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Update on Anthrax Investigations
with Drs. Jeffrey Koplan and Steven Ostroff

November 13, 2001

CDC MODERATOR: Good afternoon. This is Kay Golan at the Centers for Disease Control and Prevention. I'd like to introduce today Dr. Jeffrey Koplan, the Director of the Centers for Disease Control and Prevention, and Dr. Stephen Ostroff, Chief Epidemiologist for the National Center for Infectious Disease.

Dr. Koplan has a few remarks this morning, summarizing the efforts of CDC today, and Dr. Ostroff will give a brief update on the anthrax investigation.

DR. KOPLAN: Thanks, Kay. Good afternoon, everybody. I think we're in the afternoon, and I thought at this juncture, having, you know, been asked this now for what seems like many, many weeks, it might be a good idea to say a little more and kind of put what we're doing in a broader context, you know, step back and take a look at the bigger picture for a bit, and I'll just do that for a couple minutes so that we still have plenty of time for questions for both he and myself.

One is that although this bioterrorist event itself began on October 4th, we at CDC have been working with bioterrorism preparedness for many, many years. Indeed, our origins date back to a concern about bioterrorist events, and certainly in the 3 plus years I've been here, we have placed a high priority on this, including the establishment of a identified major operational unit here within CDC to deal with bioterrorism, and a marked increase in funding over this time period for bioterrorism. So we've gone from about $122 million in '99 up to $181 million this past year, of which nearly 80 million have gone to state and local health departments to respond to bioterrorist events. So this has been a big picture of our prioritization and our--what we think is a major thrust, is to prepare state and local health departments to have better laboratory capacity, capacity for disease surveillance, capacity to do epidemiologic investigations, communication systems and preparedness planning, and have given grants to states in all these areas for the last couple of years.

In addition we created a national pharmaceutical stockpile that you've heard about and seen in use during these last many weeks, which both provides antibiotics, but also other supplies and equipment, and as-needed equipment as things come up for almost immediate delivery to disaster sites.

And then internally we've intensified our own capacity in a range of bioterrorist agents, including anthrax, so that the state that we're in and the capability we have now to deal with anthrax is very, very different than it would have been 4 years ago.

Following the attacks on September 11th, CDC rapidly moved from a preparedness scenario to an immediate action approach to dealing with the events of September 11th and then subsequently to the anthrax attacks. But by the afternoon of September 11th, our national pharmaceutical stockpile had supplied a range of materials, including antibiotics, but also IV fluids and face masks and a range of other things to both New York and Washington, and one of the issues then was trying to anticipate the possible outbreak of disease associated either with a purposeful intent or that might occur in the aftermath of a disaster of this scope.

Other things that have gone on have been, as again you're probably well aware now, that we've worked closely with state labs, state health departments to provide support to them over these last several weeks, and indeed, the numbers of calls, requests, concerns have been in the many thousands that have come in from them and on which we interact with them, and to help facilitate this, that we've run a 24-hour-a-day support system with our colleagues in state and local health departments.

This is also--part of this has also been the fact that we've had about 10,000 false alarms coming in through state and local health departments, which has certainly taxed them, and then has taxed us to some extent, but has largely been dealt with, and we've provided support, technical assistance to over 60 countries as part of this, who have had their own share of both false alarms and concerns about anthrax scares.

Communication has been a big issue from day one on this, and communication is complex in a modern public health event of this kind, a disaster of this kind, because it involves both wanting to reach the public and to the public through the press, such as yourselves, but also health professionals who have to get information and deal with things in a clinical mode, the people who are taking care of people, but also then the public health system, a different group of health professionals in state and local health departments. And we put out--or have put out in the course of this, over 50 health advisories through our health alert network, which is probably 49 more than usually go out in the course of a month, and that's reached over 25,000 health officials and front line public health officials, but also private practice physicians and nurses and laboratory and emergency workers, et cetera, have regularly gone on the airways for satellite transmission broadcasts to reach a variety of health professionals. In the early days of this, we estimated that we reached between 50 and 100,000 practicing health professionals to deliver messages on the clinical aspects of disease, how to recognize it, how to treat it, and that's been regularly updated through our website, through publications, through our NMWRs that have weekly provided both update on numbers but also on pieces of clinical and public health information that will help people deal with this.

You know, we are proud of a couple of recent items, one of which is the early publication in very short order of the first 10 cases of inhalation anthrax published in the Journal of Emerging Infectious Diseases, but the speed with which these observations have been made and then to turn into this a peer-reviewed article to be shared with the medical establishment that then, even if the outbreak is going on, helps in the both identification and treatment of those cases. It may not be utterly unique, but certainly is very rare in the annals of dealing with a disaster, to have it come out with this level of speed and completeness.

An another item which I think we're pleased that there's been a very good cooperation and partnership between practicing clinicians who have been taking care of some of these patients and our staff who have been working with them is that this partnership has resulted in a significantly greater better survival rate for inhalation anthrax, a 60 percent survival rate rather than the usual 25 percent or lower rate that's been seen.

So lots of stuff has been going on. Lots more will be going on, but I just thought it would be good at this point to kind of put the intense activities of the last few weeks in some broader context.

CDC MODERATOR: Thank you, Dr. Koplan. Dr. Ostroff will give a brief update on the investigations.

DR. OSTROFF: Well, my comments will be very brief because there's really not very much that's new to update you about. There are no new confirmed or suspected cases, and to my knowledge, there are no illnesses being reported that are highly suspect, and we have now gone a considerable period with no evidence of any new anthrax-related illnesses.

There was a fair amount of activity over the weekend related to reports that continue to come in, and I think appropriately so, of illnesses from throughout the country. Probably the one that got the most attention over the weekend was out in Fort Collins, Colorado, where based on an illness in one of the postal workers in that city, a large number of individuals were put on precautionary chemo-prophylaxis which is the stance that we've been taking the last several weeks until more definitive information was available about the specifics and the circumstances of his illness. But otherwise at least as we see things, things are relatively quiet.

A great deal of our effort right now is concentrated on trying to assure maximum adherence among those individuals in whom the longer term chemo-prophylaxis, the 60 days of chemo-prophylaxis has been recommended to make sure that they're able to stay on that course of therapy for the duration. Sometimes it's not that easy to do it, and so we're fully committed to work with particularly the Postal Service to assure that those people who need to receive it will receive it. And so I'll stop there.

CDC MODERATOR: Questions, please.

AT&T MODERATOR: Certainly. And, ladies and gentlemen, once again, if you do have a question at this time, please press the one on your touchtone phone. You may remove yourself from the queue at any time by depressing the pound key.

Our first question is from the line of David Caravello with CBS. Please go ahead.

QUESTION: Hello, Doctors. Thanks again for helping us out. The State Department is indicating it's getting ready to check some of its mail, but has said it expects it may indeed have a Daschle kind of letter because of samples that have come back to its mail that's been locked up for three weeks. Do you have any guidance on at all, or will you be working with them as they begin to open this mail?

DR. KOPLAN: I think they recognize the precautions that are necessary, that they have--our understanding from them is that they have collected many batches of mail that were set aside as potentially of concern, have them wrapped up in some secure and protective manner, and we certainly will be providing them consultation as they go through this.

They are aware of what constitutes a suspect letter, and I suspect they've got a lot of mail they have to go through to sort this out, but precautions will have to be taken as they go through it to not expose any of the workers that are going through it.

AT&T MODERATOR: Thank you. Our next question is from Pete Williams of NBC News. Please go ahead.

QUESTION: Yes. If I may just continue on that, the State Department, in a statement to its employees, is saying that it now thinks, based on its consultations with you all, that there could have been a second contaminated Daschle-like letter sent to the State Department, sent through its system, which it bases (a) on the inhalation anthrax in the postal worker or the State Department worker in Sterling, Virginia; and (b) on the number of positive traces of anthrax found on its sorting equipment.

What is your view on whether there is a possible Daschle-like letter sent to State? And secondly, you mentioned suspect cases. Is there any update on the New Jersey cardiologist?

DR. KOPLAN: I'll let Steve do the New Jersey cardiologist.

DR. OSTROFF: I don't have any information on the New Jersey cardiologist. We can certainly try to get you that information afterwards.

As far as the situation at the State Department, I think that we have said for quite a while that one of the potential explanations for the inhalation anthrax case in that employee was that there was an unrecognized additional letter that went through that system.

There are obviously also alternative explanations such as the potential for cross-contamination. However, we think that based on the bulk of the evidence that's available to us that the first explanation is more likely, and so we have consistently consulted with the State Department with that in mind.

AT&T MODERATOR: Thank you. Our next question is from Jeremy Meniere with The Chicago Tribune. Please go ahead.

QUESTION: Hi. Thanks very much. There's a couple of documents that I think states have been looking at the last couple of weeks that are connected to the CDC. One is this model Health Powers Act. The other is a draft smallpox response plan that I think Dr. Koplan mentioned last week. I wonder if you could talk about these for just a second.

One of the things that people are bringing up to us as we report on this is that these documents are helping to show them how unprepared in some ways they are to respond to things like smallpox. They're not ready to provide food and water to people in quarantined areas; they're not ready to use law enforcement to enforce those kinds of areas. They're not even ready to give smallpox shots to a lot of people because it requires a lot of specialized skill, you know, to give this sort of complex shot to people.

Could you just comment on that, and how ready are we, and will the smallpox plan be available for us?

DR. KOPLAN: Sure. First on the last part. I could train you to give a smallpox vaccination in five minutes. And even if you're slow, I could do it in 10 minutes. So this is not a complex technical task. It has to be done right, but that doesn't make it complex or hard to train someone to do it.

We also have training videos in the hundreds that are out going to state health departments showing it and demonstrating it for them to do.

And what you indicated about this issue of quarantine and providing for it and the laws that are being done, for several years we've been working with states and with folks in academia and private sector and lawyers and ethicists about revising public health laws in the U.S. Most of our public health laws were put together at the early part of the 20th century, and what was a public health revolution, and where people really saw a golden age of, you know, that's when "Arrowsmith" was written and where there's a lot of interest in the benefits of the new vaccines and sanitation and clean water and et cetera. And with it came laws that provided for a range of things, whether it was safer work places or environments or bars on windows so kids wouldn't fall out, or how to deal with TB, and similarly with quarantine and immunizations.

However, as we reflected on it for several years now, many of these laws, many have made sense in 1890 and 1900 or 1910, but don't--aren't applicable in the social context, the way our country has changed socially and legally and ethically in the year 2001, and so we have worked with states to try to develop more contemporary laws that make sense in that regard.

On the issue of what would you do in quarantine and how would it work, it's complex and difficult. There's no doubt about it, that applying a quarantine to our sense of freedom I getting about would be difficult, but in some instances it's valuable and necessary, and just what you say, the need to provide food and water to folks that otherwise couldn't go out to get it, would have to be addressed. But again, these are logistics issues and do need to be gone through. Some places are well upon the way of planning for those. Others need to.

AT&T MODERATOR: Thank you. Our next question is from Barbara Isaacs with Knight-Ridder. Please go ahead.

QUESTION: Hi. Thanks for the briefing. I wanted to ask you to define the range of anthrax spores that you would think would constitute a trace amount, and also what strategy you're using to deal with these trace amounts in occupational settings?

DR. OSTROFF: I don't think that there is an exact answer to what would represent a trace amount. We know that many of the tests that are being used, particularly the polymerase chain reaction test, with the subsequent culture confirmation, are able to pick up very, very minute amounts of anthrax in the environment, and especially in circumstances where there's been a extended time period between when these spores would have been introduced into the environment, and when the tests are actually done. We know that over time the health risk associated with them diminishes, and so there's no exact answer to be able to give you whether there is one colony on a culture plate or whether there's 5 colonies, et cetera. I don't think that we could be quite that precise. It's a matter of looking at the totality of information that's available, both in terms of how many of the samples may be positive as well as how much time has elapsed.

AT&T MODERATOR: Thank you. Our next question is from Laurie Garrett of Newsday. Please go ahead.

QUESTION: I've got two quick questions. First, you didn't answer the second half, please, of Jeremy's question regarding when we in the media might see the new smallpox response guidelines.

And my separate question is as Congress tries to figure out why we are not further along in determining the source of the anthrax problem, Senator Dianne Feinstein last week in the Appropriations Committee was short with the FBI regarding our lack of knowledge of who exactly has anthrax in their laboratories.

Could you, Dr. Koplan, please clarify, when the 1996 Executive Order came down regarding the--I believe it's 32 suspect pathogens that CDC was meant to keep track of, was there anything specifically set in place at the CDC end that would supply you with information as to who had in the past worked on anthrax, where there might be legitimately stored samples of anthrax, academically, pharmaceutically and otherwise in the United States. Does such a list exist or has this never been done?

DR. KOPLAN: By legislation we have been charged with documenting which laboratories ship or mail anthrax, and that is the list that we have had. If a laboratory doesn't ship or mail anthrax, there's no way for us to know whether they've been working on it for 50 years and have some scientists in the corner that uses it occasionally or not.

So we have certainly met our legislated responsibility and anthrax, amongst hundreds of organisms, is a potential bioterrorist agent and it obviously has been used in this case as one. But our focus has been on those that ship these agents, these select agents around the country.

Now, I'm in danger of losing that other half of the question yet again. On the smallpox plan, right, which is that as we speak, the smallpox plan, which is really operational now, is being shared with our state and local colleagues for their input and suggestions and revisions before it goes further.

So your question was, when can you see it. And I say you can see it probably pretty soon after we get feedback back from folks who are going to be using.

DR. OSTROFF: And, Laurie, this is Steve Ostroff. Just to amplify what Jeff said, back in 1996 and 1997, when we were given that legislative responsibility, we made a number of attempts through a variety of different mechanisms to assure that those who needed to know about the regulations knew about them. We worked with the appropriate professional societies. We did extensive literature searches, looking back years and years and years. We worked with APCC, et cetera, trying to make sure that we provided information to as many individuals as we were aware of and as many laboratories that we were aware of that would potentially have to register under that regulation.

There were thousands of both individuals and laboratories that requested information as a result of materials that we provided, and as you know, the approximate number that eventually felt that they needed to be registered under these provisions as of the most recent month or so, is about 250 laboratories.

AT&T MODERATOR: Thank you. Our next question is from Andrew Holtz with Holtz Reports. Please go ahead.

QUESTION: Yes. I was wondering, now that things have been quiet for a while if you're able to return some of your staff that have been on anthrax duty to their normal duties?

And as part of that, since clearly you weren't dealing with anthrax before a number of weeks ago and then suddenly had to shift all these resources, what kind of duties did you have to defer? Were there calls from states for help with other kinds of disease outbreaks or questions that you just had to say, "Hang on till we deal with this, and then we'll get to you?"

DR. KOPLAN: Thanks. We've continued to address other disease outbreaks, and indeed there's been some [inaudible] disease, which normally would have gotten some questions, I think, interest in other times, have kind of fallen off the map. But there have been other--there have been other activities, for example, on West Nile, a hat that Dr. Ostroff used to wear. There has been other activity in dengue in Hawaii. And of course there's lots of stuff going on in occupational safety and health and the environment, and diabetes work and on tobacco, et cetera.

And yes, when I walk around and see the folks that we've got deployed currently in the anthrax work, I see a senior scientist who, until a couple of weeks ago, was one of our major epidemiologists in anti-tobacco activities, and there's folks down there who work in diabetes and the environment. We've had lots of occupational safety and health people working on it, and yes, the things they were working on before are either going slower or are on hold until they can get back to them.

I think important public health urgent activities are ongoing, but not with the same level of staff support that they would have had before.

We have started to move--we have--throughout this we have moved people in and out of some of these activities. Largely as people have gotten exhausted in what they're doing, we've shifted them and put in some fresh bodies to address some of these issues. At this stage an example would be we're trying to match the staffing we've got to requests or need. So where phone calls have dropped off in the evening shift, we've lowered the number of our folks working on that.

Some of our folks in the field have been able to come back as activity there has waned, but our level of attention and I guess awareness in this has not diminished. We're not sitting here saying, well, gee, this is over, we can relax. We are as attentive to this as we were when this started, and in part we just want to have our folks rested up a bit should they need to be deployed again for something. But unlike a naturally occurring outbreak where we could say, well, this seems to have run its course, the course on this is only run when the criminal is apprehended.

AT&T MODERATOR: Thank you. Our next question is from the line of Sarah Leak with The Wall Street Journal. Please go ahead.

QUESTION: Yes. Hi. I was wondering if you could tell us what the significance, if any, there is of the finding of anthrax traces at Howard University and whether that might be the first of other findings in nongovernmental mail rooms in Washington, and whether that should be something the public is concerned about.

DR. KOPLAN: There are a number of sites that have got their mail directly from a contaminated site such as Brentwood in which this term trace amounts has been isolated in the mail room areas. I'm not familiar personally with whether Howard is one of those or not, but there have been some of these, and what's happened is those areas have been cleaned up and have not been felt to constitute a threat, largely because of the very limited amount of material that's there.


DR. OSTROFF: I would agree with that.

AT&T MODERATOR: Thank you. We have a question from the line of Laura Meckler with the Associated Press. Please go ahead.

QUESTION: Hi. Thanks for doing this again. Two questions. One, in terms of the State Department contamination and the possibility of there being a second letter there, is it the fact that the environmental testing what has sort of pushed you over the edge to think that in fact it is likely that there is a second letter, or is there something else, other pieces of evidence? You made a reference to say some evidence we have now. I'm wondering if that's the full part of it.

And the other is I just wanted you to put this--you said there were 10,000 false alarms. If you could put that into context of how that might compare to other previous similar situations, if there are any similar situations in the past.

DR. KOPLAN: There are no similar situations. You know, when an outbreak occurs, a naturally occurring outbreak of an illness or a health problem, it may be there are some copycats who try to get in on it, but nothing, nowhere the scope of this by several logs.

On your first question about the State Department issue, we have no other information that we're not sharing with you. Everything we've got, we're talking about right now, and what happens is that if you just--there's nothing definitive in this. It's much as we've operated throughout this, is you take pieces of information as you get them and add them up, and in this case you have someone who works in a mail room with inhalation anthrax, and that requires both aerosolization and some reasonable dose of spores, thought to have been many thousand. Even if it's less than that, it's still a fair number of spores. In order for that to happen, you need something that strikes you and says yes.

You know, one of the things you have to entertain is could it be cross-contamination. Well, that would mean lots and lots of spores sitting on some letter that was in proximity to some other letter and then having it aerosolized in some way.

So our hypothesis at that point, from the first point that this case was identified, was that there's got to be some probability that there's another letter that's gone through here. And that remains, I think as Steve said earlier, you know, not the only way can put this together, but certainly the one that seems most probable to us. And the State Department is looking for other letters.

AT&T MODERATOR: Thank you. Our next question is from Kim Dixon with Bloomberg News. Please go ahead.

QUESTION: I wanted to see, looking at the New York case, that evidence seems to be lacking on what the cause is. Where do we go from here? You've tested her workplace, you've tested her route to work. Is the CDC's job done now and this is mostly a criminal investigation in New York?

DR. KOPLAN: Well, Steve can add more to this, but no, our job is not done. You know, we're--you just have to keep plodding along if you don't get the answer right away. You know, our folks frequently refer to the fact that we do shoe leather epidemiology, and it's great to have some fancy cutting edge answer that gives it to you right away. You know, you do the swab, you get a positive, and, boom, you've identified something. But in the absence of that, we have to go back and, as with law enforcement, try to get a handle on an individual who lives alone and didn't seem to have a lot of close friends and confidants, and try to get some picture.

But one way or another, and many of it will depend on law enforcement insights as to what that individual did, where she went, how she spent her time, when she did things, for the couple of weeks before her onset of illness. And so far we haven't got the information we need.


DR. OSTROFF: Well, all I would add to that is that there is in some way this woman came in contact with enough anthrax to provide inhalation disease. She appears to have been the only one that we're aware of in the city of New York like this. In that sense she represents a single case of disease and it's very, very hard to try to triangulate because there aren't any other cases in the city to be able to compare what she was doing against. And so that in and of itself is somewhat of a challenge.

However, I am an ultimate believer that there is an explanation, and as Dr. Koplan said, we will continue both on the public health side as well as on the criminal side to look into all the circumstances, to go back and re-interview, et cetera, to see if there's something that potentially has been overlooked that might shed some light on where and how she was exposed.

DR. KOPLAN: Some of it may be just someone coming forth. Much like with a criminal investigation, an epidemiologic investigation can be helped by new pieces of information, and I know there's been a great effort in New York to show photographs of the woman and to hope that someone comes forward, and we still have hopes that someone will come forth and say I recognize her and we did this together, or I saw her here. And some of those leads, I think, are occurring in the criminal investigation side, and then we get invited in and participate where appropriate in that as well.

So as Steve said, we still hope and we're still going to work hard at it, but it is difficult.

AT&T MODERATOR: Thank you. Our next question is from Lee Bowman with Scripps Howard News. Please go ahead.

QUESTION: Hi, Dr. Koplan. Getting back to the state and local planning and particularly the issue of quarantine, how much do you think in the course of this the public has been educated about these kinds of aspects of public health? I mean they've seen we had an attack and we went and got our antibiotics this time. But in another circumstance, they may need to have much more stern measures that haven't been taken in this country for a number of decades. Do you think that there's been any education in this route?

DR. KOPLAN: I think you're absolutely right. I think that with each of these diseases or health issues or disasters, different if not demands at least expectations get placed on the public in different ways. And one that we've seen in this is what began as--I think the attitude towards antibiotics has shifted over the course of this last few weeks from the stockpiling and the kind of focus on one particular antibiotic as the be-all and end-all and you need to have that in your medicine chest, et cetera, to I think a much more balanced view of both the value of the antibiotics and which ones are appropriate now. And I think your point is well taken that dealing with something like quarantine or the need for mass vaccination would put another challenge to our population as to how to deal with it. It isn't new. I've just been reading a history of immigrant health issues in the late 19th to early 20th century, and strikingly when reading that when quarantine had to be implemented for plague in San Francisco in the early part of the 20th century, there was outrage around that, and how to do it, and which groups, and where did you draw the line. And it was heavily overladen with ethnic biases and prejudices as well.

So these are complicated issues. Just trying to isolate one person, Typhoid Mary, Mary Malone who also required some legal intervention again in the early 20th century, was devilishly difficult to do even for one person. So these are complex.

You know, do we have an easy answer for it? No. These things may have to be put into place. They would have to be placed at a state and local level with potentially some technical assistance, perhaps.

Does an individual, never mind a population, being told they've got to stay in one place and not leave it for a period of time? No. But in my own experience, in my--the last days of smallpox I was called in to babysit essentially a young woman who was visiting in the U.S. from England who had potentially been exposed to one of the last remaining laboratory-associated cases of smallpox, and this poor woman that was coming for a vacation to the U.S. and on arrival was told she had to stay in the farmhouse she was visiting for the full three weeks or two weeks of her visit, with me coming over to check on her temperature every day.

So I have had some very limited experience with quarantine, and it was very unpleasant even for one person for one two-week period.

AT&T MODERATOR: Thank you. We have a question from the line of Rick Weiss with The Washington Post. Please go ahead.

QUESTION: Hi. Thanks. Just first quickly, could you tell me whether you have settled the issue in Fort Collins? Is that a confirmed negative or positive or still pending?

And then secondly, with regard to the New Jersey physician, could you tell me two things? You know, what would a positive antibody test say to you, and would you expect to see positive antibody tests in someone who might have had a brief infection before getting treated with antibiotics? And if you do get a positive test, does that mean you're going to start looking at other spider bite cases from past weeks?

DR. KOPLAN: This is Jeff Koplan. I'll do Fort Collins. Fort Collins is confirmed negative. It is not a case. I will turn to my colleague for New Jersey.

DR. OSTROFF: I'm sorry, if you can repeat the question.

QUESTION: What would a positive antibody test say to you? Would you expect a positive antibody test in someone treated very quickly in a cutaneous case? And if it is positive, you know, would you start looking at past spider bites?

DR. OLFSTRAH: We--you know, we don't have a lot of experience with what happens with the immune response to anthrax in people who are immediately treated. So I'm not sure that I have a good answer for that. We have been--you know, particularly with the cutaneous cases, we're just now at the point of getting, you know, additional follow-up blood specimens from some of these individuals to see the evolution of the immune response. And, you know, to what degree the antibody levels go up and go down. So I think it's a little bit premature to speculate about what, you know, what the test would do in the setting of somebody who was immediately treated. And I think that's probably about as much as I could say.

DR. KOPLAN: And to paraphrase Freud, sometimes a brown recluse spider bite is just a brown recluse spider bite.

AT&T MODERATOR: Thank you. Our next question is from the line of Richard Knotts with National Public Radio. Please go ahead.

QUESTION: Thanks for being available. In the agenda on line today, there's several reports about the inhalational anthrax cases, and the one that deals with the two postal workers who died makes the point of saying that these cases emphasize the need for rapid communication of epidemiologic data to front line medical providers, and so on. Also the Gilmore Commission, chaired by Governor Gilmore of Virginia, is having its meetings today and yesterday, in preparation for issuing a report soon, and they had some criticisms to make about, among other things, communication from the CDC. And I've had state health workers tell me that--or officials tell me that they've had--they had difficulty, especially in early October, getting information they felt they needed from the CDC.

I guess I'm wondering whether at this point you feel as though those communication issues have been addressed, or whether there's more to be done that needs to be done to improve it, and what kind of resources those are going to take.

DR. KOPLAN: I think you can always do more, and do it in different ways. And this is, again, the first bioterrorism event that the country has gone through, never mind us, and yes, you learn things all the time. You learn things both scientifically and about the science of communication as well.

Right now--again we've got a multiple focus on communications and how to get that information out there and who to get it to. In the early stages of the outbreak, we did have a primary focus on practicing physicians and getting information out, but getting the information out in the absence of the information is difficult, too, which is that we needed to have some experience with the case in order to describe the details of that case.

Just as an example, some of the cases we've seen of inhalation anthrax have been what would have been thought atypical, and indeed, many of the so-called experts in the field were very unsure that what we were calling inhalation anthrax really was, because it didn't seem to meet the textbook description. And so in the course of this outbreak, we have learned new things about the clinical aspects of the disease, how to treat it, and the epidemiology that just wasn't there before. But you can't report it from day one because you don't have the information.

I understand the need for the communication, and we think it's very important, too. It's this case of balance between communicating something that's worthwhile versus just saying we're here and there's anthrax around. You've got to be able to tell people something they can use, and we try to do that as soon as we've had it whenever we've had it.

CDC MODERATOR: Last question, please.

AT&T MODERATOR: Thank you, and that will be from the line of Sanjay Baht with the Palm Beach Post. Please go ahead.

QUESTION: Yes. Thanks for holding these briefings. Last week Dr. Bradley Perkins told us that there had been discussions at very high levels about the helpfulness of the EIS officers in these investigations and the potential for expanding the program or making changes to the program. Could you talk about that a little bit? It seems like they've played a core role in this.

DR. KOPLAN: Well, as two alumni of the EIS program, we think the EIS program is great, and it actually is a tremendous national resource for a variety of reasons, one of which is it provides an apprentice training opportunity for young people, what seem like young people now, but people who, you know, who have finished some level of graduate training in either medicine or other health sciences, and encourage them to get into the field of public health and epidemiology, and it's been extraordinarily successful. Not just because of CDC, or even the state health departments, but wherever you folks are sitting and working, you go to a major university near you, or the health department or a city health department, and you will find EIS alumni who have played a major role in doing something in that university or health department.

We currently have roughly 70 of them a year in a two-year program. We always get more requests from different sites to place these people than we have enough people to do it, and we have enough people that meet the requirements in a highly competitive program who could be accepted than there are slots. So should the opportunity come up to expand the program, we would be eager to do so.

DR. OLFSTRAH: And then the last thing that I'll mention before we finish is in response to a question that came up earlier about a physician in New Jersey is we do have blood specimens from that individual, and we will be testing them.

CDC MODERATOR: Thank you very much.

AT&T MODERATOR: And, ladies and gentlemen, that does conclude your conference for today. Thank you for your participation and you may now disconnect.

[End of conference call.]

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