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CDC - Interim Smallpox Response Plan and Guidelines Conference Call

November 26, 2001


CDC MODERATOR: Thank you very much for joining the CDC telebriefing today. I would just like to touch on anthrax for a moment.

The investigation is ongoing. Currently, CDC has 21 staff on-site in Connecticut. I do not have anything new to report to you today at this point, but I understand that the Connecticut Health Department is doing a daily briefing, and if you would like more information, you can call them at 860-509-7270.

The subject of this conference call today is the Interim Smallpox Response Plan and Guidelines. With us, we have four speakers. We have Dr. D.A. Henderson, the Director of the Office of Public Health Preparedness at HHS in Washington; Dr. Harold Margolis, the CDC Senior Adviser for Smallpox Preparedness; Dr. Lisa Rotz, CDC bioterrorism preparedness expert; and Dr. Joel Karitsky, Director of the National Immunization Program Preparedness and Response Activity.

We're going to have some opening remarks from Dr. Harold Margolis, and then we'll open it up to Q&A.

DR. MARGOLIS: Good morning. Today, the Centers for Disease Control and Prevention released our Interim Smallpox Response Plan and Guidelines. What this is is an outline of CDC strategies for responding to a smallpox emergency.

This plan, although released today, has actually been something that has been in draft for many years because smallpox was eradicated from the face of the earth 21 years ago, and so, in fact, we have had a strategy that if a case occurred or there was some introduction, there would need to be mobilization at the national, state, and local levels.

The plan identifies many of the federal, state, and public health activities that would need to be undertaken in case of a smallpox emergency and includes a response plan for implementation and notification procedures for suspected cases, CDC, and state and local responsibilities, as well as the responsibilities in terms of use of vaccine and personnel mobilization.

The plan was developed in conjunction with state epidemiologists, bioterrorism coordinators, immunization program managers and health officials. Many of these strategies, as I said before, were used successfully in the global eradication of smallpox, which was declared eradicated in 1980.

Lastly, this interim plan will remain a working document, which will be updated regularly, like changes in overall public health resources for responding to a possible smallpox emergency.

At the heart of the plan to maybe expand a bit on the strategy that was used to effectively eradicate smallpox from the world, and at the heart of this plan is called ring vaccination or also what is sometimes called search and containment; that is, identifying infected individual or individuals with confirmed smallpox and then identifying and locating those people who come in contact with that person and vaccinating those people in outward rings of contact.

And as I said before, this really then produces a buffer of immune individuals and was shown to prevent smallpox and to ultimately eradicate this disease.

CDC MODERATOR: Okay. We can open it up to Q&A now.

AT&T MODERATOR: You would like to take questions at this time?

CDC MODERATOR: Yes.

AT&T MODERATOR: Great. Thank you.

Ladies and gentlemen, at this time, if you would like to ask a question, please depress the one on your touch-tone phone. You will hear a tone indicating that you've been placed in queue. You may remove yourself from the queue at any time by pressing the pound key. And if you are using a speaker phone, we do ask that you please pick up your handset before pressing the numbers.

Our first question will be from the line of Odessa Middleston with Dow Jones. Please go ahead.

QUESTION: Yes. My question is was there a similar plan in place for any anthrax outbreaks?

DR. ROTZ: This is Lisa Rotz from CDC.

There was not a similar plan actually in place for anthrax specifically prior to the current outbreak. We had been working with state and public health departments to develop plans for responding to bioterrorism in general, and we are still continuing to do that.

Basically, the development of this plan is a part of the overall BT preparedness effort. And the reason that there's a specific plan for smallpox per se is that this is a slightly different disease when you talk about preparing for that and specific things need to be worked on, including issues that deal with the communicability of the disease, which is a little bit different than anthrax in general.

CDC MODERATOR: Next question?

AT&T MODERATOR: Thank you, Ms. Middleston. Does that conclude your question?

QUESTION: Yes, thank you.

AT&T MODERATOR: Very good. Thank you.

And our next question will be from the line of Andrew Revkin with New York Times. Please go ahead.

QUESTION: Hi. A couple of quick points to get out of the way on anthrax, if you don't mind.

What's the deal with Chile? There was some confusion as to whether CDC had completed its tests on anything coming from that letter.

Second, have you kind of gotten your ring yet around Ottilie, meaning do you have sort of a family tree of survivors and people who had come and gone at her house, not so much where she went, but who came to visit her?

CDC MODERATOR: I'm sorry, Andrew. We don't have anyone here to respond to your questions on anthrax. If you want to call the press office afterwards or call that number I gave you for the Connecticut Health Department.

Do you have any questions on smallpox?

QUESTION: Not right now, thanks.

CDC MODERATOR: Thank you.

AT&T MODERATOR: Thank you. And our next question is going to be from the line of Sarah Look with the Wall Street Journal. Please go ahead.

QUESTION: Yeah. Hi. Could you talk a little bit about some of the concerns you might have heard from the state health officials about the smallpox plan, and if there were to be an outbreak, you know, tomorrow or in the next few days, is it operational, and are there things that have to happen at their level before it can be implemented down the line?

DR. ROTZ: This is Lisa Rotz, again, responding to the question.

We have had some comments back and 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 this situation. So we are, as I said before, we are remaining open to all hypotheses at this point in time.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: And that's from the line of Mariam 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 weeks ago. This relates to anthrax vaccines and who you were going to give them out to. There were supposed to be about 800 folks who were supposed to get them. Have they gotten them, and also have you identified what other possible group you were going to single out or identify, including postal workers and other high risk groups? Can you just give me an update on where that is?

DR. ROTZ: 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 higher titer 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 [inaudible].

QUESTION: [Inaudible] at their level before it can be implemented, you know, down the line.

DR. ROTZ: This is Lisa Rotz again responding to the question. We have had some comments back from state health departments regarding things that they think would help us to make the plan more operational from their end of the spectrum.

However, it is an operational plan and these strategies would be implemented tomorrow if something were to occur.

The plan generally talks about specific public health actions that need to be taken, and those specific actions would not change in a smallpox outbreak. What we are trying to do with this plan is to help state health departments and local health departments identify things that they need assistance with to implement regarding these strategies.

QUESTION: Can you give some examples of those?

DR. ROTZ: Some of the examples would be say contact tracing, trying to identify people that came into contact with the smallpox patient, and some of the actions that have to be taken surrounding that; identifying the numbers of personnel that might have to be available to do that sort of thing; identifying strategies for rapidly identifying contacts. So those sorts of issues, and personnel issues, and overall, you know, vaccination of those groups, and how to set up vaccination clinics and things like that. Those are things that we try to address in the plan that identifies for public health personnel actions that have to be taken, and it's for them to help us identify how we can help them take those actions.

Dr. Henderson, is there something you would like to add?

DR. HENDERSON: Well, I think one can say also that the plan is quite detailed, and as such it has an applicability to dealing with more than just smallpox itself. So I think as the health departments begin to plan and figure out how the personnel should be dispersed and how you deal with media and how you set up the vaccination clinics, the antibiotic distribution points for anthrax, this has a broad applicability, so I think it's a very good departure point for the overall planning that is needed to deal with an outbreak.

CDC MODERATOR: Next question?

AT&T MODERATOR: Thank you for your question. Next we'll go to Jill Carroll with The Wall Street Journal. Please go ahead.

QUESTION: Hi, there. I wanted to know what do the plans say about quarantine? Obviously an idea that's sort of [inaudible] with today's society.

DR. ROTZ: Well, the plan does address the potential need for quarantine as well as the need for isolation of people that are infectious to other people. It addresses those issues and talks about strategies for isolating cases so that they can no longer continue to transmit disease until they are no longer infectious, and addresses those issues on the local and state and Federal level.

QUESTION: It allows cities to be cordoned off and let no one in or out, that kind of thing?

DR. ROTZ: It addresses the issue about the potential need for that, but it does not specifically address whether or not cities would need to be quarantined. I think that would be very much outbreak-dependent upon what we're looking at with the number of cases and the control measures that are implemented and whether or not something of that scale would be needed.

QUESTION: Okay. So it doesn't outline given today's mobile society if someone who's got smallpox flew from New York to L.A., you would need to like isolate parts of New York and parts of L.A., for example? Does it take into account the new situation [inaudible] travel and all that?

DR. ROTZ: It takes into account the potential need for isolating or quarantining off areas of cities, if needed, or areas--other areas, if needed, but again it doesn't make specific direction for doing that, because again that's going to be a decision that's going to have to be made at the time.

DR. HENDERSON: May I add just a word on this? I think the question in part relates to many comments that I've seen in the newspaper because--stating that because people travel so much that somebody's going to become infected, get on an airplane and spread it widely. But I think what many people do not, I think, understand fully is that you get infected with the disease and then you have an incubation period of 10 to 12 days when the individual feels perfectly well and is not able to transmit infection.

Then he gets a fever a couple of days and then the rash, and it's only when the rash begins that the individual transmits the disease. So in fact the people we're really concerned about are those who have a fever and isolating them so that they don't transmit it, transmit the disease. But just because somebody's infected does not mean that they're going to transmit infection during that incubation period. They won't do that.

So it's a little different, a little different problem than I think many envisage it to be.

QUESTION: Thank you.

CDC MODERATOR: Next question.

AT&T MODERATOR: Our next question is from the line of Christine Hallam with Bloomberg News. Please go ahead.

QUESTION: Hi. I have a quick question and then another question after that. The quick question is when was the last case of smallpox in the United States? Does anyone know?

DR. ROTZ: Dr. Henderson, do you want to answer that?

DR. HENDERSON: Yes. If I recall correctly, it was 1949. It was in Texas. It was an importation from Mexico.

CDC MODERATOR: Next question.

QUESTION: Okay, the next question is if someone has been in this ring around an infected person yet their immune system is compromised, for example, if they have undergone chemotherapy, if they're infected with HIV, would they be forced to undergo vaccination or how would you handle that situation?

DR. ROTZ: This is Lisa Rotz again. In general, when you have a true exposure to smallpox virus, there's no contraindication to vaccination. In other words, for people that you would normally expect that you would not vaccinate because of an underlying condition, if they were exposed to smallpox, their chance of having a poor outcome from developing smallpox much more outweighs their chance of having an adverse event to the vaccination. So in that instance they would be recommended to have the vaccine because that could potentially actually keep them from developing a very, very severe case of smallpox which would probably increase their risk of dying from smallpox because of their underlying condition.

So, you know, we would recommend vaccination in that instance.

CDC MODERATOR: Next question.

AT&T MODERATOR: Thank you. That question is going to be from the line of Larry Altman with New York Times. Please go ahead.

QUESTION: Yes. Is there a copy of this plan that we can get, and if so, where?

DR. ROTZ: Yes. You can e-mail Curtis Allen at callen@cdc.gov. He will try to e-mail it to you. It is a 300-page document. If it's not successful, then he can mail you a CD ROM.

QUESTION: For deadline purposes, is there an executive summary or some--

DR. ROTZ: Yes, the executive summary--there's a seven-page executive summary at www.cdc.gov/nip/diseases/smallpox.

QUESTION: Okay. The question that I then have is if there was a smallpox case detected today, or the threat of one, how soon could the vaccine be made available?

DR. ROTZ: The vaccine could be made immediately available.

QUESTION: Immediately meaning seconds, minutes, hours?

DR. ROTZ: Hours.

QUESTION: Anywhere in the country?

DR. ROTZ: Anywhere in the country.

QUESTION: Okay.

CDC MODERATOR: Next question.

AT&T MODERATOR: The next question is from the line of Shawn Lofflin with CNN. Please go ahead.

QUESTION: Hi. I'm wondering if you could--I'm asking you to address the obvious--but you've mentioned how this plan has been in the works for years. So talk a little more about why you're releasing it now. I mean, obviously, it's in the context of what's going on, but I wonder if you could address that, please.

DR. ROTZ: Yes, this is Lisa Rotz, again.

As I stated earlier, this is basically a part of our overall BT preparedness, and we've been working on updating this plan from a plan that was originally developed in 1972 to deal with importations of smallpox, after we stopped vaccinating routinely here in the U.S., and this is basically an update of that plan, and we've been working on it as a part of our overall BT preparedness effort and, again, the release of this plan so that state and local health departments can begin thinking about developing their own statewide, communitywide plans for smallpox response. It's, again, a part of our overall BT response.

We have no information currently that there is any increased risk of a smallpox outbreak, and this is just in response to our overall BT preparedness effort that we have stepped up.

CDC MODERATOR: BT meaning bioterrorism.

DR. ROTZ: I'm sorry, bioterrorism.

QUESTION: Right. Okay.

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

QUESTION: Hi. I just wanted to find out what the status is of the vaccine contract for producing the new supply.

CDC MODERATOR: That contract is still under negotiation, and we don't have anything new to report today.

QUESTION: Okay. Thank you.

CDC MODERATOR: Next question.

AT&T MODERATOR: That will be from the line of Marran McKenna with Atlanta Journal. Please go ahead.

QUESTION: Hi. Thanks for doing this briefing. Two questions, and then I might have a follow-up.

Could you expand a bit more on the time line for response if there were a suspected case, not just could the vaccine be available in hours, but what--is it hours or days to set up vaccination clinics to trigger the state and local part of the plan, all of the various steps that are contained in the body of the plan.

And sort of an underlying question for that, are you working with any kind of an underlying mathematical model or assumptions as to if you had an index case or cases, how many people they would be likely to infect? I guess what I'm asking is what size you would expect any potential outbreak to be.

DR. ROTZ: This is Lisa Rotz, again. I'll answer the first question and then move on to the second question.

The first question, let me reiterate, I think was about the time line for implementing the plan and getting things in place. So let me talk about vaccination clinics, contact and identification.

Again, that's part of the reason for getting this plan out there is so state and local health officials can start thinking through these issues from their local perspective and how they would start implementing the control measures very rapidly. So, as we get this plan out there, and they start thinking through that, obviously the time line piece as they start putting this in for all risk planning efforts.

As far as the second question regarding mathematical models or about how large we would expect an outbreak to be, that's a very difficult question to answer. I think Dr. Henderson can speak to the fact that most people are, at least even before they become infectious with smallpox, when they're in that phase where they have the fever, and they're feeling very poorly, are very likely to actually stay home and not go walk around because they are feeling very poorly. And even after the onset of rash, they again feel very poorly, so that, in of itself, would decrease the numbers of people you would expect to be exposed to any case of smallpox.

As to trying to determine exactly how many people might be exposed to a case of a smallpox, to the degree where they might become infected themselves, that's very difficult to assume, but we would have to say that more than likely we would expect that number to not be a large, large number.

DR. HENDERSON: I can just add a little bit to that. We know that smallpox has a seasonal period, when it's much more easily transmitted than other times. So, as we look at the introductions that occurred into Europe, which quite a number occurred between 1950 and 1972, you find that those coming in during the period, roughly, November through April, when it's cooler and when it's drier, that the disease is much more likely to be transmitted than if it comes in during the summer months, let's say, May to November.

The difference is enormous, from looking at the data that we've seen, and like a difference of maybe five- to even eight- or tenfold difference. So it depends a lot on when an outbreak might begin, and the question of how it would continue would depend, in part, on season, it depends on how many people that an individual is in contact with. As Lisa said, there is a tendency for people to take to bed with the smallpox, and this of course diminishes the number.

There have been efforts made to model what might happen if you had smallpox in a community, but I must say the models I don't find at all helpful simply because there's so many assumptions that have to be made and so many variables that you just cannot predict about.

CDC MODERATOR: That was Dr. Henderson.

Next question.

AT&T MODERATOR: Thank you. Our next question will be from the line of Carla Gayle with Reuters Health. Please go ahead.

QUESTION: Hi. I remember a few years ago, before bioterrorism was such a reality, there was concern that we didn't have adequate communication networks in the public health system for tracing a disease outbreak such as smallpox and dealing with it. Do you believe that we have adequate networks now for that?

DR. ROTZ: This is Lisa Rotz.

Part of our overall bioterrorism preparedness efforts over the last few years have been to develop communications or connectivity between local and state health departments, as well as state health departments and CDC, for rapid communications. That's part of the Health Alert Network grants that have gone out, and I do believe we have improved our connectivity quite a bit with rapid communications and rapid certifications.

CDC MODERATOR: Thank you. Next question?

AT&T MODERATOR: Thank you. I will go to the line of Cee-Cee Connolly with the Washington Post. Please go ahead.

QUESTION: Yes. Thank you. Two questions.

The first is I'm wondering if you can give us an idea of, since September 11th, has the CDC or state health departments that you're aware of checked out any potential smallpox cases? Has that kind of investigation occurred anywhere in the country and what was the result?

And, also, I think on the response, if any of you could help us with a few more details, in terms of what exactly is that response time line. Are you talking about since you believe you have that 10- to 12-day window, are you thinking that CDC would fly into an area where there's been an exposure and take over? Are you talking about getting vaccine from the stockpile, and you know you have a plan to transport it within so many hours? Who would make the decision about diluting the existing vaccine if you think that you need to go that route? Maybe some of those specifics.

DR. ROTZ: This is Lisa Rotz.

To answer your first question regarding whether or not there have been investigations of potential smallpox cases, over the last several years, I would say a few times a year we've gotten calls from clinicians who feel that they have a case or a rash that they're not sure if this should be in the differential, and we have worked with those clinicians to identify the clinical aspects and to even potentially test samples to rule those out as smallpox. To date, we have not identified any cases of smallpox.

As far as your second question regarding the time lines for implementation of the plan, obviously, certain parts of the plan would take longer to implement. As I said, part of our reasoning for getting this out there is so people can start, people that plan these things at the local level, can start thinking through some of the issues about personnel issues or setting up clinics and rapidly doing things.

One of the things that we have tried to do to make sure that we have increased rapid response capabilities here at CDC is to identify personnel that would go immediately to an area with a suspected outbreak that could help local officials start implementing these things that need to take place rather rapidly, including identifying people that need to be vaccinated and setting up a method for doing that, identifying contacts to cases and confirming cases and such and improving or enhancing surveillance in the area to find any additional cases.

We've worked to identify personnel here that would be rapidly available to go and assist state and local officials in doing that, as well as worked on training those personnel so that they can implement this plan rather rapidly.

DR. HENDERSON: I think there was one other question, and that was the dilution of vaccine.

QUESTION: Right.

DR. HENDERSON: And we're getting now some early reports in from the dilution studies, and it's very early, of course, but I know from one site they've done 77, which would presumably be three different groups included in the 77, but every one of them had a take. So it looks very encouraging not only for one to five, but with a little bit of a perhaps a cushion for even one to ten. But I think if a problem occurred today and we needed the vaccine, we'd be ready to go in one to five immediately.

QUESTION: I guess what I'm also getting at is the notion of who would be in charge in the event of a smallpox outbreak. Would CDC be making these decisions about flying people in, making decisions about who to vaccinate, making decisions about dilution? Who makes those calls?

CDC MODERATOR: Dr. Margolis?

DR. MARGOLIS: CDC has developed a number of response teams, and CDC, in collaboration with the state or local health department, would do this.

But confirmation of a case would occur here at CDC, in terms of diagnostics, and that would activate a response team going to that state and working with that state health department to put the plan in place.

The other thing which may be important in terms of the vaccine issue is that the vaccine works after exposure, and Dr. Henderson may want to comment on this. Around four days after exposure, there is still very good protection from vaccination.

DR. HENDERSON: No, I don't think I have anything to add. I think this is quite right.

CDC MODERATOR: Next question.

AT&T MODERATOR: Thank you. The next question is from the line of Ellen Beck with United Press International. Please go ahead.

QUESTION: Yes, thank you. Two questions, if I could. Have you done any studies, since 9/11, any sort of reconfirmation or validation on the status of the vaccine as far as any possible bacterial contamination over the years? And in terms of getting the vaccine to various state or locations, how would that go? Would it be special flights? How would you actually get the vaccine to where it needs to go?

DR. ROTZ: Yes, this is Lisa Rotz. In regards to your first question, we have actually been utilizing this vaccine for vaccination of laboratorians over the past 20 years. Each time the vaccine is released, it is tested. It goes through a battery of tests from the manufacturers that looks at bacterial contamination, the potency of the vaccine, and even recently all lots of the vaccine has tested and has tested as being very potent, which is it's been maintained over the last 20 years. It's a very stable, very potent vaccine.

And I'm sorry, I missed--

QUESTION: In terms of getting the vaccine to where it needs to go, should a case by diagnosed by CDC, how would that be transported? Who would be responsible for that transportation?

DR. ROTZ: That would be--vaccine would be transported either with [inaudible] from CDC that go to a site or also through the mechanisms that have been put in place through the National Pharmaceutical Stockpile.

QUESTION: Thank you.

CDC MODERATOR: Next question.

AT&T MODERATOR: Our next question is a follow-up question from the line of Sarah Look with The Wall Street Journal. Please go ahead.

QUESTION: Yeah, hi, thank you. I was just wondering if there's a contingency plan in this plan for the event that there's not enough vaccine. What can you do in the event that you don't have enough besides the dilution? Can anything be done otherwise?

DR. ROTZ: There are discussions within the plan that talk about the potential need for dilution of vaccine. However, again, the decision to dilute vaccine will have to be made after evaluation of what's occurring with the outbreak, and I think the final decision on diluting the vaccine and how it would be utilized would be sort of a decision between state, local and Federal health officials after determining what's occurring with the outbreak. But we do talk about the potential need for dilution of vaccine in there, and how that would be, and how the decision to utilize that would be made.

QUESTION: But that plan hinges on having the vaccine. There isn't another thing that can be done besides vaccination to contain an outbreak.

DR. ROTZ: Well, there are other outbreak control measures which are a part of the overall outbreak control, and that would be also including identifying persons that were, you know, transmitting smallpox and isolating those so that they can't continue to transmit that, and that's a very important part of the overall public health strategies for containing an outbreak, not just with vaccine but also in identifying people and making sure they don't continue to transmit disease.

CDC MODERATOR: Next question.

AT&T MODERATOR: Thank you. Next question is from the line of Richard Knox with NPR. Please go ahead.

QUESTION: Hi. Thanks for speaking today. Two things. One is, does the plan have a strategy for deploying the vaccine both to public health workers, first responders, medical providers now, secondly when the dilutional studies are in and, third, when the new stockpile of vaccine is available? And then I'll have a second question.

DR. ROTZ: Hold on a second. Sorry. I'm sorry about that. We were repeating the question.

DR. MARGOLIS: This is Dr. Margolis. The--at this point there is not a plan to vaccinate what you might call, as you termed it, first responders. Again, the point is that this vaccine works once exposed, so those people who would go out and respond to a confirmed case would in fact be vaccinated essentially as they're going out the door, and at that point they are protected.

QUESTION: And that would not change as more vaccine became available?

DR. MARGOLIS: Again, in terms of the current strategy, that is not part of the strategy.

QUESTION: Even though you have vaccinated the CDC workers so that--in advance?

DR. MARGOLIS: There have been--again, the initial response team, who would be those individuals who have to make the diagnosis and confirm that diagnosis, and I think that's important, the important term, is that there are many cases of varicella or chickenpox that are, you know, what trigger people going out to look, and it's those--that individual or those individuals who would confirm the diagnosis who are being vaccinated.

QUESTION: Secondly, does the plan say anything about the deployment of the vaccine immune globulin in case people have reactions to the vaccine?

DR. ROTZ: Yes, the plan addresses--this is Lisa Rotz again. The plan addresses vaccine adverse events that would require or that are--would need VIG treatment and how VIG can be accessed through that, for treatment of those adverse events.

It also addresses the fact that vaccine immune globulin is currently in very short supply and that it should be utilized for the serious adverse vaccine reactions, and there are many adverse vaccine reactions that don't require VIG treatments.

QUESTION: Again, can you just give a little sense of how the plan would deploy VIG? I mean, how much is available now, and how you would use it under the plan?

DR. ROTZ: Vaccine immune globulin would be deployed through the plan the way it is deployed now, and that's the supplies that CDC holds, they would deploy vaccine immune globulin for treatment. After consultation of whether or not a case required treatment with VIG, it would be deployed rapidly for treatment, if needed, in that area.

Currently between the DOD supplies, or the Department of Defense supplies and the CDC supplies that we have, I think there are enough to treat about 600 adverse events.

QUESTION: Do you expect that will grow?

DR. ROTZ: The adverse events, or the--

QUESTION: No, I mean are there plans under way to increase that supply.

DR. ROTZ: Yes. We are currently evaluating ways to increase our supply of VIG as well as exploring other options for treatment of adverse events.

CDC MODERATOR: Next question.

AT&T MODERATOR: Thank you, Mr. Knox. Our next question is from the line of Ted Vigodsky with Public Broadcasting. Please go ahead.

QUESTION: Yes. I believe there might be an NIP person there, but anybody can answer that. What increase with vaccine-associated mortality or morbidity would be associated with having to vaccinate very young children if that became necessary?

DR. HENDERSON: Well, let me try that one. This is Dr. Henderson. During the global program--in fact, prior to the global program, there was quite an extensive study done in Hong Kong vaccinating children at birth. And, indeed, during--and it was very successful or fewer complications than when you were vaccinating children at one year of age, in fact. And so throughout the global program, vaccination was done from birth. So I don't see that there would be a serious problem here.

QUESTION: Thank you.

AT&T MODERATOR: We do thank you for your question. Next, we'll go to the line of Laura Mechler [ph] with Associated Press. Please go ahead.

QUESTION: Thank you. Two questions. One, in terms of the time line, I'm a little unclear on exactly how this would work in sort of a practical way. Let's say it was Sunday when a sample was sent to CDC for evaluation. On Monday it was confirmed as smallpox. How many people would likely be vaccinated let's say by the end of the day Monday, by Tuesday/Wednesday, maybe by the end of the week? Could you just kind of give me a sense of--I know it goes in outer rings, but if it was in a major city, would everybody in that city be hopefully vaccinated by, you know, within four days? I mean, what are we talking about?

Did that make sense?

CDC MODERATOR: Yes. This is Dr. Margolis.

DR. MARGOLIS: Again, the strategy is contact tracing. So it's finding out how many contacts that, again, we'll start with a case, that case had during the period of time when they were transmitting infection, and we'd begin to vaccinate those people immediately. And, again, depending on when this person was found within their illness, one might actually then start on the second ring. But, in reality, there would never be vaccination of a whole city, unless it was a very small community, for one case. It would be those contacts of that case.

QUESTION: Well, let's say the person said, I went to a baseball game yesterday.

DR. MARGOLIS: Remember that transmission occurs when the person is within what's used is about a 6-foot--

QUESTION: Well, let's say they were sick, and they went anyway.

DR. MARGOLIS: Well, again, a person going to a baseball game only comes in contact with an area where they might be. They don't come in contact with the whole ballpark.]

QUESTION: So do you put out a public notice, anybody who was in Section 523 of the, you know, game on Sunday should come to this place to be vaccinated? I mean, is it a combination of you finding the people and also just putting out a notice for people who were in X, Y, or Z place?

DR. MARGOLIS: Well, those are the decisions that are going to be in conjunction with the local health department, in terms of figuring out how to do this. Because, again, no one has had experience with, you know, a person with smallpox in a baseball park. But I think one can figure out who is in what area in even these very public places.

DR. ROTZ: This is Lisa Rotz.

I think Dr. Henderson can attest to the fact that actually vaccinating somebody doesn't take a long time, that it can actually be done very quickly. And part of the efforts for getting the response plan and guidelines into the hands of folks in the states and local jurisdictions is so that they can start thinking about how they would rapidly set up vaccination clinics so that they could move a large number of people through the vaccination if required.

QUESTION: But let's say it was a situation where there was a suspicion of bioterrorism, and so therefore it's not unreasonable that there might be other cases that haven't surfaced yet in the same area; would you then go more broadly than just the person who are in contact with that one person?

DR. HENDERSON: Let me come in again, because we've dealt with problems like this certainly throughout the time of the global program and all of the situations are a bit different.

The main thing you want to do is try to get as much vaccine used in the place where it's going to do the most good; that is, around the contact of a case and around the families of those contacts so, if they do come down with a disease, there's a barrier around them.

If you do have a situation where somebody, let's say, has been on a train and gone from here to there and has been sick all the way, what are you going to do? Well, you try to get the people on the train vaccinated, to the extent you can. You put out calls, you do a number of things. You may be vaccinating people coming and going on a particular train for a few days, just to make sure that you, to the extent you can, get the frequent travelers on that train. There are a number of things you might do. You just have to use your head on that.

If you get a situation where let's say there are so many cases in a city that you can't do the contact tracing in the same way or as effectively or it's broader than that, you might very well open up the, to vaccinate the entire area, but you'd still try to keep putting more vaccine in the places where it's going to do the most good and perhaps opening it up with multiple sites, where people could come to be vaccinated.

I think one of the things that I think people think about is should we compel everybody to be vaccinated, and I think our experience, wherever we worked, was that this really did not work well at all; that, once you began compelling people and people began to try to escape from being vaccinated, you lost the confidence of the people, and it became a really, often, a very difficult situation. So I think that you're trying to persuade the population, trying to corral people in an appropriate way. Without trying to do this by force, you get ahead a lot further.

QUESTION: Last question. You said that the decisions about, all of these decisions, would be made by the CDC in conjunction with state and local authorities. What if there was a disagreement about how to proceed? Who would be the final decision maker?

CDC MODERATOR: Dr. Rotz, do you want to or Dr. Margolis?

DR. MARGOLIS: Well, again, I think in terms of, until the situation occurs, but I would think one plan puts us in that context. Part of also having the plan out there, what CDC is going to do, which is joint training with state and local health departments. So I think we will have thought out many of these scenarios. Quite honestly, there might be small-level disagreements, but in terms of how to go forward, in terms of contact tracing, getting the vaccine where it needs to be, it's pretty unlikely that there are going to be those kinds of disagreements.

QUESTION: But, I mean, have you thought through the question of what would happen if there was, for instance, a disagreement about how broadly the vaccinations needed to be issued or something like that? I mean, in a crisis moment would probably not be the best time to be deciding who was in charge.

DR. ROTZ: This is Lisa Rotz.

In the case if there were a very large disagreement with the state, and local, and federal health officials, I think the overall evaluation of the best use of vaccine will have to come over and above. I think, in general, we'll have to come to some sort of agreement what the overall best use of vaccine would be in that case because we may not just be looking at an outbreak in one area. We may have to be considerate of an outbreak in multiple areas and have to evaluate the overall best use of vaccine in that scenario.

CDC MODERATOR: We have time for one more question.

AT&T MODERATOR: Thank you. That is going to be a follow-up from the line of Odessa Middleston with Dow Jones. Please go ahead.

QUESTION: Thanks. I just wanted to know how long has CDC been updating this plan and how does this response differ because it would be a bioterrorism response and not be the same as the original global eradication plan.

And then, as a follow-up, can you tell me when the plan was actually sent to the states?

DR. ROTZ: This is Lisa Rotz.


We've been working internally, as well as with external partners, to update the plan over the several years, when we began preparing for the potential for bioterrorism, when smallpox was identified as a potential bioterrorism agent. The plan was originally developed in 1972 to help public health officials respond to potential importations of smallpox at that time.

Again, as Dr. Margolis pointed out earlier, this plan utilizes outbreak control strategies that were very successful not just in dealing with outbreaks of smallpox during the eradication period, but in combination with overall strategy activities helped to eradicate smallpox. I'm sure that Dr. Henderson can address that too.

So these outbreak strategies that are contained within the plan were developed as a part of the overall eradication program and were also identified as measures that would be taken with an importation of smallpox potentially into a susceptible society, which is why the plan was developed originally in 1972.

The plan was sent to selected state officials that helped with the review several weeks ago, but the overall distribution to all state officials occurred on Friday.

QUESTION: Okay. I just want to clarify that. You said Friday it was sent to all states.

DR. ROTZ: Yes.

QUESTION: Okay. I just wanted to follow up just a little bit on that. You said that the original plan was developed in '72, but that was for the naturally occurring disease, and as a bioterrorism possibility, what needed to be different? What are our concerns that are different because it's not naturally occurring?

DR. ROTZ: I think some of the things that are different in the current plan, as opposed to the 1972 plan, is there is a much larger educational component because you have public health officials and medical officials who have not necessarily had to deal with this disease or even been trained in this disease. So it contains a much larger educational component in the current plan, as opposed to the '72 plan.

We have a much larger communications component that talks about communications issues in association because you are looking at a potential outbreak due to bioterrorism. So there are other communication concerns that have to be taken into consideration.

We also tried to provide more direct information regarding the outbreak strategies that are needed again because this is a disease that public health officials have not had to deal with for 20-plus years.

So those things are sort of beefed up in the current plan when we talk about the strategies. We also have to take into consideration that there could be a large amount of panic, which is part of what the communications plan helps us to deal with.

DR. HENDERSON: But I think fundamentally you are dealing with an outbreak of disease. And so, in a way, it's really not a major departure from if it had occurred as a result of an importation, except that in a bioterrorist event, it might be much larger in terms of numbers initially that would cause us to move more quickly into trying to set up special quarters for isolation of patients to make sure that we have enough in the way of space.

Whereas, before, with importations, you're looking at a much smaller set of outbreaks, which would be likely, based on our experience with outbreaks that occurred in the '40s, '50s, '60s, that the outbreaks generally did not tend to be terribly large before they were picked up and begun to be controlled.

QUESTION: One last question. Does the plan include any way to trace who is responsible for the outbreak?

DR. ROTZ: This is Lisa Rotz, again.

Tracing who is responsible would be the function of the law-enforcement officials, the federal, and local and state law-enforcement officials. In general, the methods that they would utilize to do that is not something that could be addressed in a public health plan of action, which is what this is.

CDC MODERATOR: That concludes our telebriefing for today. Thank you very much, everyone, for joining us.

AT&T MODERATOR: Ladies and gentlemen, that does conclude our conference for today. We do thank you very much for your participation and for using AT&T Executive Teleconference. You may now disconnect.

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