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Update on Anthrax Investigations
with Drs. Jeffrey Koplan and Julie Gerberding

November 7, 2001

CDC MODERATOR: Thank you. And good afternoon to all the reporters listening in on the call. I'd like to introduce our two speakers today. Dr. Jeffrey Koplan is director of the Centers for Disease Control and Prevention, and also with us is Dr. Julie Gerberding, acting deputy director of the National Center for Infectious Diseases here at CDC.

Dr. Koplan has just a few brief comments, and then we'll get started with the Q and A. Thank you.

DR. KOPLAN: Thanks, Tom. Good afternoon, all of you. We are still dealing with a case count of 17 confirmed cases and five suspect cases in four sites. We still have investigative teams out in all of those sites doing a variety of different tasks including continued case detection, investigations, and a wide variety of activities as we've described before. And probably the best thing to do now is just to use the time for your questions. 

CDC MODERATOR: John, let's go ahead and start with the questions, please.

AT&T MODERATOR: Certainly. And just as a quick reminder, ladies and gentlemen, if you have a question at this time, please press the one. Our first question is from the line of Andrew Rafkin with The New York Times. Please go ahead.

QUESTION: Hello, everybody, and thanks again for keeping at this even when it doesn't seem like much is happening. 

I have a couple of sort of hygiene questions. One is that in the case in New York City, one of the only things that distinguishes her from the others obviously is that she worked in a hospital where the other inhalation cases worked in mail facilities, for the most part.

Is it possible or have you explored whether the hospital hygiene routine, meaning some janitor coming through the mail room, stock room, et cetera, every night and spritzing everything or wiping everything could have wiped away traces of spores [inaudible]?

DR. KOPLAN: Thanks, Andrew. There is clean-up that goes on in the hospital, sweeping, et cetera, but not at a level that would have eliminated what we think would have been the type of exposure that could have led to an inhalation anthrax case.

QUESTION: And the follow-up is have you--obviously this is all emerging science, but do you yet have a sense of the probability of her simply being one of the unlucky outliers who could contract this fatal inhalation case while only inhaling a few spores?

DR. KOPLAN: Well, we don't rule out anything, but we just don't have evidence for enough of that. And there's really--you have to be way out on the outlier for a few spores, so that, you know, given the numbers that have been postulated from animal experiments, given--given other physical attributes of spores that might make for a lower LD-50, a lower lethal dose, a dose that would cause inhalation anthrax, still it would be a lot more than a few, and we still have no exposure explanation that would account for that in what we see at her work, her home, or what we've learned about her daily habits.

QUESTION: Who is that who was just speaking, by the way?

DR. KOPLAN: This is Dr. Jeffrey Koplan.

QUESTION: Okay. Great.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Thank you. That's from Jerry Maniere with The Chicago Tribune. Please go ahead.

QUESTION: Thanks very much. I was wondering if you could maybe shed some more light on what came up at the hearing yesterday with Senator Feinstein. She asked, you know, if we know which labs have dealt with anthrax, and other CDC auditors select agents that are transferred from lab to lab and you have to register for that. Do we know what labs do that? Do we know which labs just possess these kind of agents? And how confident are we that the transfer even is being regulated effectively?

DR. KOPLAN: Well, as you indicated, what we do is we register labs that mail to us agents, not ones that possess them. More labs possess them than mail them, and we know some of those, but we don't have a registry. Our role in the select agent is determined by legislation. There's laws that, you know, instruct us what to do and that's what we perform. So I couldn't give you a number or certainly the names of all the others that have it.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Thank you. That's from Peter Slevin with The Washington Post. Please go ahead.

QUESTION: Yeah, thanks very much. Turning to the AMI case in Florida for a minute, can you please tell us what you learned from the two rounds of blood tests of AMI employees, particularly from an epidemiological perspective? I know there's an interest in trying to track the course of any potential letter through the building, and I'm wondering if you've been able to shed some light on that with [inaudible].

DR. KOPLAN: Sure. Thank you. First of all, the serology, the blood test that's being done for anthrax is really quite new in use in this setting. Its previous use has been largely to determine whether people have converted to vaccination, so that when laboratory workers who work with anthrax all the time receive--you know, there are certain numbers of doses, they then can get their blood tested so that they have some greater confidence that the vaccine had a successful immunologic conversion as they work with these deadly agents in the lab.

In this--as you indicated, in the AMI outbreak in Florida, for a variety of reasons there was value in seeing, for one--you know, we didn't have a letter in hand. We were able to track exposure seemingly through a mail-related route, but we never got a letter or a package in hand, and so there was value in looking at a variety of different ways to see how many people might have been exposed in this setting with different tools, and that's where nasal swabs were used as a surrogate for the environment and environmental specimens were taken. And in addition, blood specimens were taken.

But certainly we did not--we could not bank on an experience to say how to interpret those findings when the blood results came back.

I would turn it over now to Dr. Gerberding who is closer to the results of these two collections.

DR. GERBERDING: Yeah, and again, as Dr. Koplan said, those tests are not validated as a diagnostic test for anthrax at this point in time, but we are trying to learn as much about its performance as we can. 

What we can say is that in people who have anthrax disease, the test often is position and antibody [inaudible] may increase, but these are people who have all of the clinical signs and symptoms of illness.

We don't have any information to suggest that it's useful in evaluating exposure, and that's why we're no longer using it as a routine component of exposure assessment, because it's not positive unless somebody has infection.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Thank you, and that's from Adam Marcus with Health Scale. Please go ahead.

QUESTION: Hi. I'd like to follow up on something that was raised last week about possible underlying lung diseases that might predispose somebody to getting inhalation anthrax. Do you have any more information about the smoke status, asthma status, or COPD status of any of the patients?

DR. GERBERDING: Some of the patients have smoking histories, but some of them have no smoking history. We might have hypothesized that smoking would be bad because it would decrease the capacity of the lungs to clear the anthrax spores that might be deposited there, but so far with the limited number of cases that we're examining, we haven't been able to say one way or another whether it's related to disease.

DR. KOPLAN: But let me add that not one of your readers should need any more reasons to determine that tobacco is bad for your health.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Thank you, and that's from Cheryl Folberg with The New York Times. Please go ahead.

QUESTION: Yes. Hi, Dr. Koplan. I'm sure you know that Senator Feinstein is sponsoring legislation that would tighten up laboratory security, and at the same time this bill is concerning some microbiologists who feel that we don't want to make security too tight. I wonder what your feeling is about how laboratory security should work, how tight should the--should it be, and how do you feel about the bill?

DR. KOPLAN: I'm not familiar with the details of the bill itself, but I think in general it is a bit of a balancing act there. You know, we and others want, you know, secure laboratories for both safety--from safety of the workers' perspective, from the surrounding community perspective, and then from obviously folks having access with criminal intent to the agents' use therein.

I think a key element for us in this is that we are not a regulatory agency, and don't profess to any expertise or much experience in that at all, and so our role in this is much more issuing guidelines to labs on how to maintain the safety of their workers, and working with them in that mode. So that should there be legislation, we would not be the best players in a regulatory reaction.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Thank you, and that's from Daniel DeNine with Web MD. Please go ahead.

QUESTION: Thank you very much. I'd like to go beyond anthrax for a moment and ask about CDC and Federal plans to deal with any kind of smallpox outbreak or attack. Specifically can you address the plan to vaccinate first-response workers? And can you talk a little bit about what might happen in terms of a small focused outbreak immediately as opposed to what you would like to do to build up to later on? Thank you. 

DR. KOPLAN: There are several different pieces there. One is what would we do with a small focused outbreak immediately, and we would react much as we've done with anthrax or any of the other dozens of naturally-occurring outbreaks or reports we get almost weekly here, which is that we would work first with the local or state health authorities and determine what they had done, what they had found, what lab tests they'd found, what was their clinical appraisal.

We would then follow that with either an on-site field team or person, depending on what the disease is or how large it was, to investigate, including the taking of specimens or sharing of specimens with the state or the confirmation of findings that the state had done or planned to do, and then mount a response commensurate with what the scope of the problem was. 

So if the parallel is with anthrax, in Florida, we had the specimen within hours, the results within hours of getting it, and had a team on the way there before the confirmation had occurred, and a similar level of speedy, intense response would certainly occur, even in a focal smallpox outbreak.

In terms of general preparedness, this is--again it's something we have been working on for years here, and we--our preparedness extends both to laboratory and to epidemiologic capabilities, and to working with state and local health departments so that folks can try to recognize that early case of rash illness, a skin rash with fever or something unusual, so that we can detect a smallpox case as early as possible, should one occur.

Up here at CDC we have also increased the number of folks we have here who could respond to such a suspect case or cases, both in terms of diagnostic capability, epidemiologic investigation, lab back-up, immunization approaches, et cetera.

And then going backwards through your question, I think the first part involved what are our plans for first responders, I think was your question. And what we're doing is we're working closely with state and local health authorities and their umbrella organizations now to work with them to determine who are those most at risk, what would be the best use, if any, at this stage of various preventive modalities and try to--we have a smallpox plan that would be into play that the states have also been reviewing, and have given us feedback on. 

It's operational today, we could use it today if need be, but we are also trying to continue to improve it with input from state-level health departments, so that in that it includes the issue of who would be best immunized early on in this, and we're trying to get the states and local health departments to think through that with us as that decision would get made.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Thank you, and that's from Ridgely Oaks with Newsday. Please go ahead.

QUESTION: Hi. I have two somewhat unrelated questions. The first is do you feel comfortable saying now that the second wave or cluster of anthrax cases is probably over, the one that could be traced to Senator Daschle's office? And the second has to do with the international letters, sort of where we're at with that. 

DR. KOPLAN: Okay. On the first one, you know, we again look at epidemics all the time and have for a long period of time. And while it's a good thing in any naturally-occurring outbreak to see a downward slope to the curve of cases, that has little meaning when a criminal act has been performed and someone is out there potentially with the will and the tools to do this again. So we--our level of vigilance and concern is undiminished.

Sorry. International letters. We've gotten a pretty regular stream of reports of these. As you'd imagine, some are hard to assess the real threat of some of them because it's very hard to get a handle on the laboratory tests being done in different places. Some of them, we've been told, are on the way to us for study, although I'm--I haven't yet seen one in hand yet, not that I'd have it in hand, but figuratively speaking, our lab hasn't received one yet to do the studies with yet.

I think as an aside, it's another good argument for having had a long-standing interest in global health issues, and our own view of the borders for threats out there don't stop, you know, at our national boundaries. So that in many of these places, we either have folks we've worked with before or we can--or we have folks that have been assigned there, and those have been very helpful in getting some better sense of the quality of these reports.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Thank you, and that's from Charles Seabrook with The Atlanta Journal. Please go ahead.

QUESTION: Dr. Koplan, I have two questions, if I may. One is could you tell me any more about the President's visit to CDC tomorrow? And number two is yesterday I didn't hear you very well because of technical glitches, but it was mentioned about lessons learned so far, and if you could speak to that briefly, I would appreciate it.

DR. KOPLAN: On the President's visit, that's an easy answer, Charlie, which is that we understand he's coming, and--but--and we are eager to have him. This will be the first time an acting--a sitting president has visited CDC, so we're delighted.

I think our hope, and I think his intent, from what we understand, is that he wants to meet the folks who are doing the work on this, and we've got a lot of them, and it's great to have them see the President and get positive reinforcement from him directly. So a lot of folks have been working hard, long hours, and it will be very meaningful for them to get this show of appreciation.

On the other question of what we've learned so far, I'll turn it over to Dr. Gerberding.

DR. GERBERDING: Thank you. There are a lot of lessons learned, and we are learning them every day, but I think two of the big lessons that stick out in my mind are, number one, how critically important the clinicians have been as the first detector of the cases and the evolving problem. It really is the astute capacity of various front line and infectious disease specialists who really recognized that this was not an ordinary infectious disease, that it did in fact represent anthrax, and the steps they took early on not only to diagnose and treat the patient but also to report the patient to the local and state health authorities and initiate the whole chain of response that you've seen.

I think the related lesson to that is how critically important laboratory and laboratory capacity really is in this, both in terms of identifying and managing 
cases in exposed persons, but also in affecting the environment where information is needed to initiate additional public health interventions to protect people who may have had an inhalation exposure. So laboratory capacity and the interface between the clinicians, the health departments and CDC.

Maybe a third component of that, that has been new to us, is the relationship we had with the FBI and the criminal component of the investigation, which really is an ongoing process. We're working side-by-side with the FBI, and I think we're learning some tools that they use, they're learning some tools that we use, and together we are making progress.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Thank you. And that's from David Caravello with CBS News. Please go ahead.

QUESTION: Good morning, doctors. Earlier today your staff--

CDC MODERATOR: David, you're distant.

QUESTION: How is this? Can you hear me, Doctor?

DR. KOPLAN: Right now we can.

QUESTION: Earlier today your staff helped me understand a little more about select agents, and I think the role of CDC in that. What is the agency of jurisdiction or is there a loophole when we have a situation with potentially commingled waste, per se? Many of the media companies may have had garbage contaminated with anthrax spores, and that garbage is just carted off. Is there a procedure that would dictate how that's dealt with as the select agents are dictated with CDC's role?

DR. GERBERDING: I'm not sure we could actually hear your entire question, but--

QUESTION: Do we have, Doctor, contaminated waste that is commingled with anthrax spores in any of the media companies that has been taken away, not been treated? Does it need to be taken away if it's not treated by a registered agent, as the registered agents who transport anthrax spores between labs do or is there a loophole here?

DR. GERBERDING: I believe the EPA is doing the clean-up in most of the places where there has been profound contamination. And as [inaudible] said, this is again a new area, where they're having to set new guidelines for how to deal with this. In places where there has been contaminated material that we've seen, those have been treated or dealt with in a way that would decontaminate them before they got placed anywhere else, largely, through the use of bleach, a diluted bleach. Chlorine is an effective sporicide. So that is the approach that is being taken in all of the places that we have been involved in, but again, EPA will probably be coming out with some larger scale guidelines that can be used in many of these spots.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Thank you. That is from Sean Loughlin [ph] with CNN. Please go ahead.

QUESTION: Hi, Doctors. I have two questions. First, is there anything at all that you've learned in your analysis of the bacteria that killed Ms. Nguyen, anything at all that helps you determine how, just where she might have gotten it, how the case is different? Are you any further along in understanding this case than you were last week?

DR. KOPLAN: We have learned a few more things about her, and her life, and work, and home, and it has not helped us determine what the source of exposure was for her.

QUESTION: Secondly, we understand from New York that there was some evidence of anthrax contamination in a mail room at ABC. Were you involved in the tests for that or no--the ABC mail room in New York?

DR. GERBERDING: The New York City Health Department has the lead for the investigations in New York, and we were involved in evaluating the environment there, but the results of that investigation are really in the jurisdiction of that health department.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: And that is from Kevin McCoy with USA Today. Please go ahead.

QUESTION: Hi. Thanks again for holding these briefings.

To get back to Ms. Nguyen in New York, Dr. Perkins said the other day that there was some indication that she might have worked in a restaurant. Have you managed to confirm that either way?

And, also, in your checking of her route to and from work on the subway, is it possible that any anthrax that was there in the subway was dispersed by the time the tests were taken?

DR. KOPLAN: Let me comment about those. In terms of the woman with inhalation anthrax in New York, yes, there were earlier reports that she worked part time in a restaurant, and then there were reports that she liked to frequent that restaurant. As best we can determine, again, in consultation with law-enforcement colleagues, she had friends who had a restaurant, and she went there. Whether she helped them out or worked there, remains unclear, but we have been able to identify individuals who were associated with the restaurant.

The comment that she had other either work or frequented restaurants have been very hard to track down because of the people who know her either at work or in other places, they're unable to identify a specific restaurant, other than it had an Asian food cuisine served, and our colleagues in New York tell us that that limits it to several thousand restaurants in areas that she might have gone to. So it really hasn't been very helpful.

We continue to try to pursue every one of these leads and issues, but I am struck at how difficult it is to get the kind of detailed information we need on day-to-day, hour-to-hour activities when someone lives alone and didn't have a lot of close confidants.

And on the second part of your question, what we think is a more effective way to monitor for subway exposure is we've been doing very careful monitoring of subway workers who one would expect would be the most likely to be exposed in the event of an event or an exposure in subways, and we've been doing that for quite some time now and have not seen any increase in illness in them.

CDC MODERATOR: John, we'll make this the last question, please.

AT&T MODERATOR: And that will be from the line of Bob Port with the New York Daily News. Please go ahead.

QUESTION: Hello. Thank you for these briefings. I hope you can hear me. I'm on a cell phone on a street in Washington.

DR. KOPLAN: You're loud and clear. Don't move.

QUESTION: Very good. I just would like to say I don't think you could give New Yorkers enough details about the Kathy Nguyen case. Her picture is in the subways, and there's a great thirst for information.

What I'd like to ask you is I've gotten the feeling that the investigators pursuing this have to look at the mail as one theory, the subway as another theory of how she inhaled anthrax. Could you just list for us, with some explanation, the different possibilities that you have to consider.

DR. KOPLAN: Sure. First of all, it's like where you start or where we start--is there a potential for a naturally occurring case? I mean, you may say, well, that's impossible here. Well, we say let's just spread the net broadly. And obviously there's no occupational exposure, there's no evidence of a hobby or a pastime that did it, so that's way down, if not off the table.

In the past episodes in this criminal case of anthrax release, it has been via the mail or mail-related route, so that was where we started, and again we could not find an incriminating letter, likely target, had no evidence of anthrax in the testing of surfaces in places where she might have had mail, such as in her place at work, which at one point was shared with the mail room, or her home. So that hasn't been productive as showing where the exposure was.

Other possibilities are--was her home, that something happened in the neighborhood or in her home that might have caused an exposure. Again, the studies there or investigations there have involved looking in her neighborhood, interviewing people around there, an extensive study of her house or environmental specimens or anything else that might suggest something happened there, and that hasn't revealed anything.

The next step is in the course of her day, between home and work, and whatever other things she does, was she in a place where she could have been exposed to this? That can be either as an innocent bystander or something going on, as someone who was an inadvertent participant in something. And in no way am I indicating any sense of wrongdoing at all by this individual, but one has to look at every possibility of how someone might have gotten this exposure.

And so key to the investigation, without attributing any motive, lack of motive or what happened is just knowing where she was. That's the crucial thing. And so all of the posters you see out at churches, and on the streets, and elsewhere and on TV, the intent is did someone know her even casually? Did someone every now and then do something socially with her that might be able to say, you know, every Tuesday and Thursday she liked to go here or do this or she really, no one else knew it, but she liked to shop in this particular place, and it involved a fairly round-about-route to get there, but she really liked this particular food item.

You get the gist. There are things that any one of us do that aren't necessarily predictable, and you can't account for, and that's the stuff we need, and we need it for a 2-week period, and so that's what's going on, and that's the way our thinking is. We try to think our thinking as wide and bride as possible because, as you are all aware, we've learned something new with each piece of this investigation, and we don't want to narrow in too quickly or shut off possibilities, but that's where we are.

Sorry for the long answer.

CDC MODERATOR: This concludes our briefing. On behalf of Drs. Koplan and Gerberding, we want to thank everybody for participating. It is very likely that tomorrow's MNWR [ph] will contain additional information on the anthrax situation, and we will be having another briefing tomorrow at noon. And so the CDC Press Office will be sending out an announcement regarding that briefing in the morning.

Thank you very much.

AT&T MODERATOR: And, ladies and gentlemen, that does conclude your conference. You may now disconnect.

[Whereupon, the CDC teleconference briefing concluded.]

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