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Update on Anthrax Investigations
with Drs. Jim Hughes and Julie Gerberding

November 14, 2001

CDC MODERATOR: Thank you, John. Good afternoon, everyone, and we certainly appreciate you taking the time to participate in this media briefing. Our two speakers today, Dr. Jim Hughes, the director of the National Center for Infectious Diseases. Dr. Julie Gerberding, the acting deputy director of the National Center for Infectious Diseases. We don't really have any prepared remarks to give, other than to say that our case count remains at 17 confirmed cases and five suspect cases. There'll be additional information on the anthrax situation published in tomorrow's MMWR, and we'll have another media briefing scheduled at our regular time of noontime tomorrow.

So with that said, I'd like to turn it back to John, and we'll begin the Q&A session.

AT&T MODERATOR: Thank you, and ladies and gentlemen, just as a quick reminder, if you do have a question, please press the one at this time.

Our first question is from the line of Donna Nelson with NBC News. Please go ahead.

QUESTION: Hi. Thank you. I actually had two questions, if I could. One is regarding the testing of the New Jersey cardiologist, Dr. Weisfogel [ph]. What results have you gotten from those tests?

DR. HUGHES: Yeah. that work is still in progress. I've not seen the final results of that test.

QUESTION: Preliminary results that rule anything in, one way or another?

DR. HUGHES: No; no. We don't have any results, that I'm aware of, to report.

CDC MODERATOR: And this is Tom Skinner. I think it might be important for us to allude to the fact that even if we do do this testing on this sample, that, you know, we're gonna have to be careful about how these test results are interpreted, because of the way this blood test is used. I don't know if either one of you want to elaborate on that, but--

DR. GERBERDING: I think, first of all, you know, we work with the state health department and the local physicians who are involved in the care of the patient, that's our highest priority, but the sterilizing [?] tests that are being used to evaluate patients like this are tests that are not validated for clinical use at this point in time. So we're learning about their meaning and how to interpret them, but this test, in and of itself, is not usually as helpful as some of the other ways we have of diagnosing or excluding the diagnosis.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: And that's from the line of Andrew Revkin [ph] with New York Times. Please go ahead.

QUESTION: Yeah. Hi. I wanted to--I was hoping you would talk a little bit again about the State Department case and the Kathy Nguyen case in New York. Just give any update you might have, first of all, on emerging ideas about how their exposure, that resulted in inhalation in those two cases might have occurred, even though there doesn't seem to be any primary delivery of spores their way.

DR. GERBERDING: Both the cases, the State Department and the case in New York are still under very active high-priority investigation by both CDC, FBI, and others. With respect to the State Department, I think we recognize that it was obviously airborne, anthrax spores in the air there, of a sufficient quantity to cause serious disease in someone who was not taking antibiotic prophylaxis at the time, and the follow-up testing indicates that the environment was also contaminated there.

We have not found a source of that exposure. One hypothesis is that there's a letter that passed through that facility, that may be the source of these exposures, but we're open to other possibilities as well, and as more information becomes available we'll definitely provide updates.

With respect to the New York case, I think there's very little change in that investigation. The investigation, since you were updated yesterday, again, very active pursuit of all leads, evaluation of various environments that might have traces of anthrax, to suggest where an airborne exposure occurred in the past, but no definitive documentation of that at this point in time.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Thank you, and that's from the line of Laurie Garrett with Newsday. Please go ahead.

DR. HUGHES: Hi, Jim. Hi, Julie. I wonder--



QUESTION: Hi. I wonder if anyone has had enough time to take a deep breath and figure out how much over budget everybody is running, how much money has been spent both by CDC to execute all the anthrax investigations, and so on, and by your local partners, of course especially here in New York?

DR. GERBERDING: Well, let me answer the first part of the question. We are taking deep breaths, right now, and appreciating that we have not had recent cases. We obviously recognize that this is not over yet, but that gives us a chance to look at a number of issues including resource allocation, but also preparation for how we can proceed in the future, and what lessons we have learned from the past experience, and how we can improve the efficiency of our operations to be even more responsive the next time we have an event like this to contend with.

DR. HUGHES: Laurie, this is Jim. Just to follow up, and it's an important question. This has been a major full court press, this investigation at the local, the state, and the federal level. So there clearly are important resource implications here. It also illustrates the importance of planning and preparedness efforts at the state and local level.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: And that is from Greg Smith with the New York Daily News. Please go ahead.

QUESTION: Yeah. Hi. Thanks for doing this on a daily basis. This is going to the Manhattan Eye and Ear Hospital worker, and Doctor--one of you just mentioned that there's been evaluation of various environments, and my recollection with this is that you guys have kind of gone through the mail system, and you went through the hospital, and you went through her home.

What else are we talking about here?, and if you could try to focus that in on the concept of "inadvertent participant."

DR. GERBERDING: I'm sorry. I just didn't hear the last part of your question.

QUESTION: Yeah. I mean, I'm asking about the evaluation of various environments.


QUESTION: And relate that to the concept of this, that this woman was an inadvertent participant.

DR. GERBERDING: I would say, first of all, that we are looking at environments outside of the home, and workplace, including the sampling that was done in the subway system a couple of days ago. As we all recognize, retracing the day to day steps of someone's life is very, very difficult, but every effort is underway to try to identify her movements over the last couple of weeks of her life, and where there's documentation of her activity, then those environments are being looked at for the likelihood that sampling there would reveal any useful information.

We do not know what the source of her infection was, and we do not know whether or not she was in any way associated with, knew or had contact with someone who was involved in the situation. So we are, as I said before, we are remaining to all hypotheses at this point in time.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: And that's from the line of Miriam Falco with CNN. Please go ahead.

QUESTION: Hi, everybody. Thanks again from us, too, for the daily updates. I have a question about a story we did a couple of weeks ago. This relates to anthrax vaccines and who you were going to give them out to. There was supposed to be about 800 folks who were supposed to get them. Have they gotten them? And also have you identified what other possible groups you were going to single or identify, including postal workers and other high risk groups? Can you just give me an update on where that is?

DR. GERBERDING: The ACIP is reviewing updated guidelines for using the anthrax vaccine, and those deliberations are still ongoing. The existing guidance does recommend immunization for people who are at risk for ongoing or sustained exposure, including folks in laboratories that are processing high powder anthrax specimens. We would not be anticipating any dramatic departure from the previous guidance.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: And that's from the line of Michael James with ABC Please go ahead.

QUESTION: Yeah. Just stepping back a little bit, just with the whole sequence of cases apparently slowing down from the flurry and the initial mailings, is there a sense that we're in the clear in terms of new cases coming out, or is there still any--a lot of concern that, you know, at some point there might be, you know, at some point in time because of the timing of the way anthrax emerges that something else might come out on the current--you know, on the current contaminations and so forth?

DR. HUGHES: Right. If you look at the epidemic curve of when these various cases have occurred, you would see that it's bimodal. There was an initial cluster and then a second cluster of cases, and we're at the end of that. We remained on a very high level of alert, and we will do so until the criminals who perpetrated this are caught. And it's not only CDC, it's state and local health departments and other agencies as well.

CDC MODERATOR: Next question, please.

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

QUESTION: Hi. If I recall, you've been mentioning 17 cases and five suspected cases for well over a week now. Can you tell us just a little more about these suspected cases and when you might have a more definitive diagnosis?

DR. GERBERDING: These suspected cases are people who had cutaneous diseases that looked very clinically compatible with anthrax. In some of the situations they were treated and the lesions have completely resolved before it was recognized in retrospect that they were at risk for exposure.

So we don't have the same information at our disposal that we normally would have if we saw the lesion as it was initially developing, and in particular we don't have that gold standard culture information available. So we have to rely on other measures.

When you have a situation where someone is in a work setting where they were known to or possibly had contact with infected powder and they have a skin lesion that looks clinically or sounds like it was very clinically compatible with anthrax, that certainly is halfway there to suspect case. And then we require at least some laboratory evidence suggestive of anthrax to keep them in that category. So these individuals basically have some tests, these are an antibody test or some other marker that suggests that they've had exposure to the anthrax bacteria in the past, but not the full gold standard definition we need to make them a confirmed case.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Thank you, and that's from Henry Nyman with Netco. Please go ahead.

QUESTION: Hi. Thanks for having these conferences. I'm still a little confused on the cross-contamination and the argument that it takes a larger amount to get inhalational. It seems that the diseases have pretty much correlated with the--the batch that went out, the September 18th, pretty much did cutaneous. Florida just did inhalational, and the October 9th Daschle seemed to also be inhalational. And then there seemed to be a few cases that looked like they arose from cross-contamination, such as Bellmawr or the bookkeeper, and those were both cutaneous. But it seems that there's a dosing argument that's been used that for cross-contamination it's easier to get cutaneous and more difficult to get inhalational. But if it is a dose relationship, then is there any explanation why there was no cutaneous at Brentwood and no cutaneous in Florida?

DR. GERBERDING: There are many factors that affect whether someone gets infection after exposure and whether or not they get the inhalation and the cutaneous dose may be one component of that, but the characteristics of the material that contain the anthrax are very important. If the material is a material that can be airborne very easily, then there's much greater risk for inhalation disease. If it's a material that isn't very efficiently aerosolized but sticks around on surfaces, then there's a greater risk for cutaneous disease.

So that is, in and of itself, a very important piece of information in making those kinds of predictions.

The other factor relates to whether or not people took antibiotic prophylaxis. Remember, in Brentwood the four people who acquired disease basically became ill at approximately the same time and then antibiotic prophylaxis was started, so if there had been anybody at risk for cutaneous infection there, they were already on antibiotics and we wouldn't have seen it. So that's another factor that confounds the interpretation.

I think we can kind of wrap this all up by saying that the bacteria are capable of causing both forms of the illness and the variety of factors that predict in any given person are difficult to sort out, but we do believe that the few spores that might be implicated in cross-contaminated mail could cause skin disease in some people, but are extremely unlikely to cause inhalation disease.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: And that's from the line of Charles Hamish with Global Radio News. Please go ahead.

QUESTION: Thank you for having these teleconferences. I'm sort of new to the game, I just jumped on yesterday. 

There had been reports early on that the primary laboratory source for the spores was Iowa. Is that still a common factor for all the definite causes of the infected people? Or are they coming from different laboratories as you can trace them?

DR. GERBERDING: Yeah, it's very important to set the record straight on this issue. We have no evidence that any of these strains came from Iowa or any place else. These strains in the various regions of the country that we're dealing with are indistinguishable on the basis of their antibiotic susceptibility as well as their typing using more sophisticated molecular tools, and they have some characteristics in common with several of the naturally acquired strains of anthrax that have been seen in animals in the United States and in the United Kingdom and elsewhere. But that does not provide any information about where they were derived or where someone obtained them for the particular attack.

So biologically all of the anthrax strains have some properties in common and the subtyping of some have been obtained from natural epidemics are similar to these involved in the strain, but they're not identical.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: That's from Aaron Zeitner with the L.A. Times. Please go ahead.

QUESTION: Hi, and again thanks for holding these calls.

The question again on dosing, you folks have said previously that one area of vigorous investigation is whether there's some threshold--what the threshold level is to trigger a case, and that you believe that there is such a thing as a medically negligent amount. Can you elaborate on how if you are conducting that investigation if at all whether it's a data search or animal tests?

DR. GERBERDING: Yeah, one thing we're confident about are the extremes of the equation. If you have a very high dose of inhaled exposure, you're at very high risk for inhalation anthrax, and if you have exposure to a small number of spores at the low end of the extreme, you're not at risk for disease.

We do not know where to draw the line in between those two extremes, and that's an area of very active investigation. We're looking backwards at some of the experimental animal work that was done in years past to help us make those distinctions, and we are also working with experts that we've brought to CDC to help us define our research agenda to figure out how we might more precisely make those kinds of distinctions.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: That's from Brian Bechtel with Infectious Disease News. Please go ahead.

QUESTION: Yes, thanks. I had a question about the prophylactic noted in the November 9th NWR that said that there were 32,000 people who were given prophylactics. First of all, that's an astounding number. I wanted to just confirm that number and also get an update on the number of people given prophylactics at the Colorado site mentioned yesterday.

And second of all, you know, 5000 people were given a 60-day course, so I was wondering what type of course was given to the other 27,000, and also the types, the distribution.

And lastly, as a follow-up, whether in retrospect the CDC, you know, thought it wise to give prophylactics so widely, given the possibility of adverse events and shortages and side effects?

DR. GERBERDING: When an exposure occurs or when there's a suspicion of an exposure to an anthrax containing powder, the strategy is to treat all of the people in the circle of shared air. In other words, we looked at powder, where it was distributed, and where the airflow patterns were in the building, or situations, and, initially, start treatment on a fairly large number of people to make sure we've included all of those that are exposed. But as we complete the environmental evaluations, and sometimes nasal swabbing, depending on how recently the exposure occurred, we can narrow it down, and so then many of the people who start on antibiotics are instructed to stop them.

So many of the 32,000 people that were in this were started on drugs, ultimately proved not to require them because they turned out not to be in the exposure zone. So their treatment was stopped.

Those that have been in facilities where there was an inhalation case are instructed to continue antibiotics for the full 60 days. So those, much smaller group of people, are undergoing active monitoring and support to ensure that they can complete their full treatment regimen.

We don't want to be using these drugs, willy-nilly, or unnecessarily. There is a lot of thought that goes into these decisions and we're very respectful of concerns about side effects as well as antibiotic resistance. So it's like every decision. The balance between the important need to prevent inhalation anthrax in the people who are truly exposed, balanced against the risk of side effects or drug resistance down the road.

With respect to Colorado, we were able to initiate treatment on the folks in the postal facility where the suspected individual worked. As information became available, that that individual did not have anthrax, and the environmental samples of that facility were complete, and revealed that there was no anthrax in the post office, everybody who was in this was started on antibiotics, was told to stop their treatment. So there's nobody undergoing long-term treatment there because there's been nobody exposed.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: And that's from the line of Kevin McCoy with USA Today. Please go ahead.

QUESTION: Hi. Thanks, again, for holding these briefings. You mentioned the testing that's been done in the subways in New York City. Could you elaborate a little bit on that. Is that testing still going on?

DR. GERBERDING: Our understanding from the New York City Health Department is that evaluation is complete. The sample has been finished and we're just waiting for the laboratory test results to be finalized.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: And that's from Ira Dreyfus with AP Radio. Please go ahead.

QUESTION: Hi. Actually, I have two questions. The first concerns the wind-down that may be coming, eventually, to the anthrax outbreaks. What standards do you guys have for determining when the time comes for CDC to redeploy its folks away from the investigation, and how close you are to that?

And on an unrelated subject, I've heard from patients who say that conditions that they used to have treated with Cipro are no longer being treated with Cipro because doctors are saying they can't get it because all the Cipro's going to anthrax, and I'm kind of curious to see what you folks might know about that.

DR. HUGHES: Let me start with the wind-down. As the investigations continue and reach certain phases, the need for people in the field has diminished, in Florida, in particular, but also in New York City and Washington, and even in New Jersey.

So there are fewer CDC people in the field working with their state and local counterparts than there were a week or two ago. Those that have come back to Atlanta, some have continued to work on the issue here at CDC headquarters. Others have gone back to their regular jobs. You know, we have diverted people and brought people into this from all across the agency, and there has been other important work that has been at a lower level of intensity as a result of that.

So as we have opportunities to get people back to their other high-priority work, we are taking them, but that does not mean that we have diminished our level of vigilance, at al,l on this.

DR. GERBERDING: And I would just answer that that CDC is a big organization, and the anthrax situation has been of benefit in some sense, in terms of bringing the very best people to bear on the problem, and it demonstrates our flexibility and our capacity to mount this kind of response, without attenuating our other public health responsibilities. So it's been encouraging to us that we've been able to accomplish this with the expert scientists that we have, that we can rally the troops, and meet a new challenge, and at the same time sustain many of our activities.

As you know, we're coming into influenza season now, and our whole influenza program is ready to go with the immunization activities, and so forth. So we're big and we're strong.

With respect to your question about access to Ciprofloxacin, there are ongoing episodes of antibiotics shortage that we've been experiencing in the United States over the past several years for a variety of reasons. The supply of Ciprofloxacin that we have access to through vendors and through the stockpile suggest to us that there's no issue of shortage.

There have been localized examples where antibiotics has been hoarded, particularly after the 9-11 World Trade Center crisis in New York City. For a period of there were some folks there that had difficulty getting Ciprofloxacin from their local pharmacy. But, in general, the supply of these drugs is keeping up with the demand.

We are also putting more emphasis on using Doxycycline as a drug for prophylaxis of B. anthracis exposure because the organism is sensitive to Doxycycline, just as sensitive as it is to Ciprofloxacin, and we don't use Doxycycline for a lot of other conditions.

So we can preserve and protect our supply of Ciprofloxacin, but, more importantly, preserve and protect other bacterial susceptibility to it.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: And that's from Maggie Fox of Reuters. Please go ahead.

QUESTION: I wanted to ask about the genetic sequencing efforts out at Los Alamos and Northern Arizona University. Have you guys heard anything back from them on the precise genetic sequence? And I also wanted to follow up with a question on numbers of people deployed.

DR. HUGHES: In terms of sequencing, we've been working with the people at Northern Arizona on the molecular subtyping, and we know the results that they've obtained there. Those are the ones that allow us to say that all the strains isolated so far are indistinguishable from each other.

We've not seen detailed sequence data on these strains yet.

QUESTION: But you will, at some point?

DR. HUGHES: Yes. I'm sure we will.

CDC MODERATOR: And what's your question about deployment?

QUESTION: Do you have any numbers on--I know you've redeployed some people, especially, here, in Washington, D.C. I know a lot of people have gone home. Do you have any numbers on who was out in the field and who's been called back in, just general numbers?

DR. GERBERDING: We actually have an accurate accounting of that but we'll have to get back to you on the details. You can contact Mr. Skinner 'cause we're not in our office right now and don't have those figures in front of us.

DR. HUGHES: Maggie, I'll try to get that for you.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: And that's from Sara Leek with the Wall Street Journal. Please go ahead.

QUESTION: Yeah. Hi. Two questions, actually. First of all, what if any involvement did CDC have with this FBI search in Chester, Pennsylvania? Was there any testing for anthrax or other harmful substances there?

And also could you explain what improvements you're working on with the testing, I think it's serology, I'm not confident of the technical terms--but the assays you would use to test people, such as the New Jersey cardiologist, for possible exposure to cutaneous anthrax?

DR. GERBERDING: CDC is not directly involved in the investigation in Pennsylvania. We really can't provide any more information about that. The serologic test measures an antibody that's produced in people with infection, with anthrax, to a particular virulence factor that the bacteria make when its in its vegetative form. It doesn't test spores and it doesn't test for just simple exposure.

It tests for evidence of disease, and it is then used and is validated as a test for the efficacy of the vaccine for anthrax. So if you expose someone to the vaccine, you expect them to have a positive antibody test, which is assayed. But it has not been used in clinical studies because not very many people get anthrax. So it's not been possible to evaluate or validate it for this purpose. We are collecting a lot of information on the test characteristics and performance in the context of this current attack, and as we bring that information together, we'll be calling in experts from around the country to help us look at the information and determine how reliable the test is, and what recommendations we can make about its future use.

CDC MODERATOR: John, we'll take two more questions, please.

AT&T MODERATOR: Our next question is from Eric Glipton [ph] with the New York Times. Please go ahead.

QUESTION: Yeah. I was gonna ask about the results of the subway testing, which you already said they're not back, but do you have any information at all about other locations within New York City that you have been doing sampling?

DR. GERBERDING: We've been talking about sampling in a variety of environments but until we have information that really puts this patient in that environment, it doesn't make very much sense to do random testing.

I think the New York Health Department and the FBI are working with CDC, you know, as I said, retracing her steps, and seeing if there's any environment that might provide useful information. But as of today, I'm not aware of any specific pans.

CDC MODERATOR: John, last question, please.

AT&T MODERATOR: And that's from Anita Manning of USA Today. Please go ahead.

QUESTION: Well, I'm sorry. Maggie already asked my question and we're gonna have to call Tom later to get the answer. So thank you.

CDC MODERATOR: That's fine. We'll take one more question, John.

AT&T MODERATOR: And that will be a follow-up from Donna Nelson of NBC News. Please go ahead.

QUESTION: Hi. I just had a clarification on the testing of the New Jersey cardiologist. You were saying that the test is not as helpful as others. Is it because he's already been taking antibiotics, that that would interfere with your ability to accurately be able to see if he did in fact have anthrax, or has anthrax?

DR. GERBERDING: Yeah, as I explained earlier, the definition of a case of anthrax has several criteria, and when we have nothing else to go on, a blood test is not the firmest grounds to draw any conclusions, particularly a blood test that hasn't been validated.

So I don't think we are likely to be able to say anything definitive about his diagnosis based on the information that we have gathered so far.

CDC MODERATOR: Okay. Thank you very much and as I indicated earlier, there will be an MMWR being published tomorrow with additional information, and once again we'll have our normal noontime call for the telebriefing. So 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.

Listen to the telebriefing

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