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Anthrax update: October 25, 2001, telebriefing transcript


CDC MODERATOR: Welcome to the CDC anthrax conference calls. At this time all the lines are in a listen-only mode. Later there will be an opportunity for questions and answers, and instructions will be given to you at that time. If you should require assistance during the conference call, please press zero followed by a star.

As a reminder, this conference call is being recorded.

I would now like to turn the conference call over to your first speaker, Ms. 
K. D. Hoskins. Please go ahead.

MS. HOSKINS: Thank you. This is K. D. Hoskins, CDC Office of Communications. I just want to briefly explain to you the format for the telebriefing today. Our first speaker will be Dr. Jeffrey Koplan, who is the director of CDC. Dr. Koplan's last name is spelled K-o-p-l-a-n.

Dr. Koplan will give a brief overview of CDC's activities related to the anthrax investigation that will be followed by a brief Q and A. Maximum time on that Q and A will be 30 minutes.

Dr. Koplan will be followed by Dr. Julie Gerberding, who is the acting deputy director of our Center for Infectious Diseases. Dr. Gerberding will actually talk about the MMWR report today which includes specific information about cases, suspected cases, and updates of the investigation going on in the various states.

So now without further delay, I would like to turn it over to Dr. Koplan.

DR. KOPLAN: Thanks a lot. Hello, everybody on the call. This is Jeff Koplan, director of CDC. I'm just going to give a few comments to begin with, and then obviously I will be happy to take any questions you've got. But I thought I might set the scene a little bit.

Many of you are probably pretty familiar with CDC, and some less so, but let me just say that, you know, in many ways, our 50-plus-year history is both good background for this, but also this is something a little different. We've got 50 years of experience with thousands of outbreak investigations. I personally have been involved in dozens. And this shares some of those characteristics, but is obviously very different in the terms of it being a purposeful attack on the nation.

For the last several years we have recognized, have been well aware that there is a threat of bioterrorism to us and in the world, and have attempted to strengthen our capabilities in this and our capabilities really go from both CDC at the Federal level through state and local health departments.

And so we have gotten resources for this and tried to improve our ability to help laboratory response, epidemiological expertise in this, and at the same time have the state and local health departments ready to respond.

That remains uneven across the country, but the response I think we've seen in Florida and in New York and in other places as this has unfolded shows that they have taken advantage of some of this input and have improved their capabilities, whether it's laboratory or epidemiology in the last couple of years.

Back to this particular outbreak. I think people are somewhat surprised that we're learning things on a day-by-day basis, but that's really no different from any other investigation that we've done this year, five years, or over the last 50 years. The way the natural history of these investigations are, you always wish you knew on day 20--on day one what you know on day 20, and it's probably not going to be different here. We learn new things almost daily in this, and try to anticipate, of course, what's coming up the next day or the next week.

It's obviously much more difficult when you've got a purposeful intent and someone malicious at the other end engaged in combat on this, and that is different from anything else we have done before.

We have a stepwide increase in information and knowledge as this outbreak or attack has progressed. We started in Florida there with an initial case presentation of anthrax. You're unclear, is this a natural cause event, or is it intentional? And in short order, working with Florida state officials, local officials, we were able to rule out any likelihood that it was naturally occurring. And indeed, although we never had an incriminating letter there, the association in this individual first case who unfortunately died of inhalation anthrax was through both getting mail, suspect letters, and presumably opening them, those letters, and being exposed to a powder or some material.

The other case in Florida, similarly an inhalation case, worked in a room in which mail was opened in a fairly confined space, and so at that stage from the initial Florida outbreak, that was the information we walked away with, which is, one, it was intentional, not naturally occurring, seemed to be associated with mail, but we didn't have a letter in hand, and that the--that it seemed to have to be associated with, to get a case, with opening the letter or being nearby where mail was opened.

Following Florida, the investigation moved to New York, where cases began to occur and be reported. And those were cutaneous cases, not inhalation cases, but also associated with mail and with mail being opened, and that is true, and here we finally got a letter, and that letter was at NBC, associated with a case of inhalation anthrax and some fairly circumscribed environmental contamination there.

And then following that with presumed mail, not always be able to identify an incriminating letter, but with a cutaneous case at ABC and CBS, and then threats and again a letter found at The New York Post.

So information again, we were gaining knowledge about this, the use of mail to disseminate this toxic agent.

In New York, the experience with cutaneous cases, not inhalation, from these letters, and then backtracking through the mail system, again getting information in New Jersey about the fact that there was threats of exposures to postal workers there, but there initially for the first several days the threat appeared to be cutaneous anthrax as well, and we had no letter there to go on, so that it was a possibility that the postal process of sorting and more importantly, machinery dealing with letters could deal with a torn letter, or somehow a mishandling or a manipulation of a letter that made the seal broken.

The letters we had seen or had described to us--we didn't have the letter in hand, but the letters we had had described to us, both the one from The New York Post in New York and then the next set in Washington, D.C., the letter that was in the Hart Office Building that had been addressed to Senator Daschle, were described to us as well-taped, meaning that the seams along that letter were taped in a way that would have minimized, if not eliminated, the ability of a powder to seep out through openings around the letter. You would have to open the letter. And, indeed, we were told that the letter that was sent to Senator Daschle had to be opened by a scissors because of how well it was sealed.

So through this period of time we were still operating on the assumption that in order for a letter to convey this--the anthrax, it had to be either opened by someone who was opening mail, or in some way torn or disrupted in the sorting process, because the concept of a powder in a sealed letter was one that suggested that it would stay in that letter. And that was our epidemiologic experience with the cases we had seen so far. That construct obviously changed markedly with the report of inhalation anthrax in mail workers in the Brentwood facility in Washington where mail was not opened in the places where these individuals were exposed, or seem to have been exposed, and where the disease that they contracted was not cutaneous anthrax, which takes less spores, and is obviously less threatening than inhalational anthrax, and in which the physical characteristics are different.

But to get a aerosolization of anthrax requires both air currents flowing around, and some larger quantity of smaller-sized spores to be present, and not easily explained at all by unopened mail. And with that, our current construct on the risk includes, obviously, letters that are unopened as well as letters that are open, that have had, been tampered with or have been maliciously placed in the mail with anthrax spores.

Where we are now is that the sites continue to be Florida, New York, New Jersey at various mail facilities, and Washington, D.C. at both Government sites and at various mail facilities, where there is evidence of both, obviously cases, and then contamination from a pathway that contaminated letters went through in these sites.

We daily investigate reported suspect cases or concerns from all over the country. Every state in the country and many health departments, local health departments are getting suspect letters and concerns about patients who may be ill with this, and we follow up with them and where it's appropriate we get laboratory specimens with them or provide consultation, or where it would be useful, we would send people there.

But at the moment, there's nothing original in this, but the four sites that you know about, and we've talked about, and I've just talked about, are the ones on which we have a focus of attention.

I'm sure you've got a million questions, a lot of other things to ask. I think that's kind of a general summary of where we are. Let me just say that at CDC, we have turned around our own operation from the day one in this. You know, the initial report of one anthrax case was all we needed to both put our epidemiologic teams in order and deploy them in this, and our lab, and we've only built on that over time, and, indeed, put more people on than were absolutely needed at any given point, anticipating further needs, and we've always had further needs in this, even in the last two weeks.

We have moved people from other parts of CDC who work in areas that are either partially related, in some instances, or completely unrelated in others, to get skill sets to add to this team. We have physically moved people around the organization to be in proximity with each other, to meet all of the needs of this, including communications needs which we feel are very important, along with our epidemiologic and laboratory work, and we will move more, as is necessary, to get this job done.

So this is a major undertaking by us, probably as major a deployment of people and tasks, and commitment by us as anything we've done in over 50 years of history. Doesn't make it easy but we've got a lotta good people working on it.

I'm glad to answer any questions you've got.

MS. HOSKINS: Okay. Alan, would you go ahead and introduce our first caller.

CDC MODERATOR: Absolutely. Ladies and gentlemen, if you do have any questions at this time, press the one on your touchtone phone. You'll hear at one indicating you've been placed in queue and may remove yourself from queue by pressing the pound key.

If you're using a speaker phone, we do ask that you please pick up your handset before pressing the numbers. Our first question will come from the line of "Ceci" Connelly from the Washington Post. Go ahead, please.

MS. CONNELLY: Dr. Koplan, first, I wanted to ask you a little bit about the information that you're getting on these samples. You said that you did not see those envelopes, you, the CDC, did not get to see those envelopes. They were described to you. Is that the same with respect to the actual anthrax spores, or have CDC staff been able to take a look at this material, now, themselves?

DR. KOPLAN: We have gotten--we get a wide variety of different types of lab specimens to look at, we--and I'm trying to anticipate other questions as well "Ceci"--but including serum, biopsy specimens from people. We've gotten a lot of environment specimens, and yes, we have gotten spores.

Let me emphasize what our lab does and doesn't do. We're probably as good as anyone in the world at the biological, microbiological characterization of this agent, and other agents. But in this particular case, what we can do and what we've spent our time doing is we can describe, biologically, the anthrax we get, i.e., what are its biological characteristics? What are its genetic markers on its surface? What are its antibiotic sensitivities? And a huge thrust that we've been engaged in is just determining is something anthrax or not, whether it's in a person or an environmental specimen?

We do not, and don't really have the--it's a different type of laboratory technique to physically characterize the anthrax spores. That's very important in the criminal investigation aspects of this, and elements of it have a bearing on the epidemiologic investigation.

But we don't do that in Atlanta. So when it comes to particle size, additives, et cetera, we don't have those capabilities.

MS. CONNELLY: What about with respect to the coating on this anthrax? Have you been able to learn any more about that?

DR. KOPLAN: Again, we do not do that internally. What--you know, for us, we were able to draw conclusions based on the way things played out, epidemiologically. We knew from day, you know, one, that this organism was capable of causing disease, causing serious disease, causing death, and so its seriousness was not under any question from day one. It was with some relief that we found that its antibiotic sensitivities were fairly wide, consistent with organisms found in nature, and that the biological markers that we were able to look at are ones that are consistent with a number of different strains, if you will, of the disease, some of which are found in nature, some of which are used in laboratories.

But a key item for us has been throughout this, from our, just from our laboratory capabilities of identifying anthrax in what became many, many hundreds, maybe thousands of specimens that we got, and of ensuring that it had antibiotic sensitivity because that made a difference in how people got treated and taken care of.

MS. HOSKINS: Thank you, "Ceci." Alan, could you introduce our next caller, please.

CDC MODERATOR: Yes. That will be from the line of Maggie Fox.

MS. HOSKINS: Could we introduce our next caller, please?

CDC MODERATOR: Yes. That would be Maggie Fox with Reuters. Go ahead, please.

MS. FOX: Thanks very much, Dr. Koplan, for doing this. I'd like to ask you about the people who are antibiotics. Can we have a final wrap-up of numbers of who is being given antibiotics, and considering the epidemiological task you have ahead of you, how is that going to interfere with finding out who all has been exposed, considering that once you start on the antibiotics, it makes it hard to culture the bacteria?

DR. KOPLAN: Thank you. First, let me give you the last part first. It actually doesn't affect the spore carriage. So when people start on antibiotics, if you had a spore in your--or whatever number of spores in your nasal passage and you were swabbed, you would still get a positive culture for those spores.

A couple of points that I'd like to emphasize here, and I'll talk about antibiotics fully in your question. There's been some confusion about what these nasal swabs are used for. They are not a treatment indicator. I think, you know, we in medicine have always used throat swabs. You know, if you come in with a sore throat, you get a throat swab. That doesn't mean you have a strep throat or not, and we're all aware that you get antibiotics and you go off, and if you don't have a positive for a strep throat and you stay on it if it is positive for strep. But this is not the case with these nasal swabs for anthrax, which are really just environmental surrogates.

If five of us were sitting in a room and exposed, or five of us were sitting in a room three doors away from someone who is exposed, and one of us gets--has a positive nasal swab, what it serves as is indicating that there's been an exposure to anthrax in that room, and all five of us would be on prophylactics. It's just the same as swabbing the tabletop.

So we wouldn't use an individual's nasal swab to tell whether--alone whether they needed treatment or whether they were off treatment or could go off it, et cetera.

Back to the antibiotic question, Maggie. A lot of folks are on antibiotics in different places now, and they're on them for different reasons. In places where we're had more time to both investigate the environmental exposure, such as Florida and such as New York, and where we have been able to say that a smaller group of people clearly had evidence of exposure and a much larger group that we might have started on exposure, until we get some more information in, now no longer need to take it.

I'll give you an example. If a letter was opened in a given office, and in the immediate vicinity of that office there are 25 people sitting, and then on that floor there are 150, and on the two floors around it there are 400, at the earliest stage of our being involved with local health authorities, with state health authorities, all those people might well go on an initial dose of prophylaxis.

As laboratory specimens come back--and we try to get them back within 24 or 48 hours, if we're using our own lab--we are able then to say, you know, there's no evidence of spread of this beyond these three offices or beyond this floor or these two floors, and then people in other parts of the building or in other parts of the operation, we can provide assurance that there is no evidence of exposure there, and they don't need to continue taking the antibiotics from when we come back to them. I just--that was a comparable--a group, that example I just gave you would fit in New York, and this was just the same discussion we had.

There are a few people that are going to take the 60-day course. Many others have started, and now are being told you don't need to, you really are not at risk, and are not going to take the antibiotics further.

One of the questions that comes up, well, you know, is there any danger? Why don't I just take it for 60 days?

Well, we have already seen some significant adverse effects from these antibiotics. This is not a case--we have--there's no advantage to us to withholding anything from people who need it. We are health professionals. I'm a doctor. The last thing we want is to see somebody get sick who doesn't need it.

By the same token, the last thing we want to see is someone using medication that they don't need at all and then get an adverse reaction to it, or find that they then need to take it again at some time and it's of less value to them.

So there's a balancing act that goes on here which is we try to ensure that the circle of people taking the antibiotics is wider than our best evidence would advise, but not so wide as to have a lot of extra people taking it.

At the moment, in different sites around the country, particularly amongst postal workers, there are probably several thousand people taking antibiotics. We hope to be able to get back to many of them in the next few days and be able to say, great, you started it, you took it for a few days, but you really don't need it any more; or for those who do, to be able to pinpoint them and say this group here--and then we're not sure yet how large that group will be--do need it. Not only do you need to take it for 60 days, but don't do what all of us do with medications, take them till we're sort of tired of taking them and then leave the rest in your medicine cabinet. For those who need them, you need to take them for 60 days.

It's a dual message here.

MS. HOSKINS: Thank you, Maggie. Next caller, please.

CDC MODERATOR: That will be from the line of Amanda Stake with U.S. News and World Report. Go ahead, please.

MS. STAKE: Hi, Dr. Koplan.


MS. STAKE: Going back to the issue of the postal workers for a moment, given the situation in Trenton and the fact that there were cases of cutaneous anthrax, did CDC not suspect that there would be anthrax exposures among mail handlers here? And possibly cutaneous or inhalation anthrax?

DR. KOPLAN: We have been concerned about anthrax exposure in mail workers from Florida, and again we did environmental tracing there. But our experience in Florida, including going through the various post offices, was--were no cases of illness there.

MS. STAKE: Uh-huh.

DR. KOPLAN: In New Jersey, our initial link to New Jersey, to Trenton, was via the New York letters, and the cases we were seeing there were cutaneous, again which suggested both a lower dose and potentially some tearing or something of the letters as they came through, because they seemed to be associated with folks who were working on the sorting equipment, which has the potential to disrupt mail.

If we had inhalation disease there, we would have behaved very differently, and when we saw inhalation disease in Washington, we behaved differently. But that again is information we had later, not sooner.

MS. STAKE: Uh-huh.

MS. HOSKINS: Thank you, Amanda. Next caller, please.

CDC MODERATOR: And that will be from the line of Laura Meckler. She is with Associated Press. Go ahead, please.

MS. MECKLER: First, just to quickly follow up on that. So essentially you didn't think that the risk of cutaneous was significant enough to take preventative treatment in the Washington postal facilities?

DR. KOPLAN: Well, we wanted to wait and see if there was exposure there. Specimens had been taken down the line. We started off at--we were backtracking from the letter. You know, in the postal system, obviously, where do you start and where do you stop? The postal system, you can keep--and we have been going upstream and downstream from it, but it's virtually impossible to do it all at once. And then if letters can be mailed and then get put out to any one of a number of sites, the best we can do is to follow the trail of a given letter. And that's what we were doing as the inhalation cases occurred. We were awaiting environmental information from that post office, as well as the site.

Let me add that in the case of the inhalation anthrax in the Brentwood facility in Washington, a couple were associated with these machines that sort and strap, but at least one of the cases was someone who worked on the other side of the post office, something that would have been--again was a new, very new piece of epidemiologic information and required a very different construct again of the nature of the spread and the nature of what--the way this organism operated than we had before.

MS. MECKLER: Let me just ask what my question is going to be. Actually it's twofold.

One, do you have results back from the environmental testing at the outlying Washington post offices? And also do you have any results back from the genetic strain testing from the Brentwood exposures?

DR. KOPLAN: I've been away for a couple of days, and not on a secure line, so I've been getting just general information. My understanding was those specimens were actively being collected in the downstream post offices and sub-stations from Brentwood. Initially we thought there were a handful or a dozen of those. I now learned today that there are about 100 facilities in the Washington area that do get mail from Brentwood. So it's a huge undertaking to sort them out and get appropriate environmental specimens. But those are being collected.

There may be someone else on the line. I know that Dr. Gerberding has more recent information. But if those are being collected and we are getting the specimens, I think we can get a fairly prompt reading on the environmental contamination.

Julie, are you on the line? Do you have any more information on that?

MS. HOSKINS: Actually, Dr. Koplan, if we could save that for Julie's session, because we have several callers still waiting to speak with you.

DR. KOPLAN: Okay. Well, I'm giving you what I know and maybe Dr. Gerberding has some more information on that.

MS. HOSKINS: Okay. Thank you, Laura. Next caller, please.

CDC MODERATOR: That will be from UPI, Eileen Beck. Go ahead, please.

MS. BECK: Yes. Thank you. You mentioned earlier, you talked a little bit about what you can and cannot do with these anthrax spores, specifically what the genetic markers you might be looking at. From what you can do, how can you describe the different types of spores you've gotten? How are they different or how are they the same, specifically looking at these genetic characteristics?

DR. KOPLAN: The ones we have had, again, when I was last in Atlanta, are the same in terms of the biological characteristics that we look. But that doesn't mean--again, physically they can be quite different. So in terms of--and to be specific with you, in terms of the several genetic markers we look for in the anthrax, those have been the same, and in terms of antibiotic sensitivity, those would be the same.

MS. HOSKINS: Thank you, Eileen. Next caller, please.

CDC MODERATOR: That will be Diana Gonzalez from WTVJ. Go ahead.

MS. GONZALES: Thank you, Dr. Koplan. How frustrating is it for you--I know that in the weeks prior you had kind of made notes in your weekly reports for clinicians and laboratories to kind of be aware of any possible cases. How frustrating is it that the two postal workers who died in the D.C. area, it seemed were--at least their diagnosis was missed and were sent home, either from a physician's office or an emergency room? And what can be done to prevent that in the future?

DR. KOPLAN: Well, what can be done to minimize it? You know, we would like to prevent all of these, obviously--is just what we're doing. Is to have the press doing just what you're doing already, which is describing this as a major health issue, and having people recognize two elements to this.

One is that this disease can present as different types of illness, so that I would assume that a month ago, someone presenting with a skin lesion that was swollen, had a depressed center and then formed a scab over it, either would have been called a spider bite or something else, but would have been unlikely to have a lotta people think quickly of anthrax.

I think that that message of, yeah, it might be a spider bite but that's what anthrax spores look like is a very important one to get out to practicing docs, and we've been trying to do it.

MS. HOSKINS: [Inaudible - Airport voice-over.]

DR. KOPLAN: Sorry. I'm at an airport.

DR. KOPLAN: Sorry.

The--where was I?

MS. HOSKINS: Just talking about how the spider bite, how in the past might have been overlooked.

DR. KOPLAN: Oh, yeah; sorry.

Getting information out to both practicing docs, so that their index of suspicion is higher for the cutaneous lesions, and for folks who present with flu-like syndromes, headache, malaise, the trouble with the early stages of anthrax, as you're all well aware, is that it mimics lots of illnesses. You know, I can't be critical of whoever saw those patients 'cause I've been in emergency rooms and seen hundreds of patients with similar illnesses, and they do fine when treated as those people were treated.

However, the difference now is is that it's so important for medical personnel, when folks come in with those, to say where do you work and what do you do. We now have an occupational linkage that we didn't have two weeks ago, and so that medical personnel have got to have this as one of their medical questions.

Even somebody comes in with a recent cough and a light headache, and thoughts may be overwhelming that it's a viral infection, still, people need to say, Where do you work? What tasks do you do? Do you handle mail in a facility? Do you open the letters?, et cetera. It's now part of what needs to be part of a medical history.

So in the course of outbreak investigations, never mind attacks on our security, cases are missed. One of the things we try to do in any investigation of this kind is do as complete, what we call case ascertainment, as possible.

We have folks in metropolitan hospitals throughout the D.C. area and are working with the state and local health departments there and have been since September 11th, trying to get people to report unusual syndromes, not diseases by name, but combinations of skin rashes and fever, or more people than you'd expect with a cough and fever, or someone that doesn't get well quickly.

And, indeed, that kind of alertness I think picked up some of our early cases in both New York and Florida.


DR. KOPLAN: But are we gonna miss some? I'm afraid that--you know--that's the nature of these things in general. We would like to have none missed and will do everything we can to see that none are missed, but probably some will be.

MS. HOSKINS: Thank you, Diana. Next caller, please.

CDC MODERATOR: Marcus Smith from Postal World News. Go ahead, please.

MR. SMITH: Yes. Dr. Koplan, I wanted to ask basically two things. Number one, how often should people be changing these gloves, and should they be disposed of, you know, and the people who are handling mail, should they be disposed of in regular trash, or should be used, biohazard trash? And how much danger is there for someone handling mail in terms of cross-contamination from other mail pieces that may have come in contact with a contaminated piece?

DR. KOPLAN: Thank you. Let me--we'll answer your question but let me start off by just expressing our profound concern and empathy for postal workers, who are fellow Government employees. You guys perform a vital national service--

MR. SMITH: Sir, may I--I appreciate that and I agree with you. My readers, the people I write for, are people who are at the receiving end of the mail.


MR. SMITH: Who are responsible for delivering it.

[Simultaneous conversation.]

MR. SMITH: I didn't want to take credit for having a--for postal workers.

MS. SMITH: Forgive me.

DR. KOPLAN: Well, believe me, all of us are pained at what's gone on to folks that are trying to do a service job for all of us. This is--those losses are tragic, from our perspective.

Let me answer your question about gloves. The Postal Service is in the process of ordering gloves of a particular description and type, that should be effective in preventing contract of anthrax on hands. Disposal of those are--we've got a fair amount of increased experience with gloves in a microbiologic protective mode, because hospitals and health care workers in the last few years, as you're all aware, going to a dentist or a doctor, have much more use of gloves in the world of post-hepatitis, viral hepatitis, and HIV. So we have more experience with that.

And the rule is that folks who are handling mail and/or in any format, and they're wearing gloves, and those gloves get torn or nicked, or in any way, the integrity of those gloves is compromised, then what one does it remove the glove then, wash your hands with soap and water, no special soap, regular soap. The major action of soap and water--

[Airport announcement.]

DR. KOPLAN: You guys will both be able to report on anthrax and Delta's schedules when you're done with this call.

Let me continue. And I think it's an important concept, is that you knocking, physically, spores off your hands, should you get spores on them when you use soap and water. It's not killing the spores, it's just removing them or washing them down the drain.

So hand washing is an element that's valuable. You then put on--dry your hands and you put on a new pair of gloves to continue what you're doing. If you were able to wear gloves for your full day's work, or your full task, these gloves would then get disposed of at the end of the day. You wouldn't save them to use the next day.

MS. HOSKINS: Mark [inaudible], please.

DR. KOPLAN: Again, I'm--and there was a question of how they should be disposed. Does anything special have to be done with them? I believe they can just be disposed of in a routine trash receptacle and without any danger. Again, Dr. Gerberding, who's to follow, is a world expert on protective barriers in hospital settings, and which is applicable here. So if I have misspoken, she will correct me, and I'd go with what she says.

MS. HOSKINS: Thank you, Marcus. Next caller, please.

AT&T MODERATOR: Paul Monez with WCBS-TV. Go ahead.

MR. MONEZ: Yes. Dr. Koplan, my question, back to the postal workers--actually, I have several questions. I'll try to get them in here.
Many postal workers in New York City, which is the beat that I've been covering, are questioning the wisdom of being given Cipro when there's been absolutely no testing done here.

Why are these folks being given Cipro if there's no indication that they actually have anything?

DR. KOPLAN: Well, one reason is environmental testing is being done there, and, if you will, one of the things that we saw in Washington was that while we were awaiting the results of the environmental testing, even though we thought the likelihood might be--we're unclear, what the likelihood was of contamination in a postal facility--people were not being given Cipro at that time because we thought the risk was low, and then, indeed, we found that the disease was both being transmitted in a different way and apparently via a, an agent that was behaving differently than the way we had seen it before.

I think that people are bending over backwards in the case of New York, to have people on it for a few days, until these environmental specimens come back and determine whether there was exposure or not.

MR. MUNOZ: But I guess my point, if I could just interject because--

DR. KOPLAN: I'll have to say it's a case of you're damned if you do or you're damned if you don't. It's a case of how far do you extend that circle of people who get prophylaxis, while you're awaiting some more epidemiologic data and information, and environmental data and information that says whether you need it or you don't, and we try to, as I said, make that circle wide enough to include everybody in it, but not make it so wide that people are taking it completely unnecessarily.

MR. MUNOZ: Right. But the issue that people have here in New York is since no one in the New York postal system has tested positive for anthrax or for the exposure to it, and since symptoms would show that you have anthrax, people are saying, well, I have no symptoms, there's been no confirmation of anthrax here, why should I take Cipro? Shouldn't I wait till symptoms come or until they actually confirm something?

DR. KOPLAN: Well, I would say you're better off not waiting till symptoms come. Obviously, if you can take something that prevents the symptoms at all, that is advantageous, and what these folks will learn soon, is whether there's any exposure--never mind symptoms--whether there's been any exposure there or not, and if there has been--an example would be if in a given mail station, if it tests negative in every specimen taken in every part of the station, then those folks don't need to take it, and if they've taken it for three or four or five days, can go off it. If they do find that there has been a contaminant in one particular part of that station, then folks that are, with that level of exposure in that location will probably be asked to continue.

I think--you know, what you're--you're asking like an epidemiologist. You're saying do you have enough data to argue that these folks take it? I say at this point, it is prudent for them to take the prophylaxis, and for a few days, and hopefully not have to need it after that.

MS. HOSKINS: Thank you, Paul. Alan, we have time for one more question in this segment, and then we will be moving on to Dr. Julie Gerberding.

CDC MODERATOR: That will be from the line of Marilyn Marschione with the Milwaukee Journal. Go ahead, please.

MS. MARSCHIONE: Dr. Koplan, yesterday the postmaster general asked--suggested to Americans that they wash their hands after handling home mail. Is there any information come to light to suggest that home mail might have been contaminated, or that average Americans may have been exposed?

DR. KOPLAN: Thanks, Marilyn. We have no information on--no evidence that home mail is contaminated, and in some ways that was tracked back to--you know, there are billions of pieces of mail coming through the system, and there are a few contaminated pieces are purposely placed anthrax letters in there that are circulating in some parts.

You know, there's a dilutional aspect to it, that even if those are laden, if your mail which is coming through some postal facility, is there going to be enough on that mail to pose a risk to a home dweller when they get it. I think the risks of that are very, very small.

Is there anything wrong with washing your hands after you bring in the mail? No. We at CDC have been pushing hand washing for a long time as an appropriate infectious disease control mechanism, at about the same time as our mothers started to argue for it, and there's nothing wrong with doing it. If people feel--if it makes people feel more comfortable in their own home that after they bring in the mail, they wash their hands and check and see what the letters are and where they're from, I think that's fine. There is certainly no harm to folks washing their hands more.

MS. MARSCHIONE: But, again, Doctor, there's no evidence to suggest that there's been contamination other than postal workers who handle mail?

DR. KOPLAN: That is how we see it so far.

MS. HOSKINS: Thank you, Marilyn.

At this time I would like to introduce Dr. Julie Gerberding. Dr. Gerberding is going to discuss the article in this week's MMWR entitled "Update: Investigation of Bioterrorism Related Anthrax and Interim Guidelines for Exposure Management and Antimicrobial Therapy," October 2001. Dr. Gerberding.

DR. GERBERDING: Thank you. I hope all of you have had a chance to find the MMWR, but just to point out what the highlights are, this is an update on the new cases that have evolved since last week, and some additional information on the first cases that were reported.

In addition, we are presenting the information we have on the antimicrobial susceptibility of the various isolates of the traces and the treatment guidelines for individuals who have anthrax, either through the cutaneous or the inhalational route.

We also have presented some updated information about how to manage a situation where exposure may have occurred or is known to have occurred, and have referenced the new information about how to protect mail handlers and others who may be at risk as a consequence of their contact with mail.

What we are reporting in this MMWR is a total of 15 cases now of anthrax associated with this bioterrorism attack. There are 11 confirmed cases that meet our fairly stringent CDC case definition, an additional four suspected cases of individuals who have illness that is highly indicative of anthrax, but the laboratory confirmation has not yet been firmed up.

Seven of these individuals had anthrax acquired through the inhalation route, eight have acquired their infection through the skin.

Of these 15 individuals, three have died. All of these were people with inhalation disease.

So again, this is an update on the latest information involving what is really the first bioterrorism-related anthrax attack in the United States.

MS. HOSKINS: Thank you, Julie. Alan, we'll go ahead and start with our first caller.

CDC MODERATOR: Certainly. And, ladies and gentlemen, once again, if you do have a question or comment, just press the one on your touchtone phone.

Representing U.S. News and World Reports, we go to the line of Amanda Stake. Please go ahead.

MS. STAKE: Hi, Julie. Thank you. The 15 cases that you are discussing, 11 confirmed and four suspected cases, those four suspected cases, are those in the Washington area?

DR. GERBERDING: No, those cases are not in the Washington area. They are in New York and New Jersey.

MS. STAKE: Okay.

MS. HOSKINS: Thank you, Amanda. Next caller.

CDC MODERATOR: Thank you, Ms. Stake. Representing the National Public Radio, Joanne Silberner. Please go ahead.

MS. SILBERNER: Yeah, hi, thanks. Dr. Koplan got at this a little bit, but I'm wondering if you could explain it a little more, and I think it's something that's confusing people, and that is the initial dose in Cipro has been two days, three days, 10 days. Why have there been those differences in recommended times?

DR. GERBERDING: The reason that we are starting some people on shorter courses of Ciprofluoxicine or other drugs is because we expect that as the environmental sample data become available, we will learn that most of these people do not need to take any antimicrobial prophylaxis. So it's a way to make sure that everybody who might possibly be at risk is offered treatment as early as possible, but as soon as we learn new information we're going to tell them to stop the therapy. So we don't want them to be sitting around with an extra 58 or 48 doses of treatment that they're not going to need to take.

MS. STAKE: But why--you know, in some cases, it was three days; in some cases, it was 10 days.

DR. GERBERDING: Some of that has to do with the way the drugs are prepared by the manufacturer. For example, one of the allotments of drugs come in six-packs that are divided up into 10 day supplies. So it's much easier for us to just hand out a 10-day supply than it is to cut the strip up into individual pieces and hand them out to people that way. When we're trying to treat very large numbers of people, we have to do whatever is the most efficient under those circumstances.

MS. HOSKINS: Thank you. Next caller, please.

CDC MODERATOR: Next we go to Nikkai Newspapers, Kyoshi Undu. Please 
go ahead.

MR. UNDU: Hi. I understand that of the four suspected illness, one is from The New York Post. And I was wondering, they have announced that this person has cutaneous anthrax already several days ago. And what takes this long for you to confirm this more stringently?

And also I'd like to know how long you can actually trace whether a person really--if the person really had anthrax or not. If you have like weeks passed, then will it become impossible to even know whether that was the case or not?

DR. GERBERDING: The situation with the suspect patient in--one of the suspect patients in New York, I think the one you are referencing, is that we learned about the case very late in the course of the illness, after antibiotics had been provided and the skin problem was almost completely resolved. So the biopsy specimen we obtained did not grow the organism, and we were not able to find any evidence at all of the organism, even using our most sensitive techniques.

So in a situation like that, we might be able to find antibody evidence of infection by examining a blood sample early in the course and comparing it to a sample that is collected many days, two weeks later. If we see that concentration of antibodies to the bacteria have gone up significantly, that would be a clue that a recent infection had occurred.

So what we are waiting for is for a follow-up blood test on this individual after, you know, weeks have gone by, to see whether these antibodies developed.

I think that it's not a question of the delay in actually doing the test, it's a question of the time it takes for a diagnostic test based on blood antibodies to become positive.

I would also add that this antibody test that we are using was developed for evaluating the response to vaccines, and it has not been validated as a diagnostic test for anthrax. That's part of the reason why our case definitions are so specific, because we don't want to misdiagnose or overstate the number of cases.

Having said all that, I think that in a situation where you have an individual who handled a suspicious package or envelope, or who may have handled that, and then developed a skin lesion, that by the history from reliable clinicians sounds like anthrax, we think it's completely appropriate to keep this person listed as a case.

MR. UNDU: So if you missed the timing, it would be really impossible to find out clearly whether a person had anthrax or not?

DR. GERBERDING: I'm sorry, I didn't hear the beginning of your question.

MR. UNDU: If you missed the timing, the best timing for testing, it would become really difficult and possibly in some cases impossible to know whether a person really had anthrax or not, both in cutaneous and inhalation anthrax cases?

DR. GERBERDING: I think that we are confident that in the vast majority of these cases, we are going to be able to make the diagnosis, in part because for inhalation disease the patients are very sick, and those bacteria grow so prolifically that we will be able to either find it or evidence of its DNA in the patient.

In the case of cutaneous anthrax, if the diagnosis is made in retrospect, it's a bit more difficult, and we hope to improve the sensitivity of the test that we do have to make sure that we can detect even those patients.

MR. UNDU: Thank you very much.

CDC MODERATOR: And thank you, Mr. Undu. Monica Conrad with the American Broadcasting Company has our next question. Please go ahead.

MS. CONRAD: Hi. I'm going back to something Dr. Koplan talked about earlier. Can you describe to me what the envelope the Daschle letter, how it was sealed when it was arrived? And then from that, because he said that it was pretty tightly sealed and it required scissors to open, are you guys now looking at the possibility of it being more than the Daschle letter that may have created those exposures in Brentwood?

DR. GERBERDING: Well, first let me say that I have not seen the Daschle letter, so my information about that letter is based on the information that's been provided to us here at CDC. But my understanding is, based on the reliable person who saw the letter at the scene, is that the envelope was completely taped shut, including the flap, and that there is no evidence of tears or holes or punctures or any other source of leakage of that envelope. So that was one of the reasons why the suspicion of an upstream exposure was very, very low at the time this event occurred. We had basically a completely intact sealed envelope.

With respect to the question about the number of letters, I think it is very important to maintain the big picture here, and that is that we are experiencing a bioterrorism attack caused by anthrax distributed through the mail system. So we are very concerned about additional letters. We know of three letters already and I think we would be naive to think that this was over yet.

MS. CONRAD: Thank you. And can you just confirm for me that that letter was opened with scissors, it was so closely sealed?

DR. GERBERDING: My understanding again from the interview and the information we have available to us at this time, that scissors were necessary to open that letter.

MS. HOSKINS: Thank you, Monica. Next caller, please.

CDC MODERATOR: Thank you, Ms. Conrad. Next, representing--next we'll go to The New York Times, Larry Olson. Please go ahead.

MR. OLSON: I had a couple of questions here. Regarding the antibiotic sensitivities in the MMWR, is the antibiotic step that's been described there compatible with the Ames strain, the other strains that it's thought to be identical with? Is there anything different or tampered with, or is there any suspicion that there's been any bioengineering?

And the second question relates to the use of a vaccine and treatment.

DR. GERBERDING: Thanks, Larry. The information we have about the strains are limited at this point in time, but--because we haven't sequenced the entire genome. But what we do know by some very sophisticated subtyping procedures that are the best way to subtype anthrax isolates is that the strains from the three loci that have been evaluated are indistinguishable.

So they are indistinguishable from one another, and they are similar to other naturally occurring strains of anthrax that have been detected both in the United States as well as Europe, in Europe, in outbreaks in domestic animals.

So these strains cannot be distinguished from other anthrax isolates that are known to have caused disease in barnyard animals, basically.

With respect to the susceptibility testing, I don't have any information about the antimicrobial susceptibility of the Ames strains. I can't really comment on that.

I think that the fact that these are very similar to what we would expect from a reference library of bacillus anthraces strains that we have here at CDC, based on a look at the sequence of the anthraces that has been put into the gene bank, we suspect that there are [inaudible] and there are penicillin-like activities in most strains of bacillus. So the fact that we're finding them in the isolates that we have here is entirely consistent with the natural biology of the organism.

So the short answer is we have absolutely no evidence to suggest that these isolates have been genetically altered or engineered in any way. In fact, we are quite relieved that their susceptibility profile looks like we would expect from a naturally-occurring strain.

MR. OLSON: Okay. The second question then is there's no mention in there about the use of anthrax vaccine in a case of inhalation anthrax, which some [inaudible] scientists have recommended be part of the treatment.

DR. GERBERDING: I think that the role for a vaccine is in prevention of infection, either post-exposure or pre-exposure. There is no evidence that post-exposure--I mean--excuse me--post-infection vaccine contributes anything to the outcome of the patient, and the reason for that is the vast majority of these infections are immunizing.

So you're not gonna get any more antibody or protection from the vaccine than you do from the fact that your body's loaded up with bacillus bacteria while you are sick.

So we are not looking for post-disease immunization to affect treatment outcome.

You know, obviously that's a research question and we'll look forward to doing additional laboratory studies to try to evaluate that for certain.

What we are interested in to perhaps improve the outcome of these various cases is the antitoxin.

We know that this bacteria produces a toxin that accounts for the majority of the life-threatening symptoms and so if we were able to provide a specific antibody that would knock that toxin out, perhaps the patients would have a better clinical response to treatment, and overall do better.

The FDA is bending over backwards to help us get an IND to evaluate the role of antitoxin for treatment.

MS. HOSKINS: Thank you, Dr. Altman. Next question, please.

DR. ALTMAN: There was a follow-up there. But doesn't the vaccine also have an antitoxin effect? Isn't it partly antitoxin?

DR. GERGERDING: The vaccine is targeted against the protective antigen of the bacteria, so that is the activity that neutralizes the bacteria. There are other products in evaluation that are more specifically targeting the toxin, but we are not able to access those at this point in time.

MS. HOSKINS: Next a question from Eric Sabo with CBS HealthWatch. Please go ahead.

MR. SABO: Thanks. You sort of answered this but I'll ask directly. There's some reports on whether the bacteria we're finding is weapons grade or not, or at least highly sophisticated in how it was manufactured.

Two questions. What is the CDC's view on this and if the anthrax is found to be weapons grade, or sophisticated, will this change how the CDC responds to other outbreaks?

DR. GERBERDING: I'm not really--I'm an epidemiologist and a doctor and I'm not really familiar with what "weaponized" means.

What I can say is from the CDC perspective, we know a lot about this situation. We know this is a very virulent bacteria. It's obviously capable of killing people and that's our starting point, and I think what we have learned in the last week or so is that the sophistication here or the expertise in weaponry is in the mind and the actions of the person who's perpetrating these attacks and I don't know that it's a problem with the bacteria.

I think it's a problem with the method and the finesse of the individual responsible.

MS. HOSKINS: Thank you, Eric. Next caller, please.

AT&T MODERATOR: Next we'll go to Erin McClam with the Associated Press. Please go ahead.

MR. McCLAM: Yeah. On the antimicrobial treatments--actually, I'm at the MMWR today--the seven or eight other antibiotics that you're recommending to treat these confirmed cases, in addition to Cipro and Doxycycline, you say they're predicted to be effective but there hasn't been any human trials, obviously. Can you talk about how you chose those drugs and how confident you are that they're work in a human case.

DR. GERBERDING: Well, the first step was to evaluate the susceptibility of the bacteria to these agents in the laboratory, so that is where the initial list of susceptibility information came from. But then we have to step back and say, well, it's one thing to see what happens in the test tube. What can we predict about what's needed in the patient? And that's where the issue of the penicillin, and penicillin-like drugs comes into play. Because even though the bacteria tests completely sensitive to penicillin, we know from experience with laboratory strains of bacillus, that sometimes under the pressure of exposure to penicillin, these bacteria can turn on an enzyme that destroys that drug.

So they look sensitive in the test tube, but if you have a lot of them in a patient, and you treat that patient with the penicillin, they'll rev up to destroy the penicillin and the treatment may be less effective.

That is the reason why we are not including penicillin as a first-line treatment, even though the laboratory tests suggest that the organism is susceptible to it.

The other choices there are based on a variety of factors, mechanistically, which are known to be the most rapid killer of bacteria, and also depending on what tissue compartment we're interested in.

For example, if the patient has meningitis, we want to make sure that we're including drugs that get across the blood-brain barrier and would be active in the spinal fluid.

So there are a variety of issues to take into consideration and I can assure you that we have consulted with a long list of experts and spent many, many, many, many hours doing the best we could to patch together the information and literature on anthrax disease, to come up with what we think will be an effective recommendation.

What's new in this recommendation is the fact that we're very proactively supporting combination therapy and in fact while it's too early to draw any conclusions, we have at least four people who are stable or improved, in fact one person's who been discharged from the hospital after inhalation anthrax. These patients have been treated with combination therapy and that may be one clue to why they are doing better than we would generally expect.

MR. McCLAM: Thank you.

MS. HOSKINS: And next let's go to CNN's Elizabeth Cohen. Please go ahead.

MS. COHEN: I have two questions. The first is is the CDC concerned at all about antibiotic resistance developing in the communities where thousands of people are taking Cipro, and, if so, what will be the timeline for that concern?
Is that an immediate concern or more of a long-term concern?

DR. GERBERDING: Our short-term concern is making sure that anybody who's been exposed to anthrax is on appropriate prophylactic therapy and I think that's an overriding issue for the short term and sort of trumps the concern about resistance developing over the long run.

However, we are always concerned about unnecessary exposure to antibiotics, and again that's part of the reason why we don't immediately distribute the full 60 days to absolutely everybody that we think could conceivably be exposed.

We may give people a few days of treatment while we sort of it out and then not provide them additional therapy if they don't need it. It's not a concern, in our minds, at least, for the bacteria to evolve resistance to Ciprofloxacin, the bacillus bacteria, but the other bacteria that are common in colonizing people, and so forth, certainly will respond to the selection pressure and we have to be vigilant that things that used to look susceptible may certainly respond to Ciprofloxacin exposure, Doxycycline exposure, and develop resistance.

Again, while there's been a lot of emphasis on Ciprofloxacin as being the mainstay of therapy for prevention, it is just as active as Doxycycline, and perhaps some other drugs that we're evaluating.

So we don't want to send a message that the only thing that you should take for prevention is Cipro. We use Cipro and Doxy, and other agents that will help spread the resistance pressure around a bit, and ultimately may reduce this problem for us.

MS. COHEN: But the concern that resistance could develop, obviously not anthrax [inaudible] but other bacteria that's just sort of in the community, is that something that might, you might find a patient tomorrow who developed resistance because of all the Cipro that's out there? Or is this something that would happen a year from now? How quickly do these bacteria learn to become resistant to a drug, to Cipro or any other drug that's being given in big numbers?

DR. GERBERDING: Well, as you know we already have plenty of bacteria that are Cipro-resistant circulating in the community. So we are not going to be able to say it was the prophylaxis for anthrax that produced the problem. Cipro's been around a long time and this is an ongoing issue as you know.

So I don't expect we're gonna be able to detect any immediate change in resistance profiles for many, many months, to years, but I would be surprised if there was a zero impact.

MS. COHEN: Okay, and the second question is I understand why you don't want to give these nasal swabs to everything, because there's no treatment, [inaudible] be made, but we've heard lots of postal workers saying "Test me in some way."

Would it be possible to give these folks a blood test that would have meaningful results in terms of what treatments to give, and meaningful, that it would come back in time?

DR. GERBERDING: Now, unfortunately, there's absolutely no test for exposure to anthrax. The test to determine who's been exposed is to go to the environment and do the very best job you can assessing the epidemiology and sampling that space to detect the presence or absence of spores in the vicinity of the people who work there.

So when we swab noses, generally, it's only useful if you do it fairly soon after there's been a release, and even in those cases I don't think it's very helpful information to the individual.

If they were near a powder that had anthrax in it, they're gonna need treatment, regardless of their nasal swab. So at this point in time there is no test and I don't see a test for exposure becoming available any time soon 'cause I can't even think of how such a test would be targeted.

MS. COHEN: Why not try to culture the bacteria in their blood?

DR. GERBERDING: Because they don't have bacteria in the blood. If you're exposed, it simply means that you may have breathed in some bacteria but it doesn't circulate in your bloodstream unless you get sick.

MS. HOSKINS: Thank you, Elizabeth.

AT&T MODERATOR: And would you like to take another question?


AT&T MODERATOR: Very good. We'll go to Julie Deardorf [ph] now with the Chicago Tribune. Please go ahead.

MS. DEARDORF: Hi, Julie. I'm wondering, is sterilization of mail, is that effective? I mean, and how do you do that on a grand scale?

DR. GERBERDING: Well, obviously we're on the fast-track here to try to answer your question. There are theoretically means of sterilizing the mail. We're learning from the meat packing industry and the radiation of food products that's been underway in some areas, that with either gamma radiation or electron beam radiation, you can sterilize packaged materials.

However, it's going to be much more difficult to sterilize the mail than it is to sterilize beef steak. Part of that reason has to do with the way mail comes through the system.

It will likely need penetrating beams to get through the kinds of assorted packages and parcels that are sent through the mail.

But, more importantly, what we're trying to do here is eliminate a spore and a spore is basically an inert bacteria that contains no water.

So the susceptibility to any kind of radiation blow, and we have to use longer times of exposure or higher doses of the radiation in order to be effective at killing it.

We are optimistic that this can be done. There's some experience with it already, and I can assure you that we're talking with the folks who deal with this in other industries and sectors to see if there is a practical way to make this kind of approach feasible for the postal system.

In the meantime what we need to do is to protect the mail handlers the best we can and the guidance that CDC issued yesterday which includes not only the kinds of personal protective gear that we've already talked about, gloves and masks for people who are in really high-risk areas for aerosol or duct generation, but also a broader issue such as improving the ventilation of the air of hepa filtration of the air in postal facilities, and taking steps to ultimately engineer out the hazard of airborne particulates.

MS. HOSKINS: Thank you, Julie. Next caller, please.

AT&T MODERATOR: Thank you. We'll go to Loren Nergard [ph] with the Associated Press. Please go ahead.

MS. NERGARD: Hi. A couple a questions here. First of all, can you talk with us about the genetic strain testing that was done on the Brentwood samples that you were able to take to see if indeed it does match what has already been sent out, the three indistinguishable strains that you've already talked about. Can you talk about results from environmental testing at the outlying Washington post offices that you already have underway, and do you have any more suspected cases since the MMWR update was written last night?

DR. GERBERDING: At this point in time I do not have information on the genetic typing from any of the isolates associated with the Postal Service in Brentwood or elsewhere in the D.C. area.

I can assure you those are being done on a fast-track but they take time because it involves sequencing at up to 33 [inaudible] of the genome, and we're obviously very interested in getting those results as fast as we can.

With respect to the environmental sampling, as Dr. Koplan mentioned, it's not only the post offices where people have presumably been exposed and gotten sick, but it's several, actually a 100 downstream postal stations, including mail rooms in government offices as well as other postal substations that are involved in this environmental survey.

We are sending charter planes full of CDC staff and laboratorians as well as industrial hygienists who are certified to conduct these kinds of evaluations and they are literally working 24 hours a day to collect these specimens.

In order to speed up the flow of information we've sent them with the actual plates on which the bacteria grow, so while they are in the process of collecting the specimens they can transfer the bacteria immediately to the plate. That will speed up the time for detection considerably.

Some of those plates are already back here at CDC but we can't call something negative for at least 24 hours and we can't call something positive until we've had a chance to do the confirmatory test paneled.

So while we're doing everything, we can speed it up, I don't think we're gonna be able to put this picture together today.

MS. NERGARD: So at least another 24 hours?

DR. GERBERDING: I can't speculate because the number of specimens coming in is large and I haven't had a chance this morning to catch up with our lab team to get an update on where they are with this.

You know, we obviously have enormous expertise here and our senior laboratory scientist is experienced enough with this organism, that she can look at a plate and pretty much tell whether it's going to be a positive or not. So we're able to prioritize the specimens that we'll look at, initially.

But again it's going to take some time, 'cause we literally have hundreds and hundreds of plates coming in here.

MS. NERGARD: How about--any more suspected cases since last night, that you all actually classify as suspect and not just, you know, there's somebody who's shown up with some cold symptoms?

DR. GERBERDING: Well, I can tell you that in the D.C. area right now, we have a very large team of infectious disease doctors who are evaluating every single person associated with the mail system who's presenting to an emergency room, cooperating with the state health departments in Virginia, Maryland and Washington, D.C., to do enhanced surveillance of all emergency room and visits for anyone with a syndrome that even sounds potentially suggestive of anthrax.

As of this morning I am aware from our team that at least 71 people have been evaluated, the vast majority of these people absolutely do not have anthrax, and right now we are still only focusing on the four confirmed cases that we have. We're on top of this and as information comes in to suggest otherwise, we'll be updating the press appropriately.

MS. HOSKINS: Thank you, Loren. We have time for one more question.

AT&T MODERATOR: Very good, thank you, and ladies and gentlemen, thank you for the strong interest being shown today. With time now for one more question, we'll go to United Press International's Ellen Beck. Please go ahead.

MS. BECK: Thank you very much. To follow up on what we had talked about before, a little bit about this cross-contamination, specifically since now we're talking about 100 postal stations being looked at in the Washington, D.C. area, affecting potentially more than a million or so people, you know, what kind of--how do you categorize this risk? What do we say to people? You know, don't be afraid, don't be panicking, but, gee, we're evaluating 100 postal stations where your mail may come from.

DR. GERBERDING: I think we have to step back from this and take a deep breath. This is frightening. It is a biological attack, and we have no experience with this. But at the same time, there are billions of letters and parcels moving through the mail system, and we know that the vast, vast majority of the mail truly is safe. So it's a little bit like searching for a needle in a haystack, and I think the common sense recommendations for protecting people who handle mail are going to add an extra layer of security here.

For people in their homes, as Dr. Koplan said earlier, I don't think they have anything to be worried about. And if they want to wash their hands after they handle their mail, that's not a bad idea for other public health reasons. But the important message is that if you see something suspicious in the mail, set it down and leave the area immediately, contact someone for help, including law enforcement activities, or if at work, a supervisor, appropriate person, and get out of the exposure zone as quickly as you can.

MS. HOSKINS: Okay, thank you, Ellen. Thank you all for joining the telebriefing today. The MMWR is posted on line. Also guidelines for postal workers have also been posted, and there's also guidelines for first responders which will be posted later today.

Thank you.

CDC MODERATOR: Ladies and gentlemen, that does conclude the Center for Disease Control's anthrax press conference for today. Thank you very much for your participation, as well as for using AT&T's Executive Teleconference Service. You may now disconnect.

[End of press conference.]

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