. The teams are now able to investigate collaboratively with the Chinese. The WHO team is working on getting that information together.

There are a lot of things that happened sort of in sequence here. There was the report of the outbreak of atypical pneumonias in China. Then we had two patients in Hong Kong with H5N1 Avian flu, and now we have this ongoing outbreak of SARS. I think it is very important to us to be able to look back and review what happened in Mainland China and see if, indeed, it is the same clinical illness or it represents a coincidental phenomenon.

The first step in that is, of course, to review the cases and then identify if there are any laboratory specimens that could be tested and do what we always do as disease detectives, try to put all of the clues together and make some sense out of the big picture.

Yes?

QUESTION: [Off microphone.] [Inaudible.]

DR. GERBERDING: Well, what we are saying about transmission is, of course, predicated with our common denominator here, and that is we are learning as we go. But the fact that most cases are in household contacts or in health care personnel who have had very close and direct contact with infected people or their body fluids really does suggest to us that this is a probable droplet transmission infection. But it's very difficult sometimes to distinguish a droplet, which means you have to be real close, from an aerosol, which can spread in a broader area.

And to be on the safe side, we are recommending that health care workers do wear masks when they are in close contact with patients just to be sure. So we're using airborne precautions, droplet precautions, and then, of course, the standard infection control precautions that we use for everyone.

One of the things that we will be looking at very carefully in the Hong Kong hotel situation is what exactly was the nature of the interaction of all of the people there because that will provide some additional clues to the degree of contagion and modes of transmission.

QUESTION: [Off microphone.] [Inaudible.]

DR. GERBERDING: I think one of the good pieces of news that we've been receiving from WHO is that there does seem to be success in containing spread in health care environments when these infection control precautions are implemented. So it's too early to be overly confident, but we do see that there has been reduction in the number of new health care worker cases, and so I think we are making a difference in terms of prevention in that environment.

We'll take a few phone questions in a row here. Next telephone question?

AT&T OPERATOR: Dr. Gerberding, could you please repeat the room questions for the phone participants.

DR. GERBERDING: Absolutely.

AT&T OPERATOR: And we can now go to the line of Susan Dentzer, with the NewsHour with Jim Lehrer. Please go ahead.

QUESTION: Yes, Dr. Gerberding, some of us got into the call late because the conference coordinator was backlogged, so forgive us if we missed this.

But back to the Paramyxoviridae family. What is the clearest thing, and the most accurate thing, to say at this point, then, with respect to any connection of that family of viruses to these disease cases?

Is it, in fact, that the most succinct thing to say is that that remains one possibility based on having been able to identify that family of viruses in the nasopharynx, as you said, but it is not the cause at this point, and you are still looking at many other options, including the possibility of co-infection from viruses and bacteria together; is that right?

DR. GERBERDING: You did a great job of answering the question.

[Laughter.]

DR. GERBERDING: This is one possibility, and the virologists in the laboratories involved in identifying this virus under electron microscope are excellent laboratories. But seeing something in a nasal swab is not the same thing as identifying or confirming that it's a causal relationship, and so a great deal more work needs to be done before we identify the specific virus that's in those patients, as well as ascertaining whether or not it is the cause of the infection.

We'll take another telephone question.

AT&T OPERATOR: The next question will come from the line of Laurie Garrett with Newsday. Please go ahead.

QUESTION: Hallelujah. It's so hard to sit in these queues. Thank you.

DR. GERBERDING: We always appreciate your editorial remarks.

QUESTION: Sorry. One key question for the folks who work in the Crowne Plaza Hotel in New York City or were there the night and day that the individual who went on to develop SARS in Germany was here, what should be the take-home message in light of the Kowloon Hotel finding?

DR. GERBERDING: The New York Health Department can provide the specifics of how they investigated and have made contact with people who were in the hotel at the same time as the patient, but we know that we're heading towards the point in time where we're outside the suspected incubation period for this illness, and I can assure you that New York did an outstanding job of evaluating contacts wherever the individual was. So I think the folks who stayed in that hotel should be very reassured.

It is important, however, that, again, we may be wrong about the incubation period or we could under- or overestimate the degree of transmissibility, so if there are people in that situation, the health department will be giving them advice about the need for additional follow-up, should they get a fever or respiratory illness.

We'll take one more telephone call before coming back to the floor.

AT&T OPERATOR: The next question, then, will come from Seth Borenstein with Knight Ridder Newspapers.

Please go ahead.

QUESTION: Yes, thank you, Dr. Gerberding. In terms of the 11 probable or possible suspect cases in the U.S., do you know anything yet about--are any of these local transmission as opposed to people who have traveled but--contact with people who traveled and how--because I know that's a big issue elsewhere. Are we--I guess, what kind of handle do you have on the U.S. system and transmission here?

DR. GERBERDING: The 11 cases that are currently being evaluated are individuals who do have a travel history. We have no individuals at the moment who are contacts of cases or in a suspicious category. We will obviously be on high alert for this. That's one of the first things that the local health agents will do, is look at exposed persons in households or in other settings and contact those individuals and make sure that they know if they do develop symptoms that they should seek immediate medical attention. But right now we have no one on that list.

QUESTION: Just a follow-up. In terms of the paramyxovirus, I just want to make sure I'm clear. Is the virus that has been seen in the nasal passages, is that a new paramyxovirus or is that an old one that has been seen before?

DR. GERBERDING: Let me clarify a little bit, and I'll ask Dr. Anderson, our expert here, to join me, to provide [inaudible].

Paramyxovirus is a family of viruses that contains a large number of agents, and when you look at something under the microscope--this is an electron microscope--you can only say that it's in the family. You can't say anything about what specific type of virus it really is. And maybe there are additional clues that you can provide.

DR. ANDERSON: Dr. Gerberding is correct. In terms of is it new or something we already know about, we really don't know yet because we don't have more information. We do know, however, that we have looked at some specimens, a limited number of specimens, and the last in Hong Kong and in other places, have looked for the known paramyxoviruses with good techniques and have not identified it.

Based on that, my presumption--but I don't know yet because we don't have all the information--is that it may be a new virus within that family.

DR. GERBERDING: We'll take a question from the floor.

QUESTION: [inaudible].

DR. ANDERSON: Well, the data that has been reported, mostly in the Hong Kong press, was that, in fact, in addition to electron microscopy, Dr. Kam (ph) had some genetic evidence of paramyxovirus. We don't know the details of that.

QUESTION: [inaudible].

DR. ANDERSON: The question was do we have additional information over and above what's been reported in the press. We have had communication with members of the laboratory and WHO that basically are consistent with what has been reported in the press.

QUESTION: [inaudible].

DR. GERBERDING: I think what we're really saying is that--the question is exactly where did the specimens come from in Germany, and I'll be speaking generally here. These are upper respiratory fluids that have been evaluated, and you can have surface viruses or in the cold season some of the paramyxoviruses are common in flu season. And so finding them there alone does not necessarily mean that they're causing a lower respiratory tract pneumonia or the atypical pneumonia that we're seeing. But it was very encouraging to see a virus and the fact that it's being found by more than one laboratory in more than one location I think is a good clue that that's where we need to look the hardest right now.

Let me take a question from the phone, please. Is there a question from the phone?

AT&T OPERATOR: Yes. We'll now go to the line of Emily Sinnay (ph) with CBS. Please go ahead.

QUESTION: Yes, hi. Good afternoon. In the people who have died, what is the clinical progression of the disease? And what is the cause of death? And is there anything telling on x-ray or blood work or on autopsy that unifies these cases?

DR. GERBERDING: First of all, let me also provide some good news here, and that is, we're learning from Hanoi that several of the patients there appear to be improving. We're also getting that information from Hong Kong. Of the people who, unfortunately, do develop critical illness and die, we don't have all of the information, particularly from the new cases that were reported today from Hong Kong. But we understand that the progression is basically one from pneumonia that involves many parts of the lung to a situation known as ARDS, or adult--or acute respiratory distress syndrome, which means the lungs are so congested and unable to transfer air, those patients require mechanical ventilation, and generally the cause of death is either respiratory failure because it's just simply not possible to get enough oxygen to the body, or complications from that level of intensive care.

Let me take another telephone question because I recognize that there are a great number of people in the queue.

AT&T OPERATOR: The next question will come from the line of Robert Brazil with NBC. Please go ahead.

QUESTION: Good afternoon. Dr. Gerberding, for people--the 11 cases in the United States, do you have advice for local health departments and the specific hospitals about the infection control procedures when somebody is identified, either self-identified or by local authorities, as a suspect case of SARS?

DR. GERBERDING: Yes. We initiated some advice based on the early case reports and updated that advice yesterday. We are advising that individuals who present with fever and respiratory symptoms first be evaluated for their travel history or close contact with individuals who are on the suspect case list; and if there is a travel history or a clinical suspicion that this could be SARS, that they be immediately put in respiratory isolation where airborne precautions, droplet precautions, and standard precautions can be implemented.

In addition, we are advising that clinicians not assume this is SARS and, rather, they evaluate the patient with an open mind and treat them with the appropriate antimicrobial therapy that they would use for any case of serious community onset pneumonia until additional information is available to help guide them in one direction or another.

So while we can recognize that this is something we want a high index of suspicion for, we don't want it to be the only thing on people's minds, because there are other important and very treatable medical conditions that can present in the identical manner.

QUESTION: Just to follow up on that, so right now, to the best of your knowledge, there's 11 people in isolation because they're suspect SARS cases, even though, of course, you don't know that they're SARS cases?

DR. GERBERDING: In terms of where these individuals are at this exact moment in time, I can't tell you. It's possible that some of them have already been evaluated and deemed not to be a case and have been removed from the list. But as of our most recent understanding, these patients are in a state of isolation.

QUESTION: [inaudible] improved in Hanoi and Hong Kong, did they improved based on treatment or [inaudible]?

DR. GERBERDING: Right now there's been on standard approach to treatment. Some of the patients have received supportive care, mechanical ventilation and/or--actually, I don't know if any of the improved people were on ventilators, if they got sick enough to require ventilation. But the information we have right now does not give us a clue that there's anything particularly important treatment-wise in their improvement other than time, good nursing care, and supportive medical treatment such as hydration, et cetera.

QUESTION: [inaudible].

DR. GERBERDING: Can we just take one more telephone question? And I'll come back to you.

AT&T OPERATOR: Surely. That will come from the line of the Associated Press with Dan Haney (ph). Please go ahead.

QUESTION: Hi, Dr. Gerberding. I wonder if we could return to that Hong Kong hotel for a minute. The fact that there were seven people who got infected and, as best anyone knows, their main risk was that they were all on the same floor of that hotel, does that suggest that this might be more easily transmitted than we had previously thought?

DR. GERBERDING: I think that's what--that's the information we need to know: what was the kind of contact that the individuals in the hotel had with each other. We so far know that at least two of them were close visitors with each other, and so there's an obvious means of transmission between those two. We don't know how frequently or how often or exactly when they visited, but the linkages between the others are under active investigation now by the local health department, the WHO teams, and that is exactly what they're going to be trying to figure out over the next couple of days.

Last question here.

QUESTION: In the midst of investigating SARS, CDC also has to respond to an increased security level [inaudible] possibility that if, in fact, we go to war, there might be some biochemical terrorist acts here that the CDC would have to respond to. Are you concerned that you're spread too thin? And do you have [inaudible]?

DR. GERBERDING: We have never been more prepared, and I think the fact that we have activated our emergency operation center puts us in very good shape to being immediately ready to respond to any new threat that should emerge during this state of Orange Alert. Not only are we activated, we've put our emergency response teams on readiness call. We are using the principle of parsimony; in other words, we're working on the SARS investigation with the right number of staff and being very strategic not to overstaff because we want to make sure that we do have our reserves ready to go if we need them for another event.

We're also taking a number of steps here at CDC to improve our physical security. We have a very close network now with the Georgia emergency management group, with the Georgia homeland security group. We have FBI presence on campus. We are linked into the intelligence network. And all systems are up and running, and we are--we are as prepared, I think, as an agency could possibly be at this point in time to respond to what may be in store.

Thank you.

CDC MODERATOR: That concludes our briefing today. We thank you for joining us. For those reporters who are listening on the phones and who may not have had an opportunity to ask your question, please call our Medial Relations office, and we will make every effort to have someone available to you this afternoon to respond to your questions.

Again, thank you for joining us, and we will keep you up to date as we get more information.

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

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