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Update on Anthrax Investigations
with Drs. Keiji Fukuda and Julie Gerberding

November 8, 2001

CDC MODERATOR: Thank you. Today's teleconference will actually feature two speakers. The first one will be Dr. Keiji Fukuda, who will talk about distinguishing flu-like illness from inhalational anthrax, and then Dr. Julie Gerberding will talk about the update on the anthrax investigation and the interim guidelines for investigation and response to anthrax exposure. All three of these articles are in this week's MMWR, which is available online.

Also, beginning with this telebriefing, these telebriefings are now being audio webcasted. The URL is\od\oc\media.

And now to begin our telebriefing with Dr. Keiji Fukada. We are dispensing with the opening remarks and going right into Q&A.

AT&T MODERATOR: Thank you. Ladies and gentlemen, once again, if you do have a question, please press the one at this time.

Our first question is from the line of Andrew Revkin [ph] with the New York Times. Please go ahead.

QUESTION: Thanks again for doing this.

Obviously, 10 inhalation cases does not a pattern make, but I didn't know if you could, on reflection, now that there's been some time to reflect, look at the cases and tell us about any patterns you've noticed that diverged from what was already thought to be understood about the way the disease progresses. For example, it seems like a very tight patterning of onset of illness in this cases compared to some of the historical reports in from Sverdlovsk, and monkeys, and stuff like that.

DR. GERBERDING: This is Dr. Gerberding. I'll take this question.

Actually, I just spent a great deal of time reviewing some of the old case reports; in particular, a report from Dr. Plotkin [ph] that was published in 1960 in the American Journal of Medicine that described the largest outbreak of anthrax in the 20th century, and that was very impressive to me,m that the five clinical cases of inhalational anthrax described in that report were virtually identical to the 10 cases that we're dealing with in the current outbreak. Some of the things that we thought were relatively uncommon about our current case cluster actually were reported as early as 1960.

So I think that what we're seeing here is a spectrum of illness consistent with inhalation of anthrax into the chest and that presentation and clinical findings are fairly broad, but the common themes are almost ubiquitously pleural effusion, the lymphadenopathy in the interior of the chest that can lead to a variety of other symptoms and signs, and the profound toxic shock sort of presentation related to the anthrax toxin that really accounts for the overall systemic course.

AT&T MODERATOR: Thank you. Our next question is from the line of Jeremy Manier [ph] with the Chicago Tribune. Please go ahead.

QUESTION: Thanks very much.

I had a question about one of the MMWR reports that talked a little bit about adverse events. Can you go into any more detail about the adverse events in Florida from the antibiotics, and does it fall within the range of what you might expect for other antibiotics or should people be, you know, leery because of the numbers that we're seeing here?

DR. GERBERDING: We've had no surprises; in other words, the adverse events that people are reporting in Florida are no different than what we've typically seen with Ciprofloxacin or Doxycycline therapy. So there is nothing unusual in either the types of symptoms or the distribution of those symptoms in the population.

AT&T MODERATOR: Thank you. Our next question is from Sho Babu [ph] with NHK Japan. Please go ahead.

QUESTION: Yes. Good afternoon. I have two questions.

My first question is something to review the numbers. How do you think the number of spores, how many do you think is needed to make someone become inhalational, to get the inhalational anthrax?

My second question is concerning, again, about Ms. Nguyen's case. To understand that she had not been affected--infected by a tainted mail, what kind of conditions do you think should be proved to get to this new idea?

DR. GERBERDING: With respect to the infectious dose of Bacillus anthracis, the information we have is derived largely from animal studies. In animal studies, it takes a fairly large dose, somewhere between, say, 8,000 to 40,000 spores, depending on the experiment to infect and kill 50 percent of the animals.

Now that's a number that's on the high side compared to many other infectious diseases, but it doesn't tell us what the minimum number of spores that it could ever take to infect an animal or a human being, for that matter. So we have to make some extrapolations. And the information we have from these animal studies suggest that it takes more than a few spores to cause infection, but the exact number is, of course, not entirely known.

With respect to the case of the hospital worker in New York with inhalational anthrax, we are still not able to ascertain where her inhalational anthrax was acquired. Every stone is being overturned to try to determine her potential opportunities for exposure, and as we go back and try to trace her life over the last couple of weeks, the clues that emerge are being investigated thoroughly by both FBI, the New York Health Department and CDC, but as of yet we have not either ruled in or ruled out the mail as a source of her exposure and are obviously pursuing all other avenues that we can discover.

AT&T MODERATOR: Thank you. Our next question is from the line of Helen Chickering [ph] with NBC News. Please go ahead.

QUESTION: Can you give us any insight or elaborate more on the CDC's position on these new DNA or proposed DNA anthrax tests and perhaps the hospitals use of these tests in high-risk areas and any thoughts of the plethora of home anthrax tests that are now hitting the market?

DR. GERBERDING: Well, I think that the FDA is really the best source of information on these tests. What we can say, from a CDC perspective, that obviously putting a test that can accurately diagnose anthrax in the hands of clinicians is a good thing. Unfortunately, some of the new tests that are being touted have not really been adequately validated in terms of their sensitivity, specificity or their performance.

So, while the concept of having rapid or more widely available tests is a good one, we, at the current time, are sticking to our proven methods of doing the Level A screenings, the Level B laboratory confirmation and relying on those sophisticated tests at CDC for the full-fledged confirmation.

AT&T MODERATOR: Thank you. Our next question is from Justin Blum [ph] with the Washington Post. Please go ahead.

QUESTION: Originally, CDC thought that spores would not escape from the sealed letter in sufficient quantities to cause inhalational anthrax. Does CDC now believe that spores in sufficient quantities can indeed escape from a sealed letter, and is that the lesson of the Brentwood Post Office?

DR. GERBERDING: Well, we're in the process of investigating exactly how exposures might occur in various settings, including those related to letters in the post office, and I think we're very actively and aggressively pursuing some research that will help answer that question.

AT&T MODERATOR: Thank you. We have a question from the line of Kim Dixon with Bloomberg news. Please go ahead.

QUESTION: Hi. Two questions. First is looking at today's MMWR, in the editorial note it says the lack of a discernible link to previous cases or workplaces and talking about the NYC case and one previous skin case, raises the possibility of new routes of exposure or new target populations. Can you tell me what that means, and then, could you also comment what it means that we haven't seen any new cases in New York since the hospital worker's case, and does that mean she's probably not the first of a new wave of cases, looking at the incubation period?

DR. GERBERDING: We are unable to really state, definitively, what these two cases mean. We obviously consider the possibility of an exposure related to mail as one hypothesis, but our efforts to document that have failed.

So it's important to evaluate all other opportunities for someone to come into contact with either an envelope or a package that may contain spores in the workplace, or in the home, or any other place where someone might have intentionally released anthrax in the environment, or in a building, or in a vehicle, or someone may have fortuitously come in contact with someone who is nefariously producing anthrax in a city, and so obviously the possibility that this individual could have accidentally crossed paths with someone who's responsible for this outbreak is something that I'm sure the FBI is also pursuing.

With respect to your second question, what dose it mean that we have had no additional cases in New York, in this context I think it means that the exposure that affected this particular hospital worker did not involve other people, although we won't know that for sure until enough time has gone past, so that we know no one is in the incubation period.

But it doesn't tell us, certainly, that we're out of the woods, and we're not going--this is not over until the criminals are caught, and so we need to remain vigilant and be on the lookout for additional cases in new places or in new populations.

AT&T MODERATOR: Our next question is from the line of Lauren Neergaurd [ph] with Associated Press. Please go ahead.

QUESTION: Yes. Can you talk with me a little bit about how your new interim guidelines match up with these rather astounding numbers of people who have been placed on antibiotics. You're clearly saying that just a positive test for anthrax in the environment does not mean that you close a building or that you routinely do prophylaxis, and yet that's exactly what has happened to a large number of these people.

Have we overreacted? Do we need to, you know, step down the number of prophylaxis prescriptions that are going out? Or has that started to happen already?

DR. GERBERDING: I think, you know, the theme here is that good science takes some time, and when we have the immediate event where there's a case of anthrax, or a powdered envelope that proves to be anthrax, we cannot immediately ascertain who's at risk for exposure, and so, initially, larger numbers of people are treated and sometimes facilities are closed, or actions are taken to make sure that we've included everybody at risk in the action plan.

Then, as the investigation is pursued, and more information is available from the environment or from other evaluations, it's possible to narrow the circle of people who require treatment and stop antibiotics in all those who were unnecessarily started and focus efforts on trying to help those that really were exposed to continue on for the full 60 days. So it is true now, and I think will be true in the future, that larger numbers of people are started on treatment than will actually end up being in the exposed or potentially-exposed category that needs the long-term prophylaxis.

And I think it's also fair to say that in the last month we've learned a lot about the role of various assessment and investigation tools, and we are applying those lessons in a prospective sense, to try to create a more orderly management of these situations when they develop.

We're building from the scientific framework that we've acquired and have created these interim guidelines, knowing full well that they may have to be revised and improved as time goes on and we learn even more.

AT&T MODERATOR: Thank you. Our next question is from Jill Carroll [ph] with the Wall Street Journal. Please go ahead.

QUESTION: Hi there. Two things. One, I want to know, you mentioned researcher doing, to sort of look at how anthrax is spreading in new situations, that kind of thing. What kind of things are you looking at? Where is it happening? And also have you been looking at pre-September 11th cases of maybe cutaneous anthrax, that might have been mistaken as bug bites, that kind a thing, to help in the epidemiological investigation?

DR. GERBERDING: With respect to your first question, we actually had a group of scientists assemble at CDC last weekend to develop, in part, a research agenda, and that process is still ongoing. So we are actively working with some of the best scientists in the world to identify the absolutely critical questions we need answers to and have prioritized those that need to be on the fast-as-possible track.

So that effort is underway and I can't really provide you any specifics at this point. With respect to the retrospective evaluation of previous cases of anthrax prior to September 11th, those cases that were known and reported were very clearly linked to natural exposures.

They're rare but do occur, and are completely explainable by exposure to animals or animal sources that are contaminated.

The possibility of missed cases is one that we can't rule out, at least in the affected areas. When the index cases were detected, efforts were made to review emergency department records, in retrospect, to try to understand the baseline for syndromes of, for example, fever, and cough, that might have indicated prior cases, and none were detected in the framework that was evaluated.

So I think we're reasonably confident that what we've seen since September 11th represents the onset of intentional bioterrorism attack, and that we were not experiencing that prior to September 11th.

AT&T MODERATOR: Thank you. Our next question is from the line of Henry Nynan [ph] with Netcog [ph]. Please go ahead.

QUESTION: Hi. Actually, I had a, almost a similar question, so just a little bit more of a clarification. The initial cases in the New Jersey, New York area, were all cutaneous anthrax, and I believe the initial four were all diagnosed as spider bites. And so the question is how aggressively were retrospective studies pursued looking for insect bites with a black center I guess?

DR. GERBERDING: That has not been something that we've done on a wide-scale basis, but I think what is the health concern here are the cases of inhalational anthrax, and those cases are hard to miss.

AT&T MODERATOR: Thank you. Our next question is from the line of Dan Vergono [ph] with USA Today. Please go ahead.

QUESTION: In today's MMWR, there's a discussion of interim guidelines for investigation in response to exposures, and there's a short discussion of prospective environmental sampling for especially at facilities or events determined to be at high risk for bioterrorism. Could you elaborate on that and maybe talk about, you know, where is that being done.

There was some discussion yesterday of looking at the health of subway workers, I guess, in New York--I don't know if elsewhere. Is prospective environmental sampling being done by CDC now?

DR. GERBERDING: There are two issues here. One is prospective sampling of the air and the other is prospective sampling of surfaces. With respect to prospective sampling of the air, there are a number of test methods that have been developed by the military and by private-sector corporations to monitor air for the appearance of the anthrax spores or other important pathogens. These techniques are potentially very useful, but they have not really been validated, and we have not validated them in the kind of situation that we're experiencing right now. So they remain very promising, but are not in widespread use.

With respect to surface sampling on a prospective basis, the surface sampling is only a measure of what has been in the air and fallen to the surface or a measure of cross-contamination, and there are some situations that individual companies or individual venues might feel represent particular targets for bioterrorism attacks, and some of those entities are engaging in monitoring surfaces in mail rooms and so forth to identify a letter that may have passed through, et cetera.

Again, the validity of this or the utility of it, not to mention the cost-effectiveness of it, remains to be determined. This is something that we'll learn more about as time goes on and evaluate the experience of those who are doing it.

AT&T MODERATOR: Thank you. Our next question is from the line of Kyoshi Endo [ph] with Nikkai Newspaper [ph]. Please go ahead.

QUESTION: Hi. Thank you very much.

I understand that last week there was an envelope with some powdery substance from the Treasury Department. Has CDC checked what that was yet?

And, also, at the Brentwood facility, the man who has been diagnosed as inhalational anthrax and who has already passed away saw a white powder as well. The Postal people are saying it was not anthrax, but has CDC checked that substance as well?

DR. GERBERDING: CDC's role in these investigations is not to evaluate powders. The powders in question, if they existed at all, would have been considered forensic material and would have been evaluated by law enforcement.

AT&T MODERATOR: Thank you. Our next question is from the line of Elizabeth Cohen with CNN. Please go ahead.

QUESTION: Hi. Thank you.

Doctors, I was wondering if you would be able to outline for us a list of symptoms that are more typical of anthrax, the early stages of anthrax infection, than it would be of other diseases like the flu, adenoviruses, the common cold. Is there anything after all of these cases that we've seen that just seem to be more typical of an early anthrax case?

DR. FUKADA: I think it's probably easier to switch it around a little bit and say that, when you look at the symptoms of early anthrax, you know, the things which don't occur are probably a little bit more important to focus on, and these are primarily a stuffy nose and a runny nose, nasal congestion and rhinorrhea. Those happen commonly with other flu-like illnesses from a variety of common viruses and pathogens, but they happen infrequently with anthrax cases.

And then I think that when you get into the later stages of anthrax, that's when you begin to see some of the more specific findings for anthrax. But I think early on the most important things to focus on is that people who have runny noses and a variety of flu-like symptoms like headache and muscle ache are likely to not have anthrax and to have a common cold or flu, something like that.

AT&T MODERATOR: Our next question is from the line of Katie Clark with World Public Radio. Please go ahead.

QUESTION: Thank you. I'm just wondering, you touched upon this a few moments ago, but if you could just sum up some of the major points that you have learned in the investigation since early October. I think that the public perception is that the investigation is many times confused or stalled.

DR. GERBERDING: I'm sorry. Which investigation are you referring to?

QUESTION: Just to the anthrax itself, where it came from, who's doing this, your role in that.

DR. GERBERDING: In terms of the perpetrators of this bioterrorist attack, as I'm sure you're aware, the FBI really has the lead for the criminal assessment. CDC is, of course, focused on the public health implications of this, and what I think we've learned is largely a consequence of watching the mail system be used to distribute a deadly weapon--in this case, envelopes containing volatile anthrax spores.

We have learned that inhalational anthrax can occur in situations in the Postal Service where aerosols are potentially generated. We've learned that opening one of these envelopes can cause a very rapid and widespread distribution of this particular powdered material, at least in the Hart Building in Washington, where we had immediate documentation that that had occurred, and that the health risks from being in the breathing zone where such an aerosolization is ongoing can be reduced, if not completely eliminated, by prompt initiation of prophylactic antibiotics. In other words, we've had no cases of disease in people who have taken their antibiotics, even though we know for sure they were in the breathing zone where the organism was aerosolized.

So those are, I think, some of the key aspects of the investigations that have had a bearing on the new interim guidance that we've proposed.

I guess the other side of the coin is to say we've learned some things that aren't particularly helpful. For example, nasal swabs are not particularly helpful if they're not done very soon after the exposure event, and they're really only useful in terms of defining where the zone of shared air was. They have no role in making decisions about the treatment or management of individual people.

Likewise, we've learned that the serologic tests that we did in the initial situation in Florida are not useful in determining who has been exposed to anthrax. They might be useful in diagnosing anthrax disease in people who actually have the clinical symptoms or signs of either cutaneous or inhalational anthrax, but even that is something that we're still working on. So there is really very little value in the routine monitoring of serum, unless people are in a category where we're particularly concerned about the development of disease.

And, finally, we've learned that the cases of anthrax have occurred in environments that are very heavily contaminated and that we don't see cases in environments where there is not significant contamination.

AT&T MODERATOR: Thank you. Our next question is from the line of Alice Park with TIME magazine. Please go ahead.

QUESTION: Hi. I wanted to go back to Kathy Nguyen. As an epidemiological question, does the fact that we haven't seen any more cases in and around New York or in and around her environment or the people that she had contact with tell you anything in terms of how she likely might have been exposed? Does that allow you to rule out, for example, an aerosol in a subway, where the possibility is that at least one other person would also have gotten sick?

DR. GERBERDING: We simply cannot rule in or rule out any of the hypotheses of her exposure mechanism without more information and time. So as the investigation proceeds and various environments are evaluated
, as more is known about her steps in the past two weeks, and as more time goes on, so that we can be sure that we aren't seeing more cases or more events, we may be able to answer that in the retrospective scope, but from a prospective sense, we're still keeping our options open and looking at all possibilities.

AT&T MODERATOR: Our next question is from the line of Steven Russell with the San Francisco Chronicle. Please go ahead.

QUESTION: Yeah. I have two questions, if I could. The first question, how comfortable are you with the level of preparedness of the Public Health Network? We're hearing a lot about, in California, certainly, even though we had no cases, about the labs being overwhelmed with samples. We're also hearing about shortages of techs, and poor pay for techs who do this kind of work.

Do you have any observations on the status of the network now, and what might be needed to deal with a presumptive new incident or a larger incident?

DR. GERBERDING: Well, preparedness is not an all-or-none phenomenon, and I think that there was an enormous effort made to bring the laboratory response network up to speed before September 11th. Obviously, the training, the deployment of reagents, the protocols and safety procedures, and so forth, had been in place prior to the point in time when they were actually needed.

So from that standpoint, we were prepared. Since September 11th, and more precisely, since the first case of inhalation anthrax in Florida was described, that laboratory response network is even more prepared, more investments have been made, and the support needed to sustain this effort is something that's a very high priority for CDC.

We have regular conversations with the folks in the laboratory response network. We are confident that capacity currently can meet the demand, but we are also taking steps to ensure an adequate supply of reagent and looking at surge capacity to provide additional personnel and resource support.

So preparedness is a continuum, and we're doing more now than ever to try to keep the system able to accomplish the difficult task of evaluating samples and patients in the most expeditious manner possible.

QUESTION: The second question I had had to do with the earlier question about the man in the post office whose 911 tape was heard to be describing a powdered envelope. You had said that that was a, kind of a matter for the law enforcement. But I would think from an epidemiological point of view, we've only had what? three envelopes. Here you have a guy describing powder and then he dies.

Has the CDC pursued this in any way? I mean, have you heard from law enforcement that that particular envelope that he described just absolutely was not a problem?

DR. GERBERDING: Let me emphasize that CDC is in constant communication with the FBI. I personally am on the phone with the FBI at least two hours a day. In addition, our investigators are working side by side in the field with the FBI investigators. So to the extent, if there's a report of a suspicious powder or an evaluation of a suspicious powder that has a public health implication, you can be sure that CDC is aware of it.

AT&T MODERATOR: Thank you. Our next question is from the line of Elizabeth Kalledin with CBS News. Please go ahead.

QUESTION: Yeah. Hi. I just wanted to go back to the Kathy Nguyen case, and you said earlier that every stone is being overturned in that investigation, and I wonder if you can be more specific about that. Is there anything that you are looking at, that is emerging as a potential anthrax source other than the obvious sites that we know. The subway and the mail. Have there been any surprises to you, at all, in that investigation?

And, finally, is there a sense that with each passing day, that the trail is getting cold, and that you may in fact wind up not ever knowing where it came from?

DR. GERBERDING: CDC not have the lead on the investigation in terms of the linkage to the source of the exposure and the criminal aspects of it, so this question probably would best be answered by the FBI.

What I can say is that we are using the same tools that we would apply in any investigation to try and ascertain the source of an infectious disease, and I would just like to be very specific about this issue of the subway.

We have absolutely no evidence, whatsoever, that implicates the subway system in any way, shape or form in her exposure. So I don't want to leave you with the impression that that's where we're looking. That is just something that has been mentioned as one of numerous possibilities to take into consideration.

But having said that, no, I don't think the investigation has gone cold. I think that there are a number of ongoing avenues that are being pursued. Additional sampling of various places may be considered, if it turns out that there is a potential link, and we'll be continuously aggressive. So it's not over.

AT&T MODERATOR: Thank you. Our next question is from the line of Maggie Fox with Reuters. Please go ahead.

QUESTION: Hi. Thanks very much. President Bush is coming today to the CDC, and I know that you all have complained in the past that you're chronically underfunded.

I'm wondering if you're gonna show him anything special to try to get his support for better funding.

DR. GERBERDING: I think President Bush is visiting CDC today to learn about the investigation here, and to express support for the efforts that have gone on. This is not an opportunity to distract him from that mission by whatever issues we may feel are our own particular perspective.

AT&T MODERATOR: Thank you. We have a question from the line of Ellen Beck with United Press International. Please go ahead.

QUESTION: Yes. Thank you again for holding these daily conferences. Is CDC at all involved in what's going on in the post office in New Jersey, the one that was closed after it was declared to be spore-free, reopened, a few shifts, the workers participated in some sort of work activity, and then was shut down again.

Can you give us any more insight, or what you're doing up there in that case?

DR. GERBERDING: Well, what I can say about the situation in New Jersey and I haven't been updated on that this morning before this call, so just speaking generically, that the interim guidelines that were reported in the MMWR today really reflect our perspective on facilities like the New Jersey facility, and I think that our position is very consistent with the guidelines that we've put forward.

AT&T MODERATOR: Thank you. We have a question from the line of Meghan Garvey [ph] with the LA Times. Please go ahead.

QUESTION: Hi. I had a question about the Thomas Morris 911 call, that relates to advisories given out in the area about what to look for in inhalation anthrax cases.

In that instance, my understanding is on Friday evening, October 19th, and he died on the 21st of October, that the CDC and public health officials in the area had begun monitoring a case of a man at a Virginia hospital who presented with symptoms that looked like it might be anthrax.

I'm wondering if a more general advisory specifically looking at Postal Service workers might have been appropriate at that time and why it took until Sunday to tell area doctors to specifically be on the lookout for those symptoms in workers at the Brentwood facility.

DR. GERBERDING: I think that as soon as the letter was detected in the Hart Building in Washington, there was concern about exposure risk among mail handlers in communication with persons in the Postal Service, so as information became available, the appropriate public health responses, in coordination with the D.C. Health District, as well as those in Maryland and Virginia, were initiated. We also have taken advantage of the Health Alert System to let people know what to look for and to engage in surveillance.

Keep in mind that the Metropolitan D.C. area already had in place a surveillance network to look for syndromes suspicious for bioterrorism attacks as a consequence of the events of September 11th. So there were a number of methods by which the detection of cases of any of the agents that would be implicated in a potential bioterrorism release were already in progress.

AT&T MODERATOR: Thank you. Our next question is from the line of Kendrick Hagen [ph] with ABC. Please go ahead.

QUESTION: Yes. A quick follow up on that same topic. You said that any suspicious powders, you know, reports of powders, you would have been aware of it. I just wanted to clarify, were you made aware of the letter that Mr. Morris was referring to, that they have told us the FBI did take and test and it came back negative because the Postal Service said the reason they didn't do anything at Brentwood or treat the workers for anything was based on advice from the CDC.

So my question is: were you made aware of it at that time, and then advised Brentwood according to the results of that letter?

And then just a second quick follow up. Could you briefly go over the symptoms that you would have for inhalational anthrax, not just the ones you wouldn't have, because I think we've seen some different ones in Mr. Morris and like Mr. Stevens in Florida?

DR. GERBERLING: Let me just emphasize again what the procedures are when there is a suspect powder reported. The procedures are that the law enforcement makes an assessment of what constitutes a credible threat, and there are a number of criteria for that and it's very individualized to a specific situation or a specific set of circumstances.

So if law enforcement makes the assessment that there is a credible threat, which is usually more than a powder, per se, then the law enforcement is responsible for having that material evaluated, and that at such time that it becomes likely or suspicious to contain anthrax or some other pathogen, the public health officials are involved in that process.

As you know from the MMWR today, there are many, many, many powders that have been evaluated around the country in the last few weeks. These do not all come to CDC's attention in real time unless there truly is a credible threat and the responsible health investigators--public health officials determine that CDC's assistance is necessary.

In the context of the situation in Washington, D.C., because obviously there is a criminal investigation ongoing there, information that the FBI has relevant to contaminated powders is communicated directly to CDC. So with the caveat of the importance of sustaining our capacities to cooperate with the FBI in conducting their own criminal investigation, I think we're confident that the information necessary to evaluate the situation has been made available.

DR. FUKADA: In terms of the signs and symptoms that have been seen in the early inhalational anthrax cases, there's a table in the MMWR article, but let me just point out some of the more common signs and symptoms that have been seen in at least half of the 10 people that have developed inhalational anthrax.

A fever has been seen in 70 percent. Chills in all of them, in 100 percent. Fatigue or malaise in 100 percent. Cough, which is nonproductive or minimally productive, that is you bring up little when you cough, has been seen in 90 percent. 80 percent of the cases have had shortness of breath. 60 percent of the cases have had some sort of chest discomfort or chest pain. Half of the cases have had muscle aches, and half of the cases have had headache. And then 80 percent of the cases have had either nausea or vomiting.

In addition, 7 out of the 7 cases that had blood cultures taken before they were on antibiotics had positive blood cultures for B. anthracis. And then all 10 of the cases had abnormal chest x-rays.

AT&T MODERATOR: Thank you. Our next question is from the line of Greg Smith with the New York Daily News. Please go ahead.

QUESTION: Thank you. I want to ask you two questions. One has to do with the Manhattan hospital worker. We understand that she shopped for a restaurant on the 86th Street, down in Chinatown. Can you talk a little bit about what you know about that, and what if anything that means?

And then number two, the Postal Service has a bunch of tests that are outstanding at facilities around the country. Can you tell me what you know about that, and where that is in the pipeline? Thanks.

DR. GERBERLING: With respect to the specific investigation of various places where the Manhattan hospital worker has been, I would have to refer you to the New York City Health Department for those details, because they are actually leading the evaluation of the geography of her whereabouts from that standpoint. I'm not a New Yorker, and I just don't have a frame of reference to speak to that particular question.

With respect to the sampling of postal facilities that is ongoing in the United States, again, I think the question would best be addressed to the US Postal Service. CDC is working with the Postal Service and the EPA to develop a protocol for ensuring that any sampling that's being done in the most scientific and most valid way possible, and CDC is actually very pleased with the plan that the Postal Service has in development, and will do everything we can to cooperate in their efforts.

Obviously, we are hoping to include the state and local health departments in this process, particularly if there is concern about a contaminant or a spore found in a facility, that the state health department needs to be made aware of that, and we'll do what we can to facilitate that exchange of information.

CDC MODERATOR: John, we have time for one more question.

AT&T MODERATOR: And that will be from the line of Earl Wayne with Newsday. Please go ahead.

QUESTION: I was wondering how many laboratories there are in the response network, and if they would have been able to respond adequately if there had been several hundred cases rather 17?

DR. GERBERDING: The laboratory response network has somewhere between 80 and 100 hospitals depending on how you define their inclusion. And we're adding more all the time. The capacity to respond in these laboratories depends in part on what the expectation is of their--where they come into the protocol.

So the Level A laboratories have actually a very large capacity to do the initial screening of samples, this would be somewhat similar to clinical microbiological laboratories in patient care areas being able to screen clinical specimens and pick up those that are potentially suspicious.

The Level B laboratories that are doing more of the [inaudible] evaluation on some cases, assessment of powders or other materials, have to rely on reagents and more sophisticated techniques that do require support. We have worked very hard to ensure we have an adequate supply of those materials and I think our surge capacity is quite good, in that we would have been able to implement that surge capacity plan to accommodate incremental increases in the demand.

Having said all that, we are very mindful of the importance of continuing to build capacity in this network and are in regular conversations with our partners in the state health and the lab networks to make sure that we're providing them everything we can to keep them in business.

CDC MODERATOR: Thank you, ladies and gentlemen for participating in the telebriefing today. As a reminder, the transcript will be available online later this afternoon. Also, the audio webcast will be available for you to listen to again. And again we thank you, and there will be another telebriefing tomorrow at noon.

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

Listen to the telebriefing

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