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Press Briefing Transcript

CDC Telebriefing – Updates On Middle East Respiratory Syndrome Coronavirus (MERS-coV) Investigation In The United States

Saturday, May 17. 2014 3:30 p.m. ET

OPERATOR: Welcome and thank you for standing by.  Your lines are in listen-only mode until today's question-and-answer session.  At that time if you would like to cue up you may do so by pressing star one on your phone.  Today's conference is being recorded.  If you have any objection, you may disconnect at this time.  I would like to turn the call over to Barbara Reynolds.  You may begin. 

BARBARA REYNOLDS: Thank you, Kate.  Hi, this is Barbara Reynolds.  I’m with the public affairs office at CDC.  Welcome to CDC’s update on the Middle East Respiratory Syndrome Coronavirus investigation in the United States.  We have one speaker this afternoon.  After I introduce the speaker, he will give brief remarks and then we'll go into Q and A, and we hope we can answer as many questions as possible today in this call.  I want you to know that we will also be posting a transcript of this call as soon as possible after we finish.  I'd like to now introduce Dr. David Swerdlow who is CDC's lead on the response to the MERS-coV investigation and he also holds the rank of captain in the U.S. public health service.  Dr. Swerdlow? 

DAVID SWERDLOW: Thank you so much, Barbara, and thanks, everyone, for joining us.  When we recently announced the first two confirmed imported cases of MERS in the United States, we committed to keeping the public informed of new developments and that's why we’re having this telebriefing today.  Today we have updated information on one of the contacts of the first U.S. case of MERS confirmed on May 2nd in a traveler from Saudi Arabia to Indiana.  As you recall, the Indiana patient traveled April 24th from Saudi Arabia to Indiana via plane through London through Chicago.  The patient experienced increasing fever and developed respiratory symptoms on April 27th and was hospitalized on April 28th.  By May 9th he was fully recovered and was discharged.  Prior to being admitted to the hospital, the Indiana patient had extended face-to-face contact on April 25th with a business associate in Illinois.  The two had another brief contact on April 26th.  This business associate, who is an Illinois resident, has been identified as having evidence of apparent past infection with MERS-coV. 

Before discussing details about the Illinois resident, I'll do my best to explain how we test for MERS-coV infections.  There are two main ways.  We can collect a respiratory sample and use a test called PCR to determine if a patient has active infection with the virus.  We can also do a blood test that looks for antibodies to MERS-coV which would indicate a person had previously been infected with MERS-coV.  Both types of testing were done on the Illinois resident.  So, after being identified as a contact of the Indiana MERS patient, the health department began on May 3rd to monitor the Illinois resident daily.  This was done because the Illinois resident had met with the Indiana MERS patient on the two different occasions I mentioned already.  The health department used PCR to test respiratory samples from the person on May 5th.  Those tests were negative.  Again, this test can detect a virus in a person who has active infection with MERS-coV.  Public health officials are collecting blood samples from people who are identified as close contacts of the original Indiana MERS patient. 

For the Illinois resident, we learned last night that the test result was positive at CDC showing that he has antibodies to MERS-coV.  This means he was exposed to MERS-coV and produced an immune response to fight off infection with the virus.  The Illinois resident has had no recent history of travel outside the United States.  Information is still being gathered about the Illinois resident.  At this time he's reported to have had mild cold-like symptoms, but he did not seek or require medical care since exposure to the Indiana MERS patient.  He is currently reported to be feeling well.  Public health officials have advised him to remain in self-isolation until further tests are completed.  Self-isolation means staying away from other people or wearing a mask.  The investigation of the first case of MERS in the United States that was previously reported from Indiana has been very aggressive.  CDC has tested more than 50 people who were identified during the contact investigation of the Indiana MERS patient, and none of them have tested positive for active infection with MERS-coV. 

We are early in the process of testing these people for evidence of past infection.  This aggressive approach is intended not only to ensure public safety but to learn more about how the virus is transmitted and to help the global scientific community gain a better understanding of the virus.  The investigation of the Indiana MERS patient is not finished.  This preliminary finding will extend our investigation.  Just as we did with the investigation of the patient in Indiana, we will be contacting, testing, and monitoring people who had close contact with the Illinois resident.  The situation is still evolving and more results this week are expected on contact investigations that are already under way.  As the CDC gathers additional information, we will consider the implications of these findings and update our recommendations when appropriate. At this time our recommendations to the public, travelers, and healthcare providers have not changed. 

For the general public, CDC routinely advises that people help protect themselves from respiratory illnesses by washing their hands often, avoiding touching their face with unwashed hands, avoiding close contact with people who appear sick, and disinfecting frequently touched surfaces.  For travelers at this time CDC does not recommend that anyone change their travel plans.  If you are traveling to countries in or near the Arabian Peninsula, CDC recommends you pay attention to your health during and after your trip.  The travel notice for MERS-coV was upgraded to a level two alert.  The travel notice advises people traveling to the Arabian Peninsula for healthcare work to follow the CDC's recommendations for infection control and other travelers to the Arabian Peninsula to take general steps to protect their health. 

Healthcare professionals should evaluate patients for MERS-coV infection who have fever and pneumonia, or acute respiratory distress syndrome, and either a history of travel to a country in or near the Arabian Peninsula from 14 days from symptom onset or have had close contact with a symptomatic traveler who developed fever and acute respiratory illness, but not necessarily pneumonia, within 14 days after traveling from countries in or near the Arabian peninsula or part of a cluster of patients with severe acute respiratory illness of unknown ideology in which MERS-coV is being evaluated.  They should also evaluate in consultation with state and local health departments, anyone who has had close contact with a confirmed or probable case of MERS while the person was ill.  Thank you. 

BARBARA REYNOLDS: Alright. Thank you, Dr. Swerdlow.  Kate, if you would like, we'll go ahead and open up for questions. 

OPERATOR: At this time, if you would like to ask a question, please un-mute your line and press star one.  You'll be prompted to record your name.  Please record your name and affiliation.  Again, if you would like to ask a question, please press star one at this time.  If you would like to withdraw your question from the queue, you may press star two. One moment for our first question. The first question is from Elizabeth Weise.  Your line is open. 

ELIZABETH WEISE: Hi, thanks so much for taking my call.  So we have an Illinois resident who was exposed to the MERS virus, produced an immune response, and has tested positive via a blood test.  Are you saying that this person had MERS?  And second question, do we -- is there any reason to think that he might have been exposed anywhere but via the Indiana resident?  Had he ever been to Saudi Arabia?  You said he hasn't traveled outside of the country, but is there any reason to think he might have been exposed in some other way and does that make him the third MERS case in the United States? 

DAVID SWERDLOW: Thank you very much for that question.  We think that this patient was likely infected with MERS, but technically he doesn't count as an official case of MERS because the World Health Organization, which decides what the official case definition of MERS is, does not include this type of antibody testing as criteria for being a case of MERS.  In order to be a case of MERS, you need to have evidence of the actual virus detected, and that would be with a PCR test.  So although we think that this patient was likely infected and had a past infection with MERS, it's not actually being called an official case of MERS.  Your second question is we are not aware of any other previous travel to an area where MERS is occurring.  So we think it is most likely that this person's exposure was to the Indiana patient. 

ELIZABETH WEISE: Thank you. 

OPERATOR: The next question is from Caleb Hellerman.  Your line is open. 

CALEB HELLERMAN: Hey, thank you for taking the question.  One question I have is you said he had extended face-to-face contact with gentleman, the healthcare worker from Saudi Arabia.  What does that mean--what kind of contact would that mean, and does that at all change the way you're thinking as to what type of exposure would potentially cause an infection? I’m also curious as to how many people may have had similar contact with this guy who has been tested? 

DAVID SWERDLOW: Thank you for those questions.  When we did the investigation of the Indiana patient, we looked into all possible close contacts of the Indiana patient.  We determined that there were 53 healthcare workers, six household members, and this one business associate that we considered to be close contact.  So he did fall into our definition of a close contact.  So this doesn't necessarily change our interpretation of who can get MERS from other people. 

CALEB HELLERMAN: Thank you.  That answers my question.  I appreciate it. 

BARBARA REYNOLDS: Okay, next question, Kate? 

OPERATOR: Again, if you would like to cue up to ask a question, please press star one and record your name and affiliation when prompted.  One moment for our next question.  The next question is from Mike Stobbe.  Your line is open. 

MIKE STOBBE: Hi, thank you for taking the question.  I'd love a little more detail about this contact.  Could you say what kind of business meeting it was?  Was it a job interview?  How long was it?  Was it an hour, three hours?  Could you say where in Illinois?  Was it in Chicago?  I'd like to better understand the chronology.  In some of the initial reports of the Indiana case, you might have assumed that the guy got off a plane, got on a bus and went right to Munster.  Now it sounds like maybe he was in Illinois for a couple days before going to Munster.  Do you mind clarifying that? 

DAVID SWERDLOW: Nothing has changed about our initial evaluation of where the Indiana patient had been.  All the original information about the airplanes and the bus are all still correct.  This gentleman did -- the Indiana gentleman, the Indiana patient, traveled in a car to have a business meeting with this gentleman in Illinois from Indiana.  So it doesn't change anything about the conveyances or the buses or the airplanes, and he did have a business meeting with the business associate and had face-to-face contact, enough that we were concerned and included this person in our circle of people that we were monitoring, testing, and also considering for avoiding contact with other people. 

MIKE STOBBE: How long was the meeting? 

DAVID SWERDLOW: It was about 40 minutes. 

MIKE STOBBE: Was it in Chicago or where in Illinois? 

DAVID SWERDLOW: I can't really divulge that kind of confidential information for confidentiality reasons. 

MIKE STOBBE: Can you say the nature of the meeting? 

DAVID SWERDLOW: It was a business meeting. 

BARBARA REYNOLDS: The next question, please? 

OPERATOR: The next question is from Rich Besser.  Your line is open. 

RICH BESSER: Hi, Dave.  Can you talk a little bit about what symptoms the Indiana patient was having at the time of the meeting and does it change anything you're thinking about whether people can transmit before they're very symptomatic? 

DAVID SWERDLOW: The Indiana patient was reported to have already been having fever and myalgia and not feeling well.  So we don't really know exactly when people transmit this virus.  We would love to learn more and we are looking into ways to try to learn more.  But we don't know exactly when people transmit it.  We do know that the Indiana patient was having symptoms at the time of the interaction. 

RICH BESSER: Was he having a cough, any respiratory symptoms? 

DAVID SWERDLOW: Not that we're aware of. 

RICH BESSER: And you were saying that the Illinois person had symptoms of a cold.  Are you thinking that that was MERS or something unrelated? 

DAVID SWERDLOW: Well, we don't really know a lot of details about the symptoms that the Illinois resident had.  There has been some discussion about whether it could have been just allergies.  It was mild and did not require visit to a healthcare facility or hospitalization or anything like that.  He is doing perfectly well right now.  We do know that for certain. 

RICH BESSER: Thanks very much. 

BARBARA REYNOLDS: Okay, Kate, could we get the next question, please? 

OPERATOR: The next question is from Lisa Schnirring.  Your line is open. 

LISA SCHNIRRING: Hi, thanks for taking my call.  Are you able to say if the patient had any underlying health conditions or the age?  The second part of my question is, do you know if other countries are doing the serology tests on contacts like that?  It really seems like a vital piece of information to know, and I’m just wondering if you had any info about that. 

DAVID SWERDLOW: Yeah, thanks.  I really can't discuss his age, of course, but he appears to be fairly healthy.  In terms of other countries, the serologic test is being done in some other countries such as in the Netherlands, but not in, you know, Saudi Arabia at this time. 

LISA SCHNIRRING: Thanks. 

BARBARA REYNOLDS: Thank you, Kate.  Next question, please? 

OPERATOR: The next question is from Julie Steenhuysen.  Your line is open. 

JULIE STEENHUYSEN: I'd like to push a little bit on this.  I mean, clearly this patient has antibodies for MERS, and under most normal circumstances one would say that is evidence of having had MERS.  That is, you and I talked earlier this week; you guys did a study on patients in Jordan and considered them to have had MERS because they had the serologic tests.  Are you going to go back to the World Health Organization?  Does this just mean that our understanding of the virus hasn't yet -- the WHO's classification hasn't yet caught up with the science on this virus at this time?  It strikes me that this is the first non-imported case of MERS, this was transmitted on U.S. soil.  Can you speak to that? 

DAVID SWERDLOW: We are going to be in discussions with WHO to discuss the possibility of including serology.  The problem is that other countries have different serologies than ours and it's a little hard to standardize, but we are going to be in discussions with WHO.   

JULIE STEENHUYSEN: Thank you.

OPERATOR: The next question is from Rob Stein.  Your line is open. 

ROB STEIN:  Thanks very much for taking my question.  Two questions.  One was, those cold-like or allergy symptoms that the patient had, when did they occur exactly?  Also, I was wondering, if this was an asymptomatic case where somebody got infected and didn't get sick, does that change your sense of how dangerous this virus is, in that there might be a lot of people who get exposed but don't ever get sick? 

DAVID SWERDLOW: We think that this gentleman -- whether this was a cold or allergies occurred after the 14-day incubation period so it may or may not have had any association with his antibody positivity.  You know, as you know, when MERS was first reported, most people had very severe illnesses and many people died and many of those people had underlying conditions.  But we're certainly learning now that there can be a much broader spectrum of illness with MERS.  And we know that just from reports from Saudi Arabia and United Arab Emirates and other countries that at least 20 percent of the patients that they're reporting have not had any symptoms, so are asymptomatic.  So it's not surprising that we would find an asymptomatic, or a person without symptoms, in the U.S. either. Clearly, there's a much broader range of illness than we recognize with this virus because mainly only people who had very severe illnesses were being tested. 

ROB STEIN:  Thank you and so what would be the message to the public about this particular case?  How concerned should people be about this? 

DAVID SWERDLOW: Yeah, we don't think that this really changes the risk to the general public or have any significant changes to our public health practice.  If we see another case, we will probably do some similar types of investigation just so that we can learn more about how the virus is spread and who the virus is spread to.  So we certainly want to inform about what we've found out from this investigation, but it doesn't mean that we think that there has been a general change in risk to the population. 

ROB STEIN:  Just to be clear, this person is no longer experiencing even those mild symptoms, right?  He's totally fine right now? 

DAVID SWERDLOW: That's correct. 

ROB STEIN:  Can you say whether it's a man or a woman? 

DAVID SWERDLOW: It was a gentleman.  He was a male. 

ROB STEIN:  Thank you. 

BARBARA REYNOLDS: Thank you, next question, please? 

OPERATOR: The next question is from Helen Branswell with the Canadian Press.  Your line is open. 

HELEN BRANSWELL: Thank you very much for taking my question.  I have a couple if you don't mind.  One, is there any evidence that anyone who would be considered a close contact of the Illinois man is displaying any symptoms that one might think are MERS-like at this time, or he was exposed?  Secondly, I'd like to push a bit on this question about whether this actually changes our understanding of how this virus spreads.  Up until now the message has really been it doesn't transmit well person to person.  It transmits in hospitals where you have vulnerable people and procedures that put people at high risk and in household settings where you have close contact.  A business meeting is not typically close contact.  I kind of don't -- I can't get my head around how meeting somebody at a business meeting is the same as caring for somebody in a household.  One last thing if I could, given that this Indiana man was a doctor, is his business contact a healthcare professional? 

DAVID SWERDLOW: So the last one I can't reveal his business -- what business he is.  In terms of close -- we are doing the same things for the Illinois patient [Editor’s note: This should say Illinois resident] that we did for the other patients, for the Illinois gentleman that we did for the Indiana patient and the Florida patient.  So we are looking to see what kind of close contacts he had.  We are monitoring them.  We are testing them.  And we are asking them to self-isolate.  So we are treating the situation the same for now until we have more information.  So we have not changed our approach between the Illinois resident and the Indiana and the Florida patient.  So in terms of does this change our understanding that this virus – I mean for a long time we've known that this virus can be transmitted human-to-human, we’ve never said it can’t be transmitted human-to-human.  We've just said it doesn't do so easily or does so in a sustained way.  I don't think that this significantly changes our understanding.  When there is a traveler back to France, to Great Britain, to Tunisia, there were always some limited human-to-human transmissions but no generalized sustained transmission.  So given that we have looked at – you know -- even in the Indiana case we've looked at more than 60 people and there's no evidence of severe infections.  There's no people who were hospitalized, there’s no people who have likely cases of MERS.  In the Florida case we've looked at even more people.  I don't think that this changes our understanding.  It may be that as before an occasional human-to-human transmission may occur, but it's not sustained transmission and it's certainly not easy transmission. 

HELEN BRANSWELL: Can I just follow up on that, please?  You mentioned the U.K. cluster and one of the others.  In the case of the U.K. cluster, the index case went to see his dying son and transmitted and that's how it took off, so the person was probably both exposed to the second patient for a long time and also in close quarters and the man was quite vulnerable.  In a lot of the cases – in France, the index patient was sharing a room with somebody and that's how it transmitted.  Those are different scenarios than sitting across a table from somebody either at a business lunch or whatever this was.  You don't see this as different? 

DAVID SWERDLOW: Well, we don't understand a lot about how this virus is transmitted and that's exactly why, when we approached the Indiana patient and the Florida patient, that we cast a wide net and try to really understand more about transmission.  That's why we tested healthcare workers and that's why we tested household contacts and that's why we are even looking into people on the airplanes and buses.  This is exactly why we're doing this kind of investigation, to learn more.  I still don't think that we have any evidence that this virus is easily transmitted or can be transmitted in a sustained way. 

BARBARA REYNOLDS: Thank you.  Next question, please? 

OPERATOR: Next question is from JoNel Aleccia, your line is open. 

JONEL ALECCIA: Hi, thanks so much for taking my call.  I want to confirm, did you tell Mike that these two, the Indiana patient and the Illinois patient, were in a car together for several hours?  Is that right? 

DAVID SWERDLOW: No, no.  I’m sorry.  It is all a little confusing.  The Indiana patient drove from where he had stopped in Indiana back to Illinois to have a business meeting. 

JONEL ALECCIA: Okay.  And so to that point, people--you know, the public thinks of close contact, as Helen pointed out, as close contact.  So this issue of sitting across from someone at a business meeting, I was thinking if he was in a car, okay, that qualifies as close contact, but this seems much more like casual contact.  So how do we explain that to the public that you could be in a business meeting with someone?  That seems like it would be a little more worrisome. 

DAVID SWERDLOW: This person had face-to-face, close contact within six feet for over 30, 40 minutes.  Again, we are trying to learn more about how this virus is transmitted and that's why we're doing these investigations and that's why we're reporting this.  Again, we have had hundreds of other contacts and at this point certainly we'll be learning more in the future but at this point there's no evidence of transmission.  So we still don't think that this virus transmits easily, but it does transmit and that's why we've been concerned all along. 

JONEL ALECCIA: I see. And just one other question, if I could. How large is the circle of contact for the Illinois man now? 

DAVID SWERDLOW: We are reviewing all persons that the Illinois gentleman had during that time period, including family members and business contacts.  I have to say, I can't give exact numbers, but I have to say the number is actually very low because he was told on May 3rd to avoid contact with others.  So, in fact, the number is going to be fairly low. 

JONEL ALECCIA: Mmm hmm. Okay.  Can I double-check one other thing?  The Indiana patient, does he live here in the U.S., or does he live in Saudi Arabia? 

DAVID SWERDLOW: He works in Saudi Arabia. 

JONEL ALECCIA: But he lives here?  He's a resident here? 

DAVID SWERDLOW: He's a U.S. citizen. 

JONEL ALECCIA: Okay, great.  I guess I'll just ask one other thing.  So the question of calling it a case versus calling it -- if we're not calling it the third case in the U.S., we could call it the third infection in the U.S.? 

DAVID SWERDLOW: This gentleman was an apparent infection and the third known. 

JONEL ALECCIA: The third known and the first on U.S. soil? 

DAVID SWERDLOW: Apparently.  Again, a big caveat about all of this is that we are retesting and we are going to be confirming things and doing additional testing.  So I did want to make sure that everyone realized that this is an ongoing investigation.  Things could change.  We are retesting and so if anything changes, of course we will let you know. 

BARBARA REYNOLDS: Thank you.  We have time for two more questions, please? 

OPERATOR: Our next question is from David O'Neill with NPR.  Your line is open. 

JOE NEEL: It must be me; I’m Joe Neel from NPR.  I have one follow-up.  Is the Illinois man still on self-isolation precaution, or do you feel confident that he's not going to develop symptoms or present a risk to anyone from here on out? 

DAVID SWERDLOW: We think that the risk is very low but we're still not taking any chances and we're asking him to self-isolate until we have more information.  We're going to be running a couple more samples and then we might be able to have him not be on self-isolation. 

JOE NEEL: how long would you anticipate that might be lasting? 

DAVID SWERDLOW: well, hopefully we will have another set of samples on him and the results in the next day or so and then we can decide after that. 

JOE NEEL: Thank you. 

BARBARA REYNOLDS: Okay, thank you.  Last question, please? 

OPERATOR: The next question is from Elizabeth Cohen from CNN.  Your line is open. 

ELIZABETH COHEN: Hi, thanks so much for taking my question.  The first meeting, that's 40 minutes long.  How long was the second meeting? 

DAVID SWERDLOW: The first meeting was 30-40 minutes and the second meeting was shorter. 

ELIZABETH COHEN: Can you tell us how long shorter?  Five minutes, 30 minutes, 20 minutes? 

DAVID SWERDLOW: We were told that it was a short meeting. 

ELIZABETH COHEN: Okay.  During these two meetings, did they shake hands? 

DAVID SWERDLOW: Yes. 

ELIZABETH COHEN: Did they hug? 

DAVID SWERDLOW: I didn't ask that. 

ELIZABETH COHEN: Do we know beyond shaking hands? 

DAVID SWERDLOW: We can look into that more, but we were not told that he did anything other than shake hands.  I think the answer is no. 

ELIZABETH COHEN: As far as you know, shaking hands was the only actual physical contact? 

DAVID SWERDLOW: Correct. 

ELIZABETH COHEN: Okay and just to follow up on what Helen and others have said, when I hear prolonged and close which is what the CDC has been saying, I don't think of a 40-minute meeting but you're saying a 40-minute meeting in your language is prolonged? That’s considered prolonged? 

DAVID SWERDLOW: When we did the investigation, we looked into all of the contacts of the Indiana patient and we looked into all of his interactions, and this person, because of the nature of his close contact, was included in our investigation as a close contact.  We were suspicious enough in terms of his interactions that we did include him. 

ELIZABETH COHEN: I understand that.  But is that considered -- I think a lot of us had the wrong idea, like a lot of us think prolonged is someone you spend eight hours at work with, prolonged is a friend you spend the day with, prolonged is a husband or a wife or a child.  It seems like prolonged can just be a 40-minute meeting across the table with nothing but a handshake. That’s prolonged.

DAVID SWERDLOW: We know that we had face-to-face contact.  He was within six feet for a while and he shook hands.  The reason we're doing these investigations is to learn more about how this virus is transmitted and how often it's transmitted, how easily it's transmitted.  That's why we're doing these investigations.  As we learn more, we will certainly let you know and we are very committed to being able to make sure that people are protected and that's our primary concern. 

ELIZABETH COHEN: Out of the 53 healthcare workers and the six household contacts, how many of those have you tested? 

DAVID SWERDLOW: Of the 53 healthcare workers, they were all tested by PCR twice. 

ELIZABETH COHEN: And they were all negative on PCR? 

DAVID SWERDLOW: Yes. 

ELIZABETH COHEN: Are there any other tests that are ongoing or is that it? 

DAVID SWERDLOW: No, we will be doing serology on them as well. 

ELIZABETH COHEN: Okay, and so you're in the process of that? 

DAVID SWERDLOW: Yes. 

BARBARA REYNOLDS: Thank you, Dr. Swerdlow. 

DAVID SWERDLOW: Thank you.  Just in conclusion, our contact investigation indicates that there may have been some spread in the Indiana -- from the Indiana patient.  We're still not certain of all the circumstances.  We want to report as quickly as possible, but we do need to recognize that things can change, that we will be getting more laboratory tests.  We are going to continue our investigation and we'll give you any updates as needed.  There is evidence that there is a broader spectrum of illness associated with MERS than was initially thought.  There can be people with no symptoms.  Of course, our most important point is that we need to be vigilant.  Doctors need to know who should be considered a case, who should be tested, how they should be tested, and if you identify any possible case, the doctors need to know how to make sure that they are put in conditions of infection control where they're not able to spread the virus to anybody else.  We also need to be sure that travelers to the region have good educational guidance and know what to look for if they become ill and when they come back be able to monitor themselves.  So thank you very much.  We'll be sure to provide any other updates when they become available. 

BARBARA REYNOLDS: Thank you.  This concludes our update.  I'd like to give you, again, the name and spelling for our speaker.  It's Dr. David, d-a-v-i-d, Swerdlow, s-w-e-r-d-l-o-w.  I want to share that we will be posting a transcript of this briefing as quickly as possible on the CDC media website.  If you have additional questions you're welcome to call the CDC media line at 404-639-3286.  Thank you. 

OPERATOR This concludes today's conference.  Thank you for your attendance, you may disconnect at this time.  

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