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HHS Conference Call Transcript: Sec. Tommy Thompson, Dr. D.A. Henderson, Dr. Jeffrey Koplan, and Dr. Tony Fauci

November 21, 2001

HHS MODERATOR: Thank you very much.

I just simply want to turn it over to HHS Secretary Tommy G. Thompson. Thank you.

SECRETARY THOMPSON: Good afternoon, everybody. Let me start off by taking this opportunity to wishing every one of the reporters on the line a very happy Thanksgiving. I know you all have been putting in long hours covering these terrorist attacks, and I hope you have a very good, relaxing holiday.

We wanted to just come together this afternoon and update you on what we know about the latest anthrax case and make ourselves available for any questions that you might have.

I have with me today Dr. Jeff Koplan, from the CDC, and Dr. D.A. Henderson, from my office who is here in the office with me, and Dr. Tony Fauci from NIH.

Most you probably know the details by now, but to recap quickly, a 94-year-old woman in Connecticut has been confirmed to have inhalation anthrax. The woman is currently being treated in a hospital. Our prayers are certainly with her and her family.

The CDC currently has a staff of five people in Connecticut working on this case. An EIS officer has been up there working with the Connecticut Health Department and a team of four was sent to the area last night. State and local officials know that more help is only a phone call away if it is needed.

As a precaution, workers at two Postal facilities have been on antibiotics and environmental testing is being done at those facilities. I emphasize that this action is being taken solely as a precaution. The woman certainly has been exposed to anthrax, and we're simply erring on the side of caution. We do not know the cause or the source of the anthrax. There is mystery to this case. We do not know how she was exposed to anthrax. All possibilities are being investigated.

I just got passed a note, and I knew before, but the woman has passed away, and I'm very sorry. I'd like to express our sympathy to the family. All possibilities are being investigated. The FBI, with assistance from CDC and HHS, is pursuing this case very aggressively. Our Department will continue to help the investigation in any way possible.

On another subject of interest to the reporters, I met with the companies this morning on the smallpox vaccine. I will be going over their final offers, which I gave them an opportunity to submit to me this morning, and we had some very stern, but very I think very constructive negotiations, and I will be making a decision on probably Sunday evening/Monday morning on who or how many are going to get the contract. We hope to have resolution soon, and I will pass along that information as soon as I make my decision.

I can't answer any questions regarding the negotiations today because they are still in progress, and you shouldn't anticipate any news over the holiday weekend. As I indicated, I'll be making my decision over the weekend, and will be announcing it Monday morning.

With that, I now will turn it over to Jeff Koplan, who can talk further about the Connecticut case, and then Dr. Tony Fauci and Dr. D.A. Henderson.


DR. KOPLAN: I have nothing particularly much to add to what the Secretary said, over the fact that, as he just described, there's a 94-year-old woman in a small town in Connecticut, Oxford, Connecticut, who became ill a few days ago, progressive course of respiratory symptoms with a series of positive laboratory tests, which ended up being presumptive anthrax, and was confirmed here in the early morning labs.

And the Connecticut State Health Department, along with some of our staff up there, are actively investigating this along with law-enforcement officials for both a public health investigation and a thorough criminal investigation. We're hopeful that some insights can be gained as quickly as possible about the source of her exposure.


DR. FAUCI: I have nothing to add to that, Mr. Secretary. I will just wait for the questions, that I am sure will be many, in this regard.


DR. HENDERSON: I think there will be many questions, and I think there are many questions which we have. I think the fact that one does find in many outbreaks an unusual case that really is a puzzle. The work done to solve that problem can often be very revealing, and so this case, along with the one in New York, have special importance, and certainly the investigations are being pursued with all due diligence.


AT&T MODERATOR: At this time, we'll begin the question and answer session. If you have a question during today's call, you can do so by pressing star one on your telephone touch pad. If you are using speaker equipment, you may need to lift your handset prior to pressing star one. If your question has already been answered or if you wish to remove your question, you can do so by pressing star two. Once again, that's star one if you have a question and star to cancel. One moment while the questions register.

Our first question comes from David Brown of the Washington Post.

QUESTION: I was wondering if Dr. Koplan or anyone else can give a little bit more detail about the progress of the investigation. Has there been any environmental sampling?

SECRETARY THOMPSON: Can you talk up?

QUESTION: Yes. I'm wondering if Dr. Koplan can give some details of the investigation; for instance, has there been any environmental sampling that has picked up spores? Do we know anything about when the woman last left her house, how many people came to her house, anything like that? Also, one other question, do we know what her X-ray looked like on presentation?

DR. KOPLAN: I think I can give you some of that information. The Connecticut State Health Department team, in consultation, and I think in collaboration with law enforcement, began environmental specimens there yesterday, and yesterday evening. It takes about 40/48 hours before one can draw a conclusion from those environmental specimens.

So, yes, specimens have been taken and will continue to be taken today in a variety of sites in her house and any other place she may have been, but we won't have results of them probably for about two days.

In terms of her presentation and the initial X-rays, she had, as I understand it--and, again, I'm distanced from this not being there in Connecticut--but from our team and folks there, my understanding is that she presented with fever, and weakness and fatigue, but was alert when she came in. And her initial chest X-ray was read as normal, and then it deteriorated in the couple of days after that.

HHS MODERATOR: Next question?

AT&T MODERATOR: Thank you. Our next question comes from Larry Abramson of National Public Radio.

QUESTION: Are you investigating seriously the possibility that this exposure or any of the others could be due to a noncriminal source, some abandoned mill, some other kind of agricultural source that we haven't been thinking about much?

DR. KOPLAN: Absolutely. As we from the very first case on, it behooves us to keep as open a mind as possible as to the potential causes.

Now, as with the first case, and every one subsequently, we do look for the range of what activities this person engaged in, both at work, if they worked, or at home or vocationally, what is the environment in which they live, what might they be exposed to, et cetera?

The initial reading in this 94-year-old woman who has no occupational exposure, who does not engage in the variety of pastimes that have been associated with anthrax--tanning hides, sorting wool, being a veterinarian, a farmer, et cetera--have so far not let us down, the likelihood of that, but we certainly haven't ruled it out, and it'll be continued to be looked for.

QUESTION: As a follow-up to that, would you be doing typing on the strain of anthrax that was found in her blood to see if it perhaps came from outside the country? One possibility that was raised was that a strain that came from Asia was sometimes found in housing insulation a long time ago.

QUESTION: Yes. We will be looking closely at the genetic attributes of the isolate. However, our first priority--we have two first priorities. One is ascertaining that it's Bacillus anthracis, and that involves getting the culture to grow. And our initial tests, which identified it as anthrax, are short of the culture growing, and so that culture still has to grow up some more. And then, again, the initial priority is its antibiotic pattern, which also is to look to see whether it looks like the other isolates we have.

Unfortunately, the poor woman has not survived this, so it won't affect her treatment at this point, but nevertheless that's the first important determinant. Then a more careful identification of the organism will be undertaken.

HHS MODERATOR: Next question?

AT&T MODERATOR: Thank you. Our next question comes from Jill Carroll of Wall Street Journal.

QUESTION: Hi. I was wondering if you have any sense of if this is the beginning of a kind of second wave of attacks, if you have any way to ascertain that?

DR. KOPLAN: Not really. I mean, if we draw an epidemic curve, which shows which displays numbers of cases versus days or a time line across the bottom of a curve, one sees a couple of distinct clusters of cases related to previous mailings and letters. That last case in New York of the woman who died from inhalation anthrax, it was unclear whether that represented something on the tail end of the previous clusters or something that represented a new pattern of cases, and similarly with this case here, until we have a better feel for what the exposure is, it's hard to know where to place it in context of what's to come.

Of course, if we start seeing a number of other cases in the next few days or weeks, this case will then fit into a different pattern.

QUESTION: As a follow-up to that, it seems like the mail would be the most likely--are you thinking right now for the moment, the working theory is that her mail is somehow the way it got to her?

DR. KOPLAN: Well, again, we've made a list of every possible route that we can think of, of how anthrax might have been acquired by a 94-year-old woman who largely lives at home, and things that enter that home are certainly a prime suspect, and given recent history, mail is one of them. And, indeed, we are pursuing that both in terms of the environmental testing in her house, the attempts at recovering any letters or mail she may have received, and then working with the postal authorities to see if there's any evidence of contamination in a line, a mail route.

At the same time, we can't eliminate any of the other possibilities. So we'll look at every possible cause of an exposure.

QUESTION: Thank you. 

HHS MODERATOR: Next question. 

AT&T MODERATOR: Thank you. Our next question comes from Monica Conrad of ABC News.

QUESTION: Good afternoon, gentlemen. Is it possible, or are you considering the fact that people may have died from this before September 11th and we never diagnosed as such?

DR. KOPLAN: It's possible, but one would still have to raise the issue of how, if they died of anthrax, inhalation anthrax, how did they acquire inhalation anthrax. And again, we've had a total of 18 cases that have been reported to us, and we've studied over near--over 50 years of looking for this. So it's an unusual disease, and, sure, some may have been missed, but nevertheless this is a purely unusual one.

So we're not discounting the fact that, you know, they may have occurred before, we may have missed them, but we can't rest on that until everything else got exhausted and there was some evidence that there had been these undiagnosed cases occurring over time.

QUESTION: Just as a follow-up, what before September 11th and before everybody was on high alert and looking for this type of symptoms, I mean what else could this person have been diagnosed of dying from? I mean what comes close to that, or would they--would you in every case easily identify it as anthrax, even before September 11th?

DR. KOPLAN: No, I think it wouldn't be in every case identified as anthrax. Nevertheless, the fact that blood cultures were taken, and I think--I don't know, I haven't spoken to the physicians who ordered the blood cultures, but whether anthrax was in their differential. Many times people will order blood cultures, appropriately when someone has a fever and they want to use it to guide antibiotic therapy, and when those blood cultures grow, the type of organism that's characterized physically by being gram-positive--that's how the dye that is used to stain the slide ends up having a specific color, and that makes it positive, and it's a rod that's the shape, that is a species of bacteria called Bacillus that can have several different species--not species, but types of Bacillus that are diagnosed, Bacillus, serious Bacillus anthraces. And so, yes, there are other organisms that look like that that could be diagnosed in this case, and maybe misdiagnosed if it was anthrax, but over the years, if--you know, you could maybe postulate one or two or five of these, but enough of these are done in many parts of the country with people that could test for them or raise the question that I think it's unlikely but possible. And I think we're not going to have an answer beyond that, that, yes, it's conceivable that our heightened surveillance has picked things up that wouldn't have been there before, but until proven otherwise in the face of what else we've seen around us, we have to pursue this vigorously as potentially related to these other criminal acts.

QUESTION: Okay. Thank you. 

HHS MODERATOR: Next question. 

AT&T MODERATOR: Next question, Greg Smith from New York Daily News.

QUESTION: Thank you. I'd just like you to get into a little bit more detail--Dr. Koplan, I believe, is the right person to answer this--about this woman's life and what you know about it so far and how that will relate to this investigation. And then figure into that also the question of mail, specifically if she's got anything from Senator Dodds' office.

DR. KOPLAN: Our team who is doing this investigation with the Connecticut State Health Department left here at about 9:30 last night, arrived in Connecticut at 11:30, went to work right away, and are working through today and this morning. So we haven't really had a debriefing from them yet, or the Connecticut health officials, as to what more they've learned.

Keep in mind, even in this patient that the information, the kind you'd like and we'd like as to the details of her life, will have to come from--she was intubated in, you know, in the course of this hospitalization, meaning that she couldn't give a history on her own. And so it will involve interviews with whatever relatives are there, whatever neighbors may know about her, friends, people that she socialized with in some way, and so we don't have that level of detail yet for this individual. 

I'm sorry, there was a second part to your question. 

QUESTION: It was just whether or not you guys have been able to ascertain whether she's received any mail from Senator Dodd.

DR. KOPLAN: Not that we know of. And again, we'll have to ask people--I think our preliminary understanding was that either a friend or relative would pick the mail up for her from her post box and bring it in, and then this woman, who was very active, or active enough and lived alone and seemed to be in very good health for a 94-year-old person, went through her mail herself and either answered it or dealt with it. So we don't have that information yet as to what the nature of all her mail was for the last couple of weeks.

HHS MODERATOR: Next question. 

AT&T MODERATOR: Next question comes from Donna Lewsner of The Star Ledger.

QUESTION: Is there any indication that the woman had been in the Trenton area, where the previous four letters have been postmarked?

DR. KOPLAN: I think--I don't know if that question was asked specifically, but again my understanding was that she did not leave the house except with her niece or either other relatives or friends there, and that that was pretty infrequent when she did leave the house. I think a trip to Trenton would be very unlikely, but it will be asked.

AT&T MODERATOR: Thank you. Our next question comes from Henry Nieman of Netcog.

QUESTION: Thanks for holding this conference. This may be a little bit early, but do you know whether she had any chronic disease or had been receiving any medical supplies delivered to her home?

DR. KOPLAN: We believe that she did have some medicines there. They haven't all been characterized for us, and at 94, I suspect she had odd aches and pains and ailments, and one of the things I think the team is doing there probably already today is making contact with the doctor who she regularly saw as opposed to this acute crisis hospitalization to get some more information from him or her as what chronic diseases she may have had or medications she may have had prescribed. 
DR. FAUCI: I think we should not make light of the fact, as Jeff has alluded to, 94 years old, though apparently she was a reasonably healthy 94 years old, the amount of what we call host defense defect in someone who's 94, who has lungs that have been breathing, you know, variably polluted air for a long period of time could really set the stage for any of a number of things, but certainly perhaps the inoculum that you might expect someone to get inhalational anthrax from could conceivably--and this is pure hypothesis, but it is not an unreasonable hypothesis, that the amount of spores that would be required to give someone who might have age-related host defense as opposed to medication-related or what-have-you, is not something that should be just passed off. And that's, I think, an important part to consider, that this woman was 94 years old.

HHS MODERATOR: Next question. 

AT&T MODERATOR: Next question comes from Rick Weiss of The Washington Post.

QUESTION: Thank you. I wanted to get an idea from you, you know, whether and I think when you would expect to get results with regard to the strain, specifically whether this ends up being Ames strain. And I wanted to get confirmation from you that the reason I at least would be curious is accurate, which is that my understanding is that the Ames strain is a strain of anthrax that has never been found in nature in the eastern United States. Therefore, if this does turn out to be Ames strain, it clearly has a laboratory source, if not, you know, specifically the terrorist source.

DR. KOPLAN: Well, a couple things. One, we don't do that type of strain characterization at CDC, and that level of input is usually done by the FBI in labs they use. But the issue of the Ames strain itself, the Ames strain, I believe, was initially isolated from a naturally-occurring anthrax source.

QUESTION: Right, but in Iowa, and--

DR. KOPLAN: Right. And but by the same token, yes, it occurs in different laboratories or it's used in different laboratories, but even the Ames strain is not that different in its genetic characterization from some naturally-occurring strains that are found in other parts of the country, again not Connecticut.

I don't think we necessarily need the characterization of the strain to determine whether this is naturally occurring or not. As I indicated earlier, we will not eliminate natural occurrence as a possibility, but I think it is a very, very low possibility. 

AT&T MODERATOR: Thank you. Our next question comes from Loni Niegard of the Associated Press. 

QUESTION: Dr. Fauci, I wanted to follow up on something that you alluded to. Obviously the 8000 spore figure everybody has talked about recently is an LD50, and all but one of the inhaled anthrax cases so far have been people in their 50s or older, and now we've got a 94-year-old. Does this suggest that there's this progression, that as you age, it takes fewer and fewer spores to infect? And how low could that threshold actually go which begs the question of should other elderly people be careful opening their mail?

DR. FAUCI: Well, let me just take the first--the second part that you mentioned. I can't give you a number based on the projection you're talking about, what's the lower level. That would have to be done experimentally by titrating down, for example, in an animal model.

But the point that you make is a point that all of us on this conference call, from the department, are thinking about. It has not gone unnoticed the age ranges of these individuals, nor has the Sverdlost age range gone unnoticed. So it is conceivable that as one gets older, that the natural, what I referred to before, host defenses in the lung, might be not so clinically significantly decreased that all elderly people or people who get to a certain age have compromised function, but it may be just the very critical threshold which brings out an increased susceptibility to inhalational anthrax in people who have that modest otherwise clinically not significant but nonetheless in this case potentially significant defect in their ability to clear or to handle spores that come in through the lungs.

And that's the reason why I brought up that point just a few minutes ago. Don't discount the 94-year-old. That may be highly significant as to why she got infected and somebody else might have just brushed it off and no one would have ever noticed it. 

Now what that has to say for elderly people and their handling of the mail, I don't think you can really make a statement on that because what we really need to find out in this situation as best as we can what the source in this woman was, and then maybe we could address that. If the source turns out to be a secondarily contaminated letter, well, that would be something you'd have to drop back and reconsider. But I think we should wait until we find out the source, and hopefully we will find out the source of this particular infection.

QUESTION: Thank you. 

AT&T MODERATOR: And our next question comes from Bob Routh for the Center for Disease Research. 

QUESTION: Thanks. I believe my question has already been answered. I was wondering about the strain, if there are any preliminary indications of what strain you have here in this case.

HHS MODERATOR: Well, why don't we move on to the next question, then.

AT&T MODERATOR: The next question comes from Kyoshi Nedo of Nikkai News.

QUESTION: Hi. Thank you for the briefing. I was wondering, I think doctors were saying until this point that by finding the disease at the early stage, even with inhalation anthrax, people can cure, but in this case, under this very vigilant environment, has a discovery been delayed in some way? Did--you were saying like a couple of days ago, right, it was found that she had pneumonia-like symptoms. But was it too late, or this was a very special fast progress case?

DR. KOPLAN: I'd be eager to hear Dr. Fauci's interpretation as well, but as he said, an individual at 94 is much more fragile to any of the tribulations, the disease or hazardous tribulations of life, and whether that's a fall or an infection, they just don't deal with it as well. And anthrax, although we've had more success with it in the this particular outbreak, this bioterrorist event, remains an extremely serious infection. So for it to occur in a 94-year-old, even when diagnosed early, even when treated properly, as was the case here, and even when in the hands of very good clinicians and physicians at Griffin Hospital in Derby, Connecticut, which she has been under that care, it still is a long odd to survive. Tony?

DR. FAUCI: Yeah, I agree with Dr. Koplan completely. But to your original question, if you look at the previously 10 inhalational anthrax that we've had, and the alertness in being able to treat them earlier rather than later, the mortality of that original 10 was 40 percent, compared to the originally published mortality of 85 to 97 percent. So, clearly, vigilance, early diagnosis and early treatment does make a difference.

And, in fact, the two out of the four people in the Washington, D.C., area who had inhalational anthrax, two died who were treated from 24 to 36 hours later than the other two, and they likely all four had the same exposure.

With regard to a 94-year-old woman, you don't need anthrax to have a high mortality from pneumonia in a 94-year-old. Having taken care of myself, personally, a lot of elderly people with pneumonia in hospitals, the situation is such that it is unlikely that someone with a serious pneumonia who is 94 is going to do very well, regardless of the microbe source of their pneumonia.

QUESTION: Just to follow up, is the incubation period usually very short for old people?

DR. FAUCI: There really isn't a linear relationship between exposure and onset of symptoms that you could plot against age. The incubation period clusters over a period of several days to a week or so after exposure, and then there are some outlier cases later on, but I don't think you can give, from the number of cases that we've had to study, you can give any kind of a statistically significant correlation of that.

HHS MODERATOR: This will have to be our last question.

AT&T MODERATOR: Our last question comes from Marianne Falco of CNN.

QUESTION: Hi. I've got two very quick questions because most of the other one were answered already, too.

I just wanted to follow up on what Dr. Fauci said. You made reference to very polluted air that she might have breathed in, and I'm not sure what you meant there.

Also, do you know if there's any naturally occurring anthrax in that community? She wasn't quite a rural community. And if you don't find a letter, and there's not enough environmental evidence, what are you going to be looking for?

DR. FAUCI: Well, I can answer the part about the pollution so that you don't get a mis--I hope I didn't give any misrepresentation of that. What I'm talking about is that when you have someone who's been living anywhere in the United States, city or what have you, and have been breathing air, be it air that has particles on a farm or air that has pollution in New York City or any other place, after many, many years the cells that essentially filter the air that comes through, when you get particles into your bronchi, into your lungs, there are cells called macrophages that chew up these particles and consume them.

And you can look at autopsies from people 10 years old, 20, 30, 40, 50, 60, 70, 80, and on, and the older you get, the more debris that you see that has been collected just from the normal breathing in the environment.

That gets to my point earlier that an older person likely has naturally occurring host offense weaknesses that are merely a reflection of the fact that they've lived for quite a long time. You could significantly compound that by smoking, which is a big assault to the lung, but if you combine smoking with the normal, every day tar problems that you get when you breathe air in a city or what have you, that does subclinical, but nonetheless progressive damage to the lung. And when you get to be 94, you've accumulated a lot of that.

QUESTION: And what about my other two questions?

DR. FAUCI: I think Jeff might answer that.

DR. KOPLAN: Thanks, Tony. I'm glad the air quality of the Housatonic River Valley wasn't slighted in that discussion. I've spent a lot of time in Derby on the river, and the air is actually pretty clear there.

In terms of naturally occurring in the community, again, it's not, that area, Connecticut, is just not a place where we've seen many anthrax cases over decades. Could one find anthrax spores in a garden in that area? I'm sure one could. Is it likely to be a source of inhalation anthrax? Very unlikely.

Again, naturally occurring is worthwhile and needs to be looked at, and this is, as D.A. Henderson said earlier, an extremely unusual case that we hope very much will give us more clues. But the naturally occurring is a low probability here.

And if we don't find the letter, it would be helpful, if there is a letter and that was the cause, to find it, but there are plenty of other courses of investigation, including the environmental sampling in the home and elsewhere, information from her family and friends as to what she did and where she did it, and other information that might be available in her house or in her belongings, so that all of those will be pursued in trying to get an answer to this.

HHS MODERATOR: All right. Well, I want to thank everybody for joining this afternoon.


AT&T MODERATOR: Thank you. That concludes today's HHS Teleconference call. Have a great and safe holiday.

[Whereupon, the teleconference was concluded.]

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