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Update on CDC investigation into people potentially exposed to patient with extensively drug-resistant TB

Friday June 1, 2007, 2:15 pm

TOM SKINNER, PUBLIC AFFAIRS OFFICER, CDC: Hi. My name is Tom Skinner, and I´m a public affairs officer here at CDC, and I want to thank you today for joining us - excuse me - for this update on CDC´s investigation into people potentially exposed to a patient with XDR TB.

Joining us today is the director of the CDC, Dr. Julie Gerberding. Also with us is Dr. Marty Cetron, the director of the Division of Global Migration and Quarantine, and Dr. Ken Castro, the director of the Division of Tuberculosis Elimination.

We´ll begin by having Dr. Gerberding provide a very brief opening statement, providing an update on our public health investigation, and then we´ll move to Q&A - Dr. Gerberding.

DR. JULIE GERBERDING, DIRECTOR, CDC: Thank you, everyone, for joining today. I recognize that I´m on a difficult line, and if it becomes unsuccessful, I will ask Dr. Castro and Dr. Cetron to step in for me and continue.

I´m going to provide a very brief update today on the situation involving the patient with XDR TB.

First, let me mention a couple of things about the patient. We know that the patient is receiving excellent care at the National Jewish Hospital in Denver, and while it´s certainly been a difficult time for him and his wife and his family, we are hoping, all of us at CDC, that he will have a fast and successful recovery.

We know that the early evidence at the hospital indicates that the patient still does not appear to be highly infectious, and we´re thankful for that. It - we have no indication that his infectiousness has changed at all in the last few months.

That said, it´s also important to appreciate that the public health actions necessary to protect people in this situation are based not only on the degree of his infectiousness, but also on the fact that this is a very, very drug-resistant tuberculosis bacteria, and we have to be as cautious as we can to prevent exposures to other people.

The investigation into where the patient is acquiring this - where the patient acquired this infection is, of course, ongoing, and that´s likely to take some time. If we determine an ultimate source of that, we will certainly update the press.

We have some good news in terms of contacting passengers on the two long transatlantic flights that the patient was - taken in the last few weeks. There are two flights that have been long enough to meet the criteria that the World Health Organization has set out for the potential for TB transmission.

And as we have mentioned before and posted on our Web site, that´s Air Flight - excuse me, Air France Flight 385 and - also known as Delta Flight 8517, which departed May 12th from Atlanta to Paris, and the patient was seated in row 30.

There were approximately 435 passengers on that plane, including 310 U.S. citizens.

We´re also, of course, looking at Czech Air Flight 104 from Prague to Montreal May 24th, where the patient was seated in row 12. There were only two passengers on that latter flight who are U.S. citizens, and those passengers were the patient and his wife.

Now, let me start with the first plane, the Air France/Delta Airlines flight from Atlanta to Paris. We believe that we have contacted all of the U.S. passengers, people who were residents of the United States or citizens of the United States who were seated in the five rows that are the concern, based on the World Health Organization criteria.

Of course, we acknowledge that sometimes people switch seats or move around and the airline is unaware of that, and so we´re still open to the possibility that there may be additional people that need to be notified.

But from the official record, we recognize that we have been able to get in touch with every one of the passengers that we would consider to be at increased risk in front and behind the patient. This represents a total of 26 U.S. residents and citizens, and we have provided the - their names and contact information to the affected state health departments so that the health departments can facilitate their follow-up.

The - a total of 74 of the U.S. passengers and residents on that flight have been contacted, and we´ll certainly continue to work to contact all of the 310 U.S. passengers and residents on that flight.

The problem with - is obviously identifying the final remaining passengers, because they´re travelers, and so it will take time to ultimately track them down and be in touch with them.

Actually, this would probably be a good time for me to thank the media, because you´ve certainly raised awareness of this situation, and about 40 people self-identified since the announcement was first made on Tuesday. And so those people came forward themselves, and we didn´t have to reach out to find them independently.

Now, one of the things that´s not coming across in the media is that the tuberculosis organism actually grows very slowly, and so, if a passenger is in the zone of risk and reports for a skin test, we would expect all the skin tests initially to be negative, unless the patient has been exposed to TB some time in the past. So, if in the next several days a patient has a positive skin test for TB, that is most likely to represent exposure prior to this particular flight.

That´s why we are recommending that people get re-tested in several weeks because, if they´re negative now and then subsequently become positive in the future, that´s the sign that they may have acquired their infection from exposure on this flight.

I´d also just like to thank our colleagues in Canada. They´ve identified all of the 28 passengers who were seated close to the patient on the flight to Montreal, and I´m sure they´re involved in a similar set of communications and investigations.

Just like to clarify some misinformation, or some confusion that´s been perpetrated in the press regarding this organism, per se. This is a bacteria that is caused by airborne transmission. It actually takes prolonged contact for long periods of time. That´s the point of these investigations.

It´s difficult to treat, as we know, and can cause some very serious consequences, but it does take a long time before exposed people generally develop symptoms or have a positive skin test.

And during this period of time, after a person has been exposed but before they develop a positive skin test, or symptoms of illness, they´re not infectious. So, there is no hazard from exposure to these passengers who´ve been seated around this patient unless they subsequently go on to convert their skin test.

And I think some of the passengers are worried that they pose a threat to other people right now, and that´s absolutely not the case, and we want to make sure we reassure them personally, but also generically, so that people who know someone who´s been on this flight don´t erroneously conclude that there´s some kind of infection risk.

The first persons who are involved in these higher risk areas of the airplane will generally get a TB skin test, and there is also another new test called QuantiFERON/TB Gold test - that´s spelled Q-U-A-N-I-T-F-E-R-O-N/TB Gold test. We refer to it sometimes as QFT/D test - excuse me, QFT-G test, as soon as possible, and again, that test would be repeated. That´s a new, modern TB test, but I´m sure most of these people aren´t going to end up getting conventional skin tests.

And the most important message here is that people who are in the risk area around the passenger or people who were on these flights, if they have any doubts, they can call 1-800-CDC-INFO and certainly contact their local health official or their state health official´s TB controller so that they can get the absolute best information.

We´re obviously expecting that we´ll have good cooperation with this effort, and we´re certainly hoping that we do not find any people who develop positive skin tests. But we are making sure we do everything we can to protect the public and detect anyone who could possibly have been at risk on these long flights.

Now, just a couple of follow-ups in terms of CDC´s use of the isolation order. This is an order that is part of our federal quarantine authority. It´s not used very often, as you know, but it is one that we do have available to us in situations where the voluntary approach to isolation or quarantine is not successful, or unlikely to be successful.

And in this case, we used our authority because we felt that it would be the very best measure to protect people who were otherwise at risk from exposure to the patient.

The federal isolation order is still in place, and we´re assessing the continued need for that on a regular basis. I wouldn´t be surprised if, at some point in the future, we would be able to discontinue that order and rely on voluntary methods or authorities within the state of Colorado to continue to protect the public.

We acknowledge, certainly, that CDC and many others have learned a lot in this process and we are - we´ve already conducted one after-action analysis last week to go through what happened as of the end of last week, and we will be continuing to go through this kind of analysis to determine what, if anything, can we do to improve the management of the current situation, as well as learn from this so that, if we are ever in this situation again in the future, it will be easier for everyone involved.

Many people have questions about the CDC employee, the father-in-law of the patient.

It´s our certain understanding that the father-in-law´s role was limited to what one would normally expect from a father-in-law who cared very much about his daughter and her fiancĂ© and was really interested and concerned about what was their best interests, and in terms of his role in having anything to do with the diagnosis or detection of this particular health situation, what we know right now is that he may have been involved in preparing one of the lab tests to determine the type of bacteria (INAUDIBLE) sample, but he certainly has not been engaged in the details or the ongoing decisions about how to handle this particular situation.

And we´re not privy to any conversations he might have had with his family, and so we´re not going to comment on that.

We do know that, at several points in the situation, he - helped us facilitate communication with his son-in-law and the wife, and his assistance was actually extremely helpful in getting us in cell phone and telephone contact with the patient to help us determine how to help him get into a safer healthcare environment.

The CDC did not know the identity of the patient before he left the country, but we did learn about his identity, and that he traveled to Europe on May 18th, and on May 22nd we learned that he had documented to have extremely drug-resistant TB. And so, our first actual contact with the patient was on May 23rd.

Now, I´m well aware that there are many issues around the timeline and various aspects of exactly when things occurred, and the CDC is in the process of documenting those, and we´ll make those available to you as soon as we can.

But I think right now we´d like to focus Q&A on issues related to the actual public health questions and consequences of the situation overall.

So, I´ll go ahead and take some questions at this point.

SKINNER: Laura, we´re ready for questions.

OPERATOR: Thank you. At this time, if you would like to ask a question, please press star, followed by one on your touch-tone phone. To withdraw your request, you may press star two.

Our first question comes from Joanne Silberner with National Public Radio. Please go ahead.

JOANNE SILBERNER, NATIONAL PUBLIC RADIO: Yes, hi. Thanks for taking questions.

On identifying the patients on the flights, what about the non-Americans?

GERBERDING: In a situation like this, according to the World Health Organization recommendations, each country has the responsibility to notify its citizens and residents.

So, what I can tell you today is what is going on the United States. I can also tell you that European CDC and the Canadian Public Health Authority are actively engaged in similar activities, and I will have to defer to their public announcements about the status of their follow-up investigations of potentially exposed people.

SKINNER: Laura, our next question, please?

OPERATOR: Thank you. Our next question comes from Ann Carns with the Wall Street Journal. Please go ahead.

ANN CARNS, WALL STREET JOURNAL: Dr. Gerberding, thank you. I know you said you wanted to focus not so much on the timeline, but if you could clarify, I´m a little still unclear on why the CDC became involved in this patient´s care and how it became involved.

Can you explain interaction between the county health officials and the CDC on this case?

GERBERDING: You know, generally speaking, in the vast majority of patients with tuberculosis, first of all, in most cases, CDC is not involved because the health department and the patient are able to work out a safe situation.

But in this case, CDC was notified in early May that the county and state were managing a patient with drug-resistant tuberculosis, and they asked us to comment on what measures would be appropriate to try to prevent exposures to other people, particularly in the context of travel.

It´s common for us to be contacted for various kinds of advice about travel. And so, our quarantine office was contacted, and they provided their best information about options.

We became involved later in the month when the patient had already left the United States. We were recontacted by the health department, notified that the patient was out of the country, and then asked to engage in whatever way we could to try to reduce the chance that he was exposing other people to tuberculosis.

I think those time points will be included in the timeline that we´ll be putting out on our Web and making available to people as soon as we´ve verified that we have the time points as correct as we can get them.

SKINNER: Next question, Laura.

OPERATOR: Thank you. Our next question comes from Jeremy Manier with the Chicago Tribune. Please go ahead.

JEREMY MANIER, CHICAGO TRIBUNE: Thanks very much.

Dr. Gerberding, I think one of the questions that comes up with this - forgive me if it´s been asked before in previous appearances - I mean, is that, in some ways, this is an ideal situation, where you´ve got one patient. You´ve got a family relationship from the CDC. You know what needs to be done to prevent him from coming to the country.

And yet, this system has obviously failed pretty significantly in this case, and Border Patrol didn´t catch him. Do you need better alerts for the Border Patrol? Do you need a better system, because all - you know, for the last three years, we´ve been hearing about, you know, bird flu and the measures that we´d use to prevent that from coming into the country, what we´d do once it got here and, you know, this is one case and it failed.

GERBERDING: Well, I think the one thing that you don´t realize is that, yes, this is one case, but there are actually many, many, many cases where we have been successful.

And, you know, obviously this has been very visible, but what´s not visible to you are the many patients for tuberculosis where health officials have been notified, patients have complied voluntarily with the recommendations and advice, and there has not been a risk to other people in the community.

So, in this case, we had the juxtaposition of a patient who did not feel sick and had very compelling reasons to be somewhere else in the world, and an organism that was just particularly important to prevent.

And so, in this case, I think we´ve learned a number of things within the travel system that need to be improved.

But also, just mention that the statutes that we´re operating under were designed primarily to respond to people and keep them in one environment, and they were not exactly invented in an environment where we were dealing with international transfers.

So, we are looking at the current statutes with perspective to determine if we need additional statutory authority to deal with a person who wants to leave the country as opposed to someone who wants to move from state to state.

So, there are a number of legal, regulatory, statutory issues that will be very closely examined, and you can believe me when I tell you that we will aggressively approve any changes in statutory authority that will help us be able to clarify what, if anything, can be done in the future to minimize this kind of problem.

Take the next question, please.

OPERATOR: Thank you. Our next question comes from David Brown with The Washington Post.

DAVID BROWN, THE WASHINGTON POST: Thanks.

Dr. Gerberding, you mentioned that you learned the identity, presumably the name of this man, on May 18th. Was that the day that you learned that he was now the son-in-law of someone who worked in your TB Elimination Division, or if not, what day did you learn that?

And once you learned that, did you ask that person, his new father-in-law, to do something other than provide you with his cell phone in order to try to get this man to, you know, stop traveling.

SKINNER: David, that - you know, again, we´re not going to get into issues around the timeline and what was said when and by whom and where. And so, we really want to use this to answer questions around the public health investigation.

Laura, next question, please.

OPERATOR: Thank you. Our next question´s from Mike Stobbe from the Associated Press.

MIKE STOBBE, ASSOCIATED PRESS: Hi. Thanks for taking the question.

Did the CDC notify Greece, Italy, the WHO, that an MDR case was coming their way? And also, at what point - I mean, Bob Cooksey made the trip to the wedding in Greece. I mean, he didn´t tell colleagues at the CDC about the trip? At what point did you get that information?

SKINNER: Mike, again, we´re not going to get into who said what, where and when in regards to the timeline. We want to use the Q&A to talk about the public health investigation, the science of tuberculosis, and if there aren´t any further questions around that, we´ll move on.

Laura, next question.

OPERATOR: Thank you. Our next question comes from Helen Branswell with the Canadian Press.

HELEN BRANSWELL, CANADIAN PRESS: Hi. I do have a question about the science. I´m not clear. Can you tell with - at this point, the susceptibility testing in the lab, can you tell if the strain of TB that this man carries is susceptible to any antibiotics? I mean, can you tell, at this point, whether this is complete drug-resistant TB?

GERBERDING: Yes. What we know so far - and keep in mind that the patient has had several samples obtained to look for his bacteria, and the first positive sample that we have from him is the one that we´re looking at in the greatest detail, because it´s the one we´ve been able to work with the longest. And there are additional samples that will be coming forward with additional information over the next several weeks.

The earliest sample does indicate that there is drug resistance to the drugs we would consider first line, but there are at least two drugs on the list of things that we would normally use to treat TB as a backup to which the patient is susceptible.

And as the patient is further evaluated for treatment options in the - in the next several days, there may be additional less traditional drugs, or possibly even new or investigational drugs that will be assessed to see whether or not they could contribute to his treatment.

So, there are drugs available that are likely to be contributory, but the number and the specifics of that are still under investigation.

I think it´s - you know, it´s easier with a bacteria like Staph aureus that grows fast. With tuberculosis, the problem is the organism grows so slowly that it takes a long time to accurately determine the true extent of the susceptibility.

And for some of the investigational drugs that we have available to us, the criteria for determining susceptibility or resistance are not standardized yet, so there´s some ambiguity in the interpretation.

Can you take the next question, please?

OPERATOR: Thank you. Our next question comes from Lisa Stark with ABC News.

LISA STARK, ABC NEWS: Hi. Two questions, if I may.

You mentioned you´ve already had one after-action meeting. Can you tell us what, if anything, you have decided you needed to do differently based on that after-action meeting?

And secondly, could you talk at all about whether - about the comment by the patient that the CDC was not, in fact, working to get him back from Rome? Thank you.

SKINNER: Yes, the second question again ...

GERBERDING: Yes, I´m fine with this, Tom.

In terms of the after-action, right, I hope that the media will be hearing from CDC the term "after-action" frequently, because we are trying to make this a part of everything we do as an agency, and we will be doing many after-actions in the context of this particular investigation.

Our focus last week was on issues around statutory authorities, laws, regulations, agency responsibilities, and so forth, because we want to be able to go forward and make sure that the laws give us the full range of empowerment that we need to take actions to protect the patient.

There was some concern about whether the current law providing our quarantine authorities actually was appropriate when we´re talking about a person who wants to leave the country as opposed to move within the country. And so, we had to develop a mechanism to engage lawyers in investigating this.

In addition, there are issues on the statutory authority for CDC to use its assets, and also, in new World Health Organization regulations, the international health regulations, while these are wonderful statements of principal, the operational details of things like who should pay to move a patient, or who should care for a patient in isolation or quarantine, are not spelled out in those regulations.

And so, we wanted to really make sure we were familiar with what was and was not included in the regs so that we, at some point in the future, will be able to sit down with the World Health Organization, with our Canadian colleagues, our European colleagues, and say, look, here´s what we have learned from this situation, and let us provide some context and some recommendations to the World Health Organization about the reality of implementing these new regulations that would have been difficult to anticipate until someone was actually in the phase of having to deal with them.

So, that was our main focus in terms of what went on last week.

And in terms of CDC´s engagement in conversations with the patient about what options were available to him over the holiday weekend, I can assure you, at least from my perspective where I was working with the people at CDC, we were engaged in exploring all conventional options, as well as some unconventional options, including use of air ambulance within the private sector, use of Department of Defense air ambulance type services, use of CDC aircraft, use of boats, use of non-passenger shipping, vessels, et cetera.

We were really looking for every single viable option that would possibly have allowed the patient to return to the United States and do that in a way that did not pose a risk to other people. And that´s another thing that we´ll be focusing on in the future is, can we create a protocol so that, if such a thing happens again, we don´t have to invent a solution. We have a set of solutions that work for us and work for the World Health Organization and the other countries who could easily find themselves in a similar situation.

Take the next question, please.

OPERATOR: Thank you. Our next question comes from Elizabeth Cohen with CNN.

ELIZABETH COHEN, CNN: Hi, Dr. Gerberding. Thanks for having this teleconference.

This question is not about the timeline. It´s about a public health policy that Dr. Gerberding herself said didn´t work quite as well as it should have in a press conference on Wednesday.

How long - can you be specific about number of days - did it take you to get the passenger manifest from the two transatlantic flights? You can discuss each one separately.

GERBERDING: I think that is a timeline question, and I think that will be obvious as soon as we are able to present the timeline, and if it´s not, could I ask you to get back to Tom and ask that specific question? We´ll try to make sure that we include that information on the timeline.

Can I take the next question, please?

OPERATOR: Thank you. Our next question comes from Beth Galvin with WAGA-TV Atlanta.

BETH GALVIN, WAGA-TV, ATLANTA: Dr. Gerberding, thank you for taking this call.

I´m wondering, you know, you talked a little bit about what you´ve learned so far. If this incident were to happen again tomorrow, what would the CDC be able to do to maybe better handle this, in your mind?

GERBERDING: There´s - in terms of the early stages of the investigation, when the jurisdiction for the patient was in the state and county, I´m not sure that we are in a position where we can guarantee that an infectious person is not going to leave the United States. That´s the reality of the world in which we live in, and we have to acknowledge the fact that, whatever laws we create, or whatever authorities we have, they´re probably never going to be 100 percent.

But I do think that, in this case, if we had had a better operational standards for how we would implement what the World Health Organization is recommending that countries do in this context, we would have known what our options were, and we would have a better basis for the conversations with the various other health ministries.

What is the irony here is that the international regulations that we are using as the basis for a lot of our decision-making, while we have agreed to them as a country, they are officially not in place until June 15th.

And so, we´re anticipating our behavior in response to some regulations which actually have not been formally implemented yet in the world´s health community. So, we were kind of acting, assuming that everyone would agree in principal to these recommendations, even though, actually, we were not required to. No country was actually required to adhere to the World Health Organization guidelines.

So, I think the most important thing that we´re going to do from here on in is work with the World Health Organization and the affected countries to go beyond what is the statement in terms of the strategic intent and really get down to the nitty-gritty.

I think the central question that we´ll be grappling with is, whose citizen is it? If we are talking about the safe care and isolation or quarantine of a U.S. citizen, is it our responsibility to assure that that person gets home safely and gets in isolation? Is it the host country who has jurisdiction, wherever he or she may be, and how do we adjudicate those differences?

Think about what would happen if the exact same situation occurred in the United States, where, perhaps, some traveler came here with a highly infectious disease. What would our expectation be of that person´s host country versus our responsibility as a public health agency here to isolate or quarantine the individual? They just need to kind of get this worked out in the kind of fair details that work for all of the, you know, 190-some countries that are signatures to the agreement.

So, this is a very important opportunity for the global public health community to get around the table with the support of the World Health Organization and move these guidelines forward into a state where we don´t have to figure out how to implement them - we´ll already have the protocols and the standards established.

Take the next question, please.

OPERATOR: Thank you. Our next question comes from Anita Manning with USA Today.

ANITA MANNING, USA TODAY: Hi. Thank you again, adding my thanks to everybody else´s.

Given the fact that this patient was asymptomatic, as you have said in the past, and he had been under treatment since January, was there - I mean, is there any logical reason for him and his family to really think that it - that travel was safe?

And under what circumstances is it safe for a person who has active TB disease to travel on commercial transport?

GERBERDING: I mean, to be - to be fair, Anita, as a - as a doctor, I mean, I think we just need to accept the principle that people with active tuberculosis should not fly on long air flights, period.

And the situation in this case was complicated because it was drug-resistant tuberculosis, so there was - you know, sometimes when people have active TB and they´ve been on treatment, you know, obviously they´re less infective so long as they´re treated.

And so, there is a point in time in which they are no longer cultured positive for the organism, and their infection risk really is negligible.

But the problem here was the patient wasn´t on - ever on the best regimen for his treatment, and although, at the point in time where he was evaluated, he did not appear to be highly infectious, several weeks had gone by since that point, and with simply no effective therapy. So, for all anyone knew, his infectiousness could have increased over that period of time.

That´s why we´re so thankful to the health officials in New York, who very quickly were able to get a set of respiratory secretion samples to look at and determine that, from their laboratory analysis, the infectiousness had not increased.

So, you know, as a - as a - as a - as a principle in a TB controller´s world, when a patient is diagnosed with tuberculosis, they´re asked to cooperate with a set of recommendations about reducing the hazard to others while they - therapy is being initiated, and not traveling among air flights is one of those things that we would routinely recommend to any patient, regardless of whether it was drug-resistance or susceptible.

Next question please.

OPERATOR: Thank you. Our next question comes from Joe Contreras with Newsweek magazine.

JOE CONTRERAS, "NEWSWEEK": Yes. I´d like to ask, first of all, for the director, Julie, to spell her last name at some point.

And secondly, there is a clear dispute between what the patient has said he was told by Fulton County health authorities on May 10th, what those authorities say they told him. And I want to find out whether the CDC backs ...

OPERATOR: We just lost that question. We´ll go on to the next question from Joanna Smith from the Globe and Mail.

GERBERDING: Hello, I´m sorry. Are you able to hear me?

JOANNA SMITH, GLOBE AND MAIL: Yes.

SMITH: OK, I - the speaker was asking a question, and I believe he was cut off, and I think I can answer part of his question.

Should I continue with that?

OPERATOR: Yes, go ahead, ma´am.

GERBERDING: OK. And I understand the first speaker wanted me to spell my name, which is G-E-R-B-E-R-D-I-N-G.

But secondly, in terms of the conversation that the health department had with the patient, we weren´t there. We cannot validate the specific content of that conversation.

But we can say that the officials who were involved in that conversation are people who have been in the business of controlling tuberculosis and dealing with communicable diseases in Fulton County for many, many years.

These are extraordinarily effective and responsible people, and I have confidence that their advice to the patient was appropriate under the circumstances.

But I can take the next question, perhaps, from someone whose line is a bit - a bit clearer.

OPERATOR: Thank you. Joanna Smith, please go ahead with your question.

SMITH: Hi. Thanks again for having this conference.

I was wondering - we´re from a newspaper in Canada, and we´re very interested in sort of the communication between our own public health agency here and the CDC.

I was wondering what reason you have given the PHAC in Canada for not informing them about the patient being in the country until after he had already arrived back in New York?

GERBERDING: Well, the reason that people were not notified where the patient was is because we didn´t know where the patient was. And so, it was very difficult for us to provide information specific about his whereabouts when, for all we knew, he was anywhere in the world.

So, as his whereabouts became clear, we did continue our communication with Canada to engage in that respect.

And I just want to be absolutely clear that the health agency in Canada has just been remarkably collaborative, and once again, our two agencies have really been able to work seamlessly.

Next question, please.

OPERATOR: Thank you. Our next question comes from Larry Altman with The New York Times.

LARRY ALTMAN, THE NEW YORK TIMES: Yes. Dr. Gerberding, could you go back to the question that Anita Manning asked, and can you tell us what the CDC and/or the WHO regulations say as to what health officials should tell any of the following three categories of people: if they are smear negative and culture positive, what they should do about air travel; the same thing for people who are smear negative, culture positive with MDR TB; and lastly, XDR TB.

But what is there in writing in the regulations that would guide health officials and doctors?

GERBERDING: Larry, I think the easiest thing for us to do would be to forward relevant page, I think it´s page 14 or something, of the guide. Anyway, we can get you the specific page.

But the guidelines are framed in a little bit different way from your question, and they basically define which air travelers would be considered to pose a hazard. And people who pose a hazard are either people who are smear positive, or people who have ineffectively-treated drug-resistant tuberculosis.

And so, the patient qualifies for the potential hazard category requiring the kind of investigation that we´re doing on the basis of the drug-resistant nature of his tuberculosis.

But it´s easy for us to get you those specific pages, and I´ll ask Tom to fax them up to you if you can get to him offline and let him know how to get them to you.

Next question, please.

OPERATOR: Thank you. Our next question comes from John Lauerman with Bloomberg News.

JOHN LAUERMAN, BLOOMBERG NEWS: Hi. I was wondering, how long - now that you´ve identified the people on the Air France flight, how long do you think it will take to test all of them? How long will it be until we know the results of their tests. And will you make public the results of that test - that is, will you at least let us know, you know, how many of those people turn out to be positive, if any of them?

And then, the second question I have is, you said earlier that you do not think that he is highly infectious, the patient in Denver. And I was just wondering if you could just give us some details, is that just because of the bacterial count in the sputum, or any samples, or why is that?

GERBERDING: You know, in terms of the outcome of these investigations, I want to make sure people understand there´s really, in a sense, two phases of this. One is finding people and doing their first test, which hopefully will be negative in most people, but in some people will be positive because they´ve been exposed to TB at some point in the past. Now, this is always a complication when we do these investigations on airplanes.

And our experience has shown us that some people were already exposed to TB before, and it´s important that we get this baseline skin test done so that we can determine that. Then, in a few weeks when we repeat the skin test, when we would expect a new infected person to acquire a positive skin test, it´s those changes from negative to positive that are the most meaningful in the context of this exposure.

And we will assume that those people represent infections related to this exposure, although I suppose it´s possible that they could acquire TB through some other mechanism in the meantime. We´re going to err on the side of assuming that, if they demonstrate new skin test positivity, that it is temporarily associated with this exposure and most likely related to it.

And I can speak for the U.S. side of this investigation, that we certainly intend to provide information about what we learn about the baseline status, as well as anybody who converts their skin test over time as soon as we validate and have that information. But you won´t be getting it this week. You´ll be getting it over the next several weeks as the investigation is ongoing and we get verification of information from the clinicians around the country, and potentially around the world, who are doing this testing and getting back to us.

We have assigned epidemic intelligence service officers to the task of facilitating this tracing, and we are probably in the best case scenario because we have a workforce that is a size enough to be able to help us with it. But not every health ministry has that luxury, and so there are going to be places where this may not be as easy.

We will certainly volunteer to help others if they need assistance from CDC, because we feel that this XDR TB exposure situation is unique, and we´d really like to have the best possible science and include as many people as possible in the follow-up so that we not only do the best we can for each individual, but we also learn whether there really was an exposure here.

And the basis of our determination that the patient was not highly infectious is based on the fact that, on repeated assessment of his respiratory secretions, there weren´t enough bacteria to be seen under a conventional microscope using the tests we do.

But we know from his earlier tests that ultimately bacteria did grow, tuberculosis bacteria did grow, from his respiratory secretions, and that is the determination of infectivity.

So, while he didn´t have so many that it would be highly probable that any given cough or exposure would infect someone, he certainly had enough bacteria in his respiratory secretions that we could grow in the laboratory.

And that´s why we keep making the point that, while he may not have been highly infectious, he certainly was potentially capable of transmitting this infection to someone else. And again, it was a matter of not only his own risk of transmission, but the fact that this is just such a bad bacteria that we really - we really had to be assertive as a public health agency in protecting people in this case because of the nature of the bacteria.

And, although I mentioned earlier that there were some drugs that look like they´ll be effective, these are not easy drugs to take. One of them is intravenous. And we would not want to be in a situation where this bacteria gained momentum in any (INAUDIBLE) country, because it is just extremely difficult and capable of causing a very high fatality rate.

I think, Tom, I´m going to be able to take two more questions. So, I don´t know how the queuing up is going. And if people have more questions, I could defer to Dr. Cetron or Dr. Castro to take them if you feel it´s necessary to continue the press briefing. And I apologize for that, but I have an airplane to catch.

OPERATOR: Thank you. Our next question comes from Nick Ricardi with the Los Angeles Times.

NICK RICARDI, LOS ANGELES TIMES: Doctor, thank you for taking the question. I just want to clarify something that you had said about the father-in-law, that his only involvement had been to be involved in one of the tests on the bacterium.

Was that before or after the CDC was aware that there was a family relationship with the patient?

GERBERDING: Now I - I´m sorry, I simply don´t know the answer to your question, so I will make sure that that´s included in the timeline, or else that someone at CDC gets back to you with that information.

I myself was not aware of this relationship until after we were dealing with the patient in Europe. And I don´t know who at CDC understood the relationship at an earlier point in time.

Take one - the last question, please.

OPERATOR: Thank you. Our next question comes from Andy Miller with the Atlanta Journal-Constitution.

ANDY MILLER, ATLANTA JOURNAL CONSTITUTION: Thank you, Dr. Gerberding. The question is, when you were mulling over - when CDC was mulling over transportation for this patient back from Europe, why didn´t the agency move faster to offer up the CDC jet for the return trip for this patient?

GERBERDING: One of the issues that we faced was the authority of using our government assets and the determination of whose jurisdiction was involved. At that time, the patient was in Italy, and - when we were first discussing this.

And so, how the patient is handled in Italy is really, ultimately, something that the Italian minister of health has the responsibility for determining. And it wasn´t even clear to us whether or not whatever transportation availability we had, whether or not the Italian Health Ministry was in the position to say, fine, come and get your patient, you know, do what you need to do, because ultimately it´s their authority.

So, these are the kinds of things that are not spelled out in the World Health Organization authorities, and these are the kinds of things that we are getting legal clarification of, but also, as we go forward with this, I think we´re going to be in a position to help the World Health Organization know that there´s some specifics in their regulations that need to be spelled out.

And again, I´m sorry that I can´t take additional questions, but I really appreciate people´s interest in this topic. And I want to just emphasize that, as always, this has been a very challenging situation for hundreds of public health officials around the world who, in my opinion, have really pulled together to try to do the best they can for this patient and this family that we all hope the best for, but also, to do what public health does best, and that is protect, people´s health, in the fairest and fastest way that we can.

Thank you.

SKINNER: Laura, I think we´ve got enough people in queue that we´ll try to take a few more questions, and Dr. Castro and Dr. Cetron are standing by.

So, let´s try to take just a few more.

OPERATOR: Thank you. Our next question comes from Tim Brien with KUSA Denver.

TIM BRIEN, KUSA DENVER: I wonder if it´s possible to know what the chances are that, when all the dust settles from this, and all the tests and monitoring happen of all the patients who were close to him come back, that in fact there won´t be anybody else infected.

I mean, is there any way to know what the chances of that are? And I was also curious about the timing on the release of the timeline.

SKINNER: Yes. We´ll try to get the timeline completed as soon as possible. It´s a - you know, it´s a detailed timeline that includes information of our interactions with other agencies and other institutions that we just have to make sure we run, you know, past them as far as verification.

So, there´s just a lot of work going into this.

As far as your other question, I´ll get Dr. Castro to respond.

DR. KEN CASTRO, DIRECTOR, DIVISION OF TUBERCULOSIS ELIMINATION, CDC: Hi. This is Dr. Ken Castro.

On the question regarding the findings, there is a very finite number of possibilities. The ideal scenario is one in which we invest a lot of energy and effort and find that no one else has evidence of infection. That would be the ideal scenario.

Second possible scenario is that you have evidence of transmission in the aircraft. And that type of information could be used to further reinforce existing policy guidance.

The fact that we´re going into this with WHO recommended policy is based on previous investigations that provide the scientific basis for these guidelines.

So, either way, we will learn from it to further improve our public health response to the situation. Obviously, if persons are thought to be infected with this particular strain, they will be flagged and followed very closely. And there´s an algorithm that´s been developed for clinicians with suggestions to be used in the United States and overseas.

SKINNER: Next question, Laura.

OPERATOR: Thank you. Our next question comes from Matthew Berger with Congressional Quarterly.

MATTHEW BERGER, CONGRESSIONAL QUARTERLY: Thank you.

You mentioned that there needs to be a reliance on the patient to follow the guidelines. But does there need to be more allowance for health officials to quarantine or prevent travel for those who could be highly infectious, like, in a pandemic scenario?

And is there a protocol for adding patients with infectious diseases to the no-fly list?

DR. MARTIN CETRON, DIRECTOR, DIVISION OF GLOBAL MIGRATION AND QUARANTINE, CDC: This is Dr. Cetron with the Division of Global Migration and Quarantine.

And I believe your question, is there a protocol for adding that, you know, that is not something - adding a person to such a list is not something that CDC has the specific authority to do. We work that through the intergovernmental relationship with our federal partners in the Department of Homeland Security.

We have protocols for our relationships in terms of reaching out and making that request, and then the implementation of those activities occur in the Department of Homeland Security. So, I would defer you to those folks to ask on the specifics of that.

But it is one of the tools in the toolbox, and it´s - as part, in fact, of the ongoing process of pandemic preparedness, we are maturing and trying to improve the communications, the systems, the methods by which we operate between federal partners in order to accomplish this seamlessly.

SKINNER: Next question, Laura.

OPERATOR: Thank you. Our next question comes from Pat Wingert with Newsweek magazine.

PAT WINGERT, NEWSWEEK: Thank you very much for taking the question.

I wonder if you could clarify for me a little bit about the morbidity and mortality of XDR TB? I´ve been told by some doctors that 30 percent of the patients are cured. I´ve been told by other doctors that 30 percent of the patients die.

And is it possible that someone will continue to have this in a chronic form for a long period of time?

CASTRO: This is Dr. Ken Castro, director of the Division of Tuberculosis Elimination.

First, just to clarify, extensively drug-resistant tuberculosis is being abbreviated XDR TB.

And what we have learned through collaborations with other persons in Europe and Peru is that the cure rate for these individuals is hovering between 30 percent and 50 percent. Contrast that to cure rates of better than 95 percent for people who have the usual drug-susceptible or absence of drug-resistant type of tuberculosis.

The mortality has been unacceptably high in persons with HIV infection, as noted very recently in an outbreak-type situation in the province of KwaZulu-Natal, South Africa, where 52 of 53 persons succumbed within about 16 weeks since the diagnosis. That´s unacceptably high for a disease that´s supposed to be curable.

So, what we do is we rely on our ability to diagnose these persons - and by the way, this gives me an opportunity to also highlight the need for newer diagnostic tests to rapidly and reliably identify persons with drug-resistant TB, and also for additional drugs so that you don´t run out of options. And what we´re having here is that there haven´t really been new drugs for tuberculosis since about 1972, and that shouldn´t continue.

SKINNER: Laura, we´ll take a few more questions.

OPERATOR: Thank you. Our next question comes from Colleen Slevin with the Associated Press.

COLLEEN SLEVIN, ASSOCIATED PRESS: Hi. Thank you.

And this may be a timeline question, but wanted to know when the CDC began talking to National Jewish about the patient´s care?

SKINNER: We´ll kind of - we´ll have to include that in the timeline, and if that is available and we can include it in the timeline, we will.

Next question, Laura.

OPERATOR: Thank you. Our next question comes from Lori Geary with WSB TV.

LORI GEARY, WSB TV: Hi, gentlemen, and thank you for taking my question.

There seems to be some confusion, or maybe it boils down to semantics, over could somebody or some agency have ordered him not to fly in the first place? He said that the Fulton County Health Department preferred him not to travel. But should they, or could they, have ordered him not to? I mean, who has jurisdiction in this, or is it something that still needs to be worked out?

CETRON: This is Dr. Cetron with Global Migration and Quarantine.

The issue of whether the county can place somebody on a no-fly list, I think, is one of those after-action issues that needs to - needs to be worked out, I suspect.

The - as Dr. Gerberding indicated, in general, the quarantine laws in this country are designed to prevent importation and interstate spread. We know that, as global citizens, we have a responsibility to prevent exportation of disease as well.

And so, the issue of whether the - how the county does that interface, or whether that interface goes on through another method other than their - what their own legal authorities just needs to be worked out as part of that - of that after-action.

CASTRO: This is Dr. Castro from Division of Tuberculosis Elimination.

I wanted to add that each and every single one of the states of the union have TB-specific laws, and they therefore have the authority to intervene.

However, the onus is on the health department to demonstrate that they have exhausted the least restrictive method before they can obtain a court-ordered restriction. So, it is a process, and it is for very good reason. We don´t want any, either state or federal authority, to abuse these authorities.

So, there is a procedure that takes place, and it doesn´t happen overnight. And as you heard, as part of the after-hour, we may need to look at how to expedite some of these situations where you really are justified in doing so.

SKINNER: Laura, let´s take one last question, please.

OPERATOR: Thank you. Our final question comes from Deborah Lum with NBC News. Please go ahead.

DEBORAH LUM, NBC NEWS: Yes. Has it been determined where this particular strain can be found in the world?

DR. CASTRO: This is Dr. Castro.

That is part of the investigation. We are curious to determine where this person developed this form of XDR TB. Part of our investigation is reaching out to our international partners to compare the fingerprint patterns of their libraries that they have developed, as well as the libraries that we have here in the United States. It is a very unusual type of strain, so we´re looking out, and I´ve been seeing some of my colleagues in our own division already receiving responses, but we haven´t seen a clear-cut match yet.

SKINNER: Laura, thank you for hosting, and thank you all for joining us. And as new information becomes available, we´ll be sure to continue to provide updates to you all as needed.

Thank you.

OPERATOR: Thank you. This does conclude today´s conference call. We thank you for your participation. Please disconnect at this time.

END

####

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

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