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CDC Telebriefing Transcript

SARS: CDC Involvement in Global SARS Investigation

March 21, 2003

AT&T OPERATOR: [In progress] -- At this time all participants are in a listen-only mode. Later we will conduct a question and answer session. If you would like to ask a question, you can depress the 1 on your touchtone phone. You may remove yourself from queue any time by pressing the pound key. Also if you're using a speakerphone, please pick up your handset before pressing the numbers. Also if you should require any assistance during the call today, please press 0 then star.

Your host for your conference today will be public affairs officer with the CDC, Dan Rutz and you will now hear background noise until the conference begins.

CDC MODERATOR: I'm Dan Rutz from the Communications Office of the National Center for Infectious Disease at CDC.

We're glad you're here, and we appreciate the fact that you consider this story as important as we do. We know there's a great deal of public interest in the continuing investigation of SARS, and although we do not have any breakthrough news today, the story is progressing incrementally. There is some progress to report, and Dr. Julie Gerberding, the Director of the CDC will be offering some opening statements and then responding to your question both on the telephone and in the room. Thank you.

Dr. Gerberding?

DR. GERBERDING: Thank you again for joining us for this update. The CDC MMWR came out today with a good summary of what's going on in the progress of the investigation, but I did want to update you on a few specific points.

First of all, to date WHO is reporting 337 cases of SARS from 14 countries. That is including 10 people who have died from the illness internationally, and in the United States we are aware of 22 reports of SARS that are under investigation in a total of 12 states. We have not had deaths in the United States to this point in time.

Two notable aspects of the investigations ongoing in the United States, first of all, we have identified situations where a case in a traveler may have involved transmission to others in the United States. So first of all, in one cluster, an individual who traveled to Asia may have been the source of infection in two health care workers who provided care, and in the second situation, one person who traveled to Asia may have been the source of infection in a family member. Again I'll stress these are undergoing active investigation, and so we can't confirm that this is the situation, but we wanted to alert you to the fact that spread to contacts of travelers with this illness may be occurring in the United States.

In addition, we're aware that two Americans stayed in the hotel in Kowloon, Hong Kong, that's been implicated as the initial source of most of the spread of this disease. The two Americans were staying on the ninth floor of the hotel, which is the place where almost all of the international cases appeared to have been exposed initially during sometime in February. Those two Americans are here and are included in the 22 cases that I mentioned earlier, and we are continuing to investigate the situation in Hong Kong.

The Hong Kong Health Department is doing a very thorough job of evaluating who was in the hotel and where they are now, and the investigation will evaluate potential modes of spread in that environment. And we look forward to their updates as we go forward.

We are of course very appreciative of how stressful this is right now to the people who are undergoing evaluation of suspect cases in their families and the health care workers who are taking care of them.

We know that we can apparently prevent spread of this illness by use of appropriate precautions in health care environments, and that still seems to be the case in Hong Kong, where once properly isolated the potential for transmission to other health care personnel is decreased.

However, we also know that in Hong Kong at least, where there are 203 patients reported with this illness, about a third of them involve family members and close household contacts. The other two-thirds are health care personnel. And so far we are not seeing any cases even in Asia outside of these groups.

From the standpoint of the identification of the cause of SARS, CDC is continuing to receive samples from the international outbreak, and our laboratories, I can assure you, are working around the clock to get clues to the etiology. It would be premature to make any announcements today, but we are working in close collaboration with the other laboratories around the world, including those that have identified virus particles that are likely to be paramyxoviruses.

We also have convened a consultation with molecular biologists who have international expertise and experience in looking for unusual organisms. That consultation occurred over the last 24 hours, and we will be sharing specimens and engaging the support of these expert scientists to assist in identifying the organism.

We are not making any new treatment recommendations for this illness beyond those that we had already recommended, and that is to be sure that clinicians don't overlook more common causes of infection and treat accordingly. SARS is really a diagnosis of exclusion and we want to make sure that people get state of the art care for other conditions that would easily be confused with this illness.

We have taken several steps in the last few days, even in the last 24 hours to assist in our progress in the investigation, and interventions to prevent spread. We've issued about 35,000 health alerts to arriving travelers and have intercepted more than 5 planes and boats that have passengers ill that have recently traveled to the affective areas. So these efforts are resulting identification of additional suspect patients and have led to I think a much greater awareness among travelers of the need to seek medical attention if a fever and respiratory are developed after departure, within 7 days of departure from one of the suspect countries.

Our emergency operations center continues to manage this operating in conjunction with our National Center for Infectious Diseases. We are probably in full court press in terms of the degree of support going into this operation. We have established several teams at CDC including epidemiology and surveillance team, an information technology team, a laboratory investigation team, a communications team, and a quarantine team, and I think new to CDC this time is a hotel team which is assisting in the evaluation of the hotel in Kowloon that has been implicated as the potential epicenter for spread of this infection.

We will continue to provide you updates if we have breaking news over the weekend. We'll of course make that information available to you, and will do everything we can to continue to put information out to the medical community as well as all of our partners in the public health community who are really doing a gold standard job of evaluating the suspect patients and getting the word out to their communities that we need to be highly vigilant for this condition.

Let me stop now and take some questions. We have questioners on the telephone and in the audience, and we'll start with a question from the telephone.

AT&T OPERATOR: Liz Cohen with CNN. Please go ahead.

QUESTION: Hi, Dr. Gerberding. I want to make sure I heard it correctly. WHO's reporting 337 cases in 13 countries?

DR. GERBERDING: 337 cases in 14 countries.

QUESTION: 14 countries, okay. And the other thing was you then talked about the two situations, one contact with family members, one was different. Could you go over those again please?

DR. GERBERDING: One situation involves a case patient who had traveled to Asia and may have been a source of virus transmission to two health care workers. That's not confirmed at this point in time, but the health care workers are included in the list of suspected cases.

And second, an individual who traveled to Asia to the affective areas may have been the source of infection in a family member in close household contact.

Can we have a question from the floor?

QUESTION: Marian McKenna, Atlanta Journal Constitution. Do you have any sense of how many generations of cases there have been so far, and is there any indication that whatever the organism is, that it's weakening at all, or reducing the infectiousness, whatever the appropriate terminology is as it moves from generation to generation?

DR. GERBERDING: The question is how many generations have occurred. We have very little information to ascertain that accurately, in part because in both the household and the health care situation, it's sometimes difficult to tell who's the source and who's the recipient, since there are multiple combinatorial events occurring simultaneously.

But I think the fact that we have been able to prevent spread to the community suggests that the infection control isolation practices in the hospital have been effective. In Vietnam, for example, there are no new cases reported in the last 24 hours, and that is I think a success story of infection control, and suggests that we may have limited spread beyond the first generation of individuals.

And so in answer to your question, it's too soon to tell whether or not there's any change in the attack rate or the virulence of the organism as it moves forward in the clinical population.

And let me just clarify one other issue. When I said that WHO is reporting 337 patients today, that does not include the 22 cases from the United States. We have a complex logistic problem here in that the time zone differences between Asia, Geneva and CDC Atlanta mean that we're getting a synchronous update on the number of case count. So CDC is putting out one set of information from WHO that does not include the U.S. cases because those get updated and refreshed at one point in time, but we want you to have the most recent information about domestic cases under investigation, so we're providing that information separately to be sure that everybody has the most up to date number from the states under investigation by CDC and other health agencies.

Can we take another question from the phone, please?

AT&T OPERATOR: We'll go to Seth Borenstein with Knight Ridder. Please go ahead.

QUESTION: Thank you very much.

Dr. Gerberding, about the local transmission, now that you have suspect--two local transmission suspect situations, how does that change, in other words, the magnitude of this for the CDC and in terms of how you control what your recommendations are?

DR. GERBERDING: The pattern of transmission here is exactly the same that we've observed in the other affective countries in Asia, and that is, health care workers and close personal contacts.

Now, what this means to us is that when you have an individual who's traveled to an affective area and that person develops fever and respiratory symptoms within 7 to 10 days of their departure, they should seek medical care, and they should be isolated immediately while the situation is being sorted out to prevent that transmission to health care personnel or ongoing risk to family members. So early detection and early isolation are really critical here.

Question from the phone.

AT&T OPERATOR: Our next question is from Robert Bizelle, NBC News. Please go ahead.

QUESTION: Dr. Gerberding, could you give us some more details? You said 5 arriving either planes or ships, so I assume they're planes, have been investigated. What does that mean? Does that mean the passengers are quarantined for some period of time, or they're given a card to go home and watch for symptoms? Tell us more about that process and how it unfolds.

DR. GERBERDING: Certainly. Dr. Cetron, who's our scientist and expert in quarantine and isolation is here, and he's really been handling this part of the investigation, so let me ask him to step to the podium.

DR. CETRON: My name is Marty Cetron. I'm Deputy Director for the Division of Global Migration and Quarantine. And Dr. Gerberding is right. The process basically goes something like this. We meet all the direct and as many of the indirect arriving flight as we're aware of, and that's an ever-increasing number. More than 50 flights a day are being met arriving from these locations where there's transmission.

Those flights are met and all the disembarking passengers are handed a passenger alert card, and we'll pass those out here. This card is available in four languages, and indicates that if you develop fever and respiratory disease within a week after returning from one of these areas where there's local transmission, keep the card with you, call your health care provider, and make an appointment right away. Bring the card to the provider, and there's the contact information for numbers on how to report the case, both to your state and local health department, as well as reporting the case here to the CDC through the emergency operation center.

And this goes on routinely on a daily basis. We're up to about 10,000 air arriving passengers a day.

Most of the cruise ship arrivals from that part of the area don't come directly to U.S. ports of call, so we've distributed these passenger alert notices to the directors of those lines, cruise lines, as well as cargo ships and all the other sort of networks we have for handing that out for arrivals by sea.

Now, in the event that there is a sick passenger reported either in flight in transit or at the airport on arrival, a quarantine inspector or a designee of the quarantine station will meet that flight, get on board, isolate and take off the ill passenger, and facilitate that person's going to a health care facility and getting that case reported. But in addition they will temporarily detain the arriving passengers and request that they fill out an information sheet with their contact information over the next 14 days and alert them to signs and symptoms of this possible disease. In that way those passengers who are no longer--who are not ill, can go home and just be alert to symptoms. In the unlikely event that one of those persons becomes ill, they can quickly get into isolation.

So, technically no, we're not quarantining any passengers on arriving flights. We're isolating sick cases, people that have consistent symptoms.

DR. GERBERDING: Thank you. Can you take another question from the telephone?

AT&T OPERATOR: Rob Stein with the Washington Post. Please go ahead.

QUESTION: Yes. The transmissions that have occurred locally, can you tell us where they occur, what states?

DR. GERBERDING: We're going to again defer that information to the state and local health agencies, and when they have made that information public, it will be reflected on our web, and you can follow up with our press office to get those details.

We have a question from the floor.

QUESTION: Betsy McKay from the Wall Street Journal.

Dr. Gerberding, could you tell us anything more about the samples that you've received and that you're working with, remind us when they came in, where they come from, and what they're showing that these are similar to or different from what other labs around the world may be showing?

DR. GERBERDING: Let me summarize the big picture and then I'll ask Dr. Anderson to fill you in on a little bit more of the detail.

Samples are coming in from a variety of sources, including domestic patients in the United States that are under active investigation by their state and local health agencies, but in addition, we have received specimens from Canada. We have a very close working relationship with Health Canada and health officials there, so an excellent collaboration there. We also have received specimens from multiple patients in Asia.

Maybe Dr. Anderson could just give a big picture of sort of the protocol as we approach them for the diagnostic evaluation.

DR. ANDERSON: Thank you. We're looking broadly. There are a number of hypotheses that a number of labs have identified and we're trying to pursue those, and all the specimens that do come in, we cross-section those that we think are closest to the case definition and most likely related to this outbreak we're pursing in depth, doing tissue culture isolation, a variety of molecular techniques to identify viruses, bacteria or any agent that might be possibly associated with the outbreak. And then those hypotheses that we generate, we try to go back and make sure that it's not, it's a real finding, and then if it's linked to the outbreak, so we're in the process of doing these things.

[Start Tape 3.]

Question from the phone, please.

AT&T OPERATOR: Jeremy Manier with the Chicago Tribune, please go ahead.

QUESTION: Thanks very much. Dr. Gerberding, can you just describe a little bit if there's any information on what kind of people have been known to have died from this in Asia. I know that some of the reports suggest that the victims have been in their forties, some of them. Can you tell us what that might mean as far as the virulence of the infectious agent, and is it more concerning that some of the victims who died might be younger, rather than in their sixties or elderly, as a lot of the [inaudible] patients [inaudible].

DR. GERBERDING: Let me just tell you that your reception is a bit broken, so I'll try to recapture your question. I believe you're asking me about the individuals that have died from the infection, what is their age distribution and what does that tell us about the virulence of the organism.

QUESTION: That's right.

DR. GERBERDING: We do not have complete information on all of the patients, including those that have died, but what we can say so far is that some of the individuals with severe pneumonia and death have been relatively healthy, middle-aged people, and that tells us that this is a disease that can be virulent and life-threatening, even among those who are otherwise probably immunologically healthy.

Of course, until we have all of the information about those individuals, we can't conclude that for sure, but I think the high attack rate in health care workers caring for the early hospitalized patients in those regions of the country suggests that it is certainly contagious, and it is certainly a virulent pathogen capable of causing severe disease.

On the other hand, the fact that we're now hearing more reports of recovery and that some patients are released from the hospital, for example, in Vietnam, this is very encouraging that even in the absence of any specific therapy, that good, supportive medical care can get people through the crisis and that they can recover.

Do you have another question from the phone?

AT&T OPERATOR: Robert Benjamin, Baltimore Sun. Please go ahead.

QUESTION: Yes, thank you.

I've seen some conflicting reports on the involvement of the WHO in China as to when they were exactly called in. I've seen one report that says they weren't formally asked to get involved in this outbreak in China until this spring, and then I've heard another report that they were actually in country last fall and maybe concluded it wasn't much of a problem then.

Can you clarify this at all for me?

DR. GERBERDING: I can't clarify for you the communication that WHO has had with China. What I can say is that right now the government in China has indicated a great desire to engage the support of the WHO, that the CDC investigator has been invited to participate on the team, that China is issuing visas to join the team at the airport, which indicates I think that they are willing to side-step a lot of paperwork and bureaucratic process to speed up the investigation and that right now, from the CDC standpoint, we're in a very collaborative and cooperative mode.

So we really look forward to getting in there and being able to try to understand a bit better what has happened there over the past several months and what may possibly be happening there now.

Let me take another telephone question because I understand the queue is long.

AT&T OPERATOR: And we have a question from Erika Niedowski with the Baltimore Sun. Please go ahead.

QUESTION: Thank you. Dr. Gerberding, the other day you told us that the paramyxo virus had been found only in a sample from basically a nasal swab. Has the virus been found in other types of samples and have there been any other agents that have been identified?

DR. GERBERDING: My information is that the status of the laboratory investigation is incomplete from the international perspective, but laboratories in Germany and Hong Kong have identified particles that appear to be paramyxo viruses. Other laboratories are providing preliminary evidence that they may be seeing something that doesn't quite look like a paramyxo virus.

This is just far too early to draw any firm conclusions, and I think what we really want to do is see an agent in affected tissues, so in lung tissue, and we want to be able to culture that organism or at least sequence its DNA or RNA so that we can definitively associate it.

But in addition, like all scientific investigations, it's not enough to just find it in one person. We have to have identification of the agent in most of the affected cases and not find it in individuals who are not in the case category.
This is going to take some time, and as Dr. Anderson indicated, we want to focus initially on the most likely specimen to harbor the virus and then work out from that circle into a broadened investigation.

I think we all remain confident that we eventually will be able to identify this pathogen, but it is too preliminary to ascribe the disease to any particular agent at this point in time, and we still have an open mind about what we're ultimately going to learn.

QUESTION: Would you just clarify for us the report of two Americans who were staying in the Metropole Hotel. First, is either of those Americans the American citizen who subsequently went on to Hanoi and may have been the source of the outbreak in the hospital there? And if neither of those people are, that doesn't sound good. Can you tell us anything else about them?

DR. GERBERDING: The two Americans that have been added to the list beyond what was initially reported from Hong Kong, one of them was an official who was there in February and left at the very beginning of March, and there are no known cases of secondary transmission associated with that individual.

The second person arrived in very early March and departed soon thereafter, and again there are no known cases of transmission associated with that individual during their illness, but it's early, and the evaluation assessment of that is still ongoing.

If we can take a phone question, please.

AT&T OPERATOR: Maureen Taylor with the Canadian Broadcasting Corporation. Please go ahead.

QUESTION: Yes, thank you. I don't know if the American media is aware that there was a transmission from patient-to-patient in one Toronto Hospital, and I just wonder if you can comment on that transmission and what that says about the ease with which it is transmitted.

DR. GERBERDING: We are referring questions about the transmission modes in Canada to the Canadian health officials there. We have not yet confirmed that report here in Atlanta, but I think again it stresses the importance of respiratory isolation for these individuals, strict airborne precautions.

What that really means is that patients are to be in a negative-pressure room, health care personnel are advised to wear N95 respirators that are properly fitted and that hygienic practices to prevent exposure to droplets, including face masks and so forth. Patients should be isolated in these rooms and not share that space with other patients.

Part of the reason that we updated our guidance to clinicians for infection control over the weekend was to emphasize the importance of early isolation, even when patients are coming into the ambulatory care setting so that we minimize the potential for exposure before the syndrome is fully recognized and the patient is submitted to the health care facility.

So it's an ongoing concern that's going to take a great deal of vigilance to prevent spread within the health care setting.

I'll take one more question from the phone, please.

AT&T OPERATOR: John Mullerman with Bloomberg News. Please go ahead.

QUESTION: Yes, thanks for taking my question.

How many of the 22 patients in the U.S. are showing signs of pneumonia?

DR. GERBERDING: I'm going to quickly defer to Dr. Hughes here because I'm not sure I have that line listing in front of me.

We can get back to you with that information after the press conference. I apologize for just not having it at my fingertips here.

We'll just take one last question from the phone, please.

AT&T OPERATOR: We'll go to Tom Watkins with CNN. Please go ahead.

QUESTION: Do you have the legal authority to isolate people who may not want to be isolated? And in any of the cases where you've asked people to be isolated have they balked?

DR. GERBERDING: I'm going to answer that question, first, from the standpoint of people who are in the health care setting, and then I'll ask Dr. Cetron to address it as it applies to ports of entry in the U.S.

The authority for quarantining patients who pose a public health threat resides within the jurisdiction of individual states. Hospitals are required to have infection control or health care epidemiologists who has the ability to identify when there is a need for isolation and quarantine and to work with local health officials under the appropriate state statutes to ensure that individuals are placed in situations where they don't pose a contagion threat to others in the community.

Let me just ask you to comment on that applies to passengers arriving from international travel.

DR. CETRON: Yes, as you know, the quarantinable disease list is made at a time when they don't anticipate all of the diseases that could emerge, and we've had lots of diseases to emerge.

There are federal quarantine authorities that deal with international arrivals, and this disease, as you can imagine, is not anticipated, not specifically on that list. There are many ways to work through the authorities at the state and local level, as well as airlines have their own rights and refuse boarding to people who are sick.

DR. GERBERDING: I'll take one more question from the floor.

QUESTION: Daniel Ye with Associated Press. I have like a couple of just partial questions.

How many of the American cases have been upgraded to probable or are they still all setbacks?

And then I guess we've heard today that WHO has a diagnostic test, and what do you all know about that, and how definitive is it, and when can it, I guess if it is definitive, how soon would it come to the United States?

And then I guess in a follow-up question you mentioned that regarding one of the Americans, there was a source of virus transmission to a health care worker. Are we now calling it a virus, as opposed to any other type like a bacteria or something else?

DR. GERBERDING: Thank you. Let me clarify your last question first. If I used the term "virus" that was incorrect. I should still refer to this as a pathogen of unknown etiology because we have not established that it is a virus, and that is a very, very important point.

We are still looking broadly, we're looking at unusual bacteria. We are looking at a number of viruses. Our clinician consultants who provided input yesterday agreed that this disease does not follow a pattern of something that they are familiar with so it's either an unusual presentation of something we already know about or a new or different version of something that we've had experience with in the past.

With respect to the diagnostic test, it would be very unlikely that we would have a reliable diagnostic test when we don't have an etiology for the condition. We do have a case definition, which is based on clinical findings and clinical observations, as well as the epidemiologic history, and that's what we're using right now to define probable or suspect case.

And, finally, with respect to the categorization of individual patients in the United States, we are collectively referring to them as cases under investigation or suspected cases, without specifically categorizing them as suspect or probable for the time being because, first of all, this is evolving as we go, and, second, we're looking forward to the identification of the pathogen.

I think when we have an organism, that is going to help us provide a great deal more accuracy in the case definition.

I am understanding we have a few more people on the phone, so if there are additional telephone questions, I would be happy to take a couple more questions.

AT&T OPERATOR: We'll go to the line of Marilyn Marconi. Marilyn Marconi with the Milwaukee Journal, please go ahead.

QUESTION: Thanks, Dr. Gerberding and Dr. Anderson. I want to return to that specimen issue.
Has any lab anywhere reported finding paramyxo virus particles in a specimen other than nasal samples?

DR. GERBERDING: Dr. Anderson, can you answer that?

DR. ANDERSON: One laboratory reported finding paramyxo virus-like particles in serum or a blood specimen as well.

DR. GERBERDING: I'll just add that on the first tissue specimen that we received, which may not have been the ideal sample, we did not find paramyxo virus-like particles in the initial evaluation of the sample. So we have a long way to go before drawing any conclusions from that at CDC.

Another telephone conversation?

AT&T OPERATOR: We'll go to Susan Dentzer with The NewsHour. Please go ahead.

QUESTION: Yes, Dr. Gerberding, would you just relate the 22 cases being mentioned today to the 40 that were mentioned two days ago. Is the 22 a subset of the 40 or are they new cases as others fell off the list? What exactly is the relationship?

DR. GERBERDING: Yes, what we reported initially were the number of calls we had received from concerned clinicians or health officers asking about whether a particular patient might or might not be a case of SARS, so we reported the total number of inquiries that we received about individuals that could fall into this definition.

When we get an initial report like that, of course, we ask specific questions to see if there's any criteria in the case definitions that are not met, and once we have done that initial screen, we can determine relatively easily, no, for goodness sakes, that's the person who definitely doesn't have any of the attributes of this illness, and there's no need to investigate them further as a SARS case or, if they do have the fever, the travel history and the respiratory symptoms, then they would be included as a case under investigation.

So the 40 was the broad group, a kind of potpourri of queries, and the number we're reporting today, the 22, represents individuals who meet the screening definition for inclusion as a case and are under much more active investigation and would be isolated and treated as if they were a case until information became available to suggest that that was not true.

A question from the floor?

QUESTION: David [inaudible] with Fox News.

Dr. Gerberding, sometimes what you don't know is as good a clue as what you do know in investigating these things. With all of the resources being put into determining what this is, domestically and internationally, do we have any indications that this may not be a naturally forming organism, if I can call it that, or any other clues that you're getting from what you've eliminated?

DR. GERBERDING: I agree with your statement that sometimes what you don't find is as informative as what you do find, but we are not finding our garden-variety activity, and no one is reporting influenza viruses from any of these patients, and so that suggests that this is unlikely to be an influenza illness.

But the fact that we're not being able to say what virus specifically it is is actually not unusual. In this country, we report many thousand cases of pneumonia every year, and we often do not have the etiologic diagnosis.

What's unique about this situation is that clearly there is a chain of transmission, a great degree of contagion before precautions are implemented, and we are searching hard to find this specific agent because we want to understand better what's going on and determine whether there are specific therapies.

QUESTION: [Off microphone.] [Inaudible.]

DR. GERBERDING: The information we have right now in terms of spread to health care workers and close personal contacts is very consistent with a naturally transmitted pathogen of some nature.

The situation in Hong Kong in the hotel, where there were so many people infected by being in this particular area at the same point in time is also consistent with having a source patient or a source individual who is a very good transmitter of the pathogen, but we are keeping an open mind about terrorism, especially given the time that we are operating in, and I can assure you that the Hong Kong Health Department has engaged law enforcement officials there and the full cadre of epidemiologists and experts to make sure that we're not leaving any stone unturned in identifying the ultimate cause of the problem.

So all indications right now is that this is naturally occurring infectious disease, but we are not ruling out any possibilities until we've pinned down the actual source.

I have time for one more phone question, and then we will end the press conference. So if I can have the last phone question, please.

AT&T OPERATOR: We'll go the Steven Smith with the Boston Globe. Please go ahead.

QUESTION: Hi. Good afternoon, Dr. Gerberding.

I was wondering if you or one of your associates could be a bit more concrete in describing what has happened and what will happen in the future when you intercept incoming planes on which there is a suspected case.

What are the steps that happen at the airport and then in transporting that potential patient to a health care setting and what happens when the person gets to the health care setting?

DR. GERBERDING: If we could ask, again, Dr. Cetron to take that question, and if you need more details, we could also perhaps arrange for you to talk with him after this press conference.

DR. CETRON: As Dr. Gerberding pointed out, the earlier we identify suspect cases and get them in isolation, the greater the likelihood of containing further person-to-person spread.

So if we are fortunate enough to hear about these cases while the flight is ongoing, a call gets made from the pilot through, it gets forwarded through to the quarantine station at the port of entry that has jurisdiction. A quarantine inspector is dispatched to meet the flight, and they meet the suspect case, put a mask on the case, separate the case from the other passengers.

There are even some guidance emerging about how they could potentially isolate a case in flight, in terms of having masks available and locations and so on, but that's what can be done.

That case is then taken, with infection control procedures in place, and transported to a health care facility with the identification and the alert card in hand. So the ambulatory setting is already one step ahead, and it prevents spread in that ambulatory setting as we've seen.

The other passengers who are well, they're interviewed to see that they are, in fact, well and not febrile and coughing. Those that are well are not put in quarantine. They are asked to provide contact information for where they will be reachable over the next 14 days. And if they develop any signs or symptoms, as it says on their Health Alert card, they can follow up by contacting a health care provider and take exactly the same steps.

In that 14-day period, we also plan to follow up actively with those folks through the state and local health departments. So they are contacting the contacts of passengers who are on planes with ill passengers to make sure, if we can know for sure that this is not transmissible during the routine course of international flights. That will have everybody rest much more comfortably.

I hope that answers your question.

DR. GERBERDING: Let me thank you, again, for coming here to participate in this update. We will make any news available to you over the weekend, but we are not planning to have a regularly scheduled press conference over the weekend unless we have breaking news or some other information that we really need to get out.

So I appreciate your time and have a safe and pleasant weekend.

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