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CDC Telebriefing 

November 29, 2001

CDC MODERATOR: Thank you, everyone, for joining us today. We have received a lot of very positive feedback from journalists about these telebriefings and have decided to try to do one at least every Thursday on the MMWR as well as others on an as-needed basis. And we're going to expand them to not just anthrax articles but selected articles in the MMWR for that week. And today we're going to do an experiment and address three different articles and divide the telebriefing up into three sections and see how it works, and we look forward to your feedback on it, and we'll be evaluating it.

From noon to 12:15, we will be discussing the article "Investigation of Bioterrorism-Related Inhalational Anthrax, Connecticut, 2001," and our speakers are Dr. Stephen Ostroff and Dr. David Swerdlow. From 12:15 to 12:30, we'll address the article "Adverse Events Associated with Anthrax Prophylaxis among Postal Employees in New Jersey, New York, and D.C., 2001," and our speaker is Dr. Nancy Rosenstein. Then from 12:30 to 12:45, we'll address "Alcohol Involvement in Fatal Motor Vehicle Crashes in the U.S. 1999 to 2000," with Dr. Ruth Shults.

We will start off with the first article, and Dr. Stephen Ostroff is going to give some brief remarks.

DR. OSTROFF: My remarks will actually be quite brief, and that is that essentially the article is meant more as a summary of the investigation to date. It does not, at least to my knowledge, contain any new information, but probably provides information that's somewhat more detailed than has been--previously been provided.

This remains a very active investigation, and that active investigation is being done in a highly collaborative fashion between CDC and our colleagues in the State of Connecticut. And we continue to explore all possible explanations for the illness in this woman. And I'll leave it with that statement.

MS. SWENARSKI: Okay. We can take the first question now on that subject.

AT&T MODERATOR: And, ladies and gentlemen, once again if you have a question at this time, please press the 1. Our first question is from Laura Meckler with the Associated Press. Please go ahead.

QUESTION: Hi. I guess--and you may not have anything to add to this, but looking at both the Connecticut case and the New York case that also remains a mystery, what makes you think at this point that you're going to come up with some information that would break--break through? I mean, it seems like you've done all the things that have in the past helped you to trace the source of the anthrax. What is there left to do that could be useful?

DR. OSTROFF: Well, in all sites, we continue to investigate, and, you know, clearly there are limits to what can be done on the public health and epidemiologic side. There is also a very active investigation going on in the law enforcement side, which I am not able to comment on.

However, I think all of us acknowledge that things won't come to a close until those who, you know, have been identified who are responsible for this episode from the very beginning.

Having said that, we continue to pursue many different avenues in Connecticut, including environmental sampling, including interviews, and many other avenues. And so, you know, I think it's quite premature to suggest that the trail here is growing cold.

CDC MODERATOR: Dr. Swerdlow wants to add something.

DR. SWERDLOW: In addition, we are working very closely with the New York investigators to be sure that we are looking into any possible--any possible source of contamination that could have been the same between the two investigations. So we're working very closely with the New York team to see if there are any clues that would be the same for both cases.

CDC MODERATOR: Next question, please?

AT&T MODERATOR: And that's from Henry Neiman with Netco(?). Please go ahead.

QUESTION: I was following up on chronic conditions that we asked last week. I noticed in the MMWR that Ms. Lundgren had COPD. Was she getting any inhalants, and has any possible medical supplies that would be associated with that condition be investigated for contamination?

DR. OSTROFF: Well, I think the specific details of that nature would need to come from our colleagues in Connecticut. I would choose not to comment on them. However, I would point out that COPD, chronic obstructive pulmonary disease, is certainly not an uncommon condition, number one; and, number two, particularly in senior citizens.

CDC MODERATOR: Next question?

AT&T MODERATOR: And that's from Rick Weiss, Washington Post. Please go ahead.

QUESTION: Thanks. Given all the negative results on environmental swabs so far in the Connecticut case, it seems that probably relatively few spores were involved in the end in her infection. And I'm wondering if you could speak to the issue of, getting away from the LD-50 figures and getting down to the, you know, LD-2's and 5's, has anyone really calculated out the curves and figured out how few spores it might take to infect, you know, one out of a hundred people or five out of a hundred people?

DR. OSTROFF: Rick, this is Steve Ostroff. Thanks for that question. I think that I'm not ready to conclude to the degree that you may have stated that we would say that there are very few spores involved. We, as I'm sure every--the public is--are frustrated that we haven't been able to detect any positive samples from the large numbers of environmental samples that have been taken. That is similar to what happened with the Asian woman in New York, and I think all of us are working to try to figure out what it is that that's telling us.

However, I would suggest that there are other possible explanations, one of the obvious ones being we simply didn't sample the right place. And I think that we have to keep that as an alternative explanation or that these exposures could have occurred in a way or in a place where the spores may have really widely dispersed.

Having said that, it is very clear, and I think it's clear from historical data, that you're talking about a curve that is not uniform, and, you know, that when we use statements like 8,000 to 10,000, or whatever, that that's an average. And, clearly, there will be some cases with fewer than that, and, clearly, there will be some cases where it takes a larger exposure. And that needs to be recognized.

CDC MODERATOR: One more thing from Dr. Swerdlow.

DR. SWERDLOW: I just wanted to say that we are continuing the environmental investigation, and while we have done many environmental tests, we are certainly not finished. And there are several tests that are pending, and we continue to look into any possible place where this woman had been in the 60 days before she became ill.

CDC MODERATOR: Next question.

AT&T MODERATOR: Thank you. It's from Bill Hathaway with the Hartford Courant. Please go ahead.

QUESTION: Yeah, hi. I have a couple quick questions. One, I was interested in why you changed teams here in Connecticut. And, number two, I was wondering if you could give me any estimate about how many domestic labs may have anthrax and whether or not the CDC recommends disposing of samples they're not using for research.

DR. : The first question, I'm not sure which teams are alternating. We sent up an initial team, and then we supplemented that with an additional large group of epidemiologists and environmental testing folks, as well as laboratorians. And there may be some people coming and going because of, you know, family issues, et cetera, but basically we've had one team the entire time.

DR. : The second part of your question about how many facilities may possess anthrax, as I'm sure you're aware, CDC has responsibility for overseeing the transfer of select agents of which anthrax is one. And so we are aware of the number of facilities which have been registered under the select agent program.

We do not regulate all facilities that possess anthrax, although, as I'm sure you're aware, there are many bills currently going through Congress which would expand the select agent rule. So I can't give you some definitive number.

In regard to your other question about whether or not CDC has made a recommendation that facilities should destroy their stocks of anthrax, to my knowledge the agency has not made such a recommendation, and I'm not sure where that information is coming from.

We have definitely stated that if there are facilities that possess this agent, that they ought to be handling it in accordance with what we refer to as the BMBL, the Biosafety Manual for Biological Laboratories, which is the joint publication by the Centers for Disease Control and Prevention and the National Institutes of Health.

CDC MODERATOR: Next question.

AT&T MODERATOR: Thank you. It's from Debra McKenzie with the New Scientist. Please go ahead.

QUESTION: Hi. Thanks very much. I'd like to know if you've been looking for signs of any immune reaction to Bacillus anthracis in the populations who potentially were exposed and are presumably now on antibiotics, such as postal employees, post-contacts with Mrs. Lundgren. It would be interesting to know, I would think, how many people were showing either (?) or cell-mediated immunity to the Bacillus. Do you have an idea of how many people might have been exposed, how many might have had a sub-clinical infection, or got the antibiotic in time?

DR. : Well, that's a little bit outside the scope of this particular MMWR. You may recall very early on in the investigations, particularly in Florida, that there was some information that came out very early about four, I think, or five other workers at the first targeted location that had low-level reactivity against Bacillus anthracis. So, clearly, there were sero surveys done within that facility. Part of the reason to do them is for epidemiologic reasons. Potentially part of it would also be for forensic reasons, and so I agree with you that, you know, there may be some useful information in doing that, but I don't want to go into any more specifics.

CDC MODERATOR: Okay. I think we have time for one more question on the Connecticut article.

AT&T MODERATOR: And that will be from Greg Smith of the New York Daily News. Please go ahead.

QUESTION: Thanks. It's a two-parter, but it's related to the New York case and the comparisons with the Connecticut case. The first part of it is, I think it's Dr. Ostroff who said that you're looking at the possibility that the exposure occurred in a way or a place where the spores were really widely dispersed. I think what you're saying essentially is that the exposure occurred outside. If you could address that concept.

And then number two, could you get into more specific detail about any kind of parallels between the New York case and the Connecticut case?

DR. OSTROFF: Sure. What I would say is that we remain open to any possible explanation for the cause of these illnesses, and clearly an outdoor exposure would be among the many hypotheses that one could think about.

As far as the second part of your question about whether there are any obvious epidemiologic parallels between the woman in New York City and the most recent case in Connecticut, clearly there are some. These were both women who lived alone. That's one obvious parallel. And they spent a large amount of their time by themselves. One of them was in her 60s. The other one was in her 90s. They clearly lived not that far away from each other. However, they clearly lived in very different worlds. And as was mentioned by Dr. Swerdlow, the investigators in New York and the investigators in Connecticut are in very close contact, and are certainly comparing notes.

CDC MODERATOR: Dr. Swerdlow?

DR. SWERDLOW: Just want to add one thing about we certainly have considered the possibility of an outdoor exposure, and that is one of the reasons we are really retracing our steps for the 60 days before she became ill and trying to find out every single thing she did on every single day.

And we have also set up surveillance, looking for cases of human disease through laboratories and doctors and emergency rooms and radiologists, looking for any additional cases that could have--that might have happened if there was indeed an outdoor exposure.

In addition, we're even looking among veterinarians and animal control teams in the area to see if there are any dead animals, because for an outdoor exposure, you might actually expect that there be dead animals.

So we've set up that kind of surveillance. We haven't identified any possible cases.

And finally, we have done some--some of the sampling, environmental sampling has been outdoors, including around her house and several other locations, and so far those samples have all been negative.

DR. OSTROFF: Right. But I think the--you know, the story shouldn't be "CDC thinks that this is from an outdoor exposure." I think basically what I'm trying to say to you is that we remain open to all possible hypotheses. We have no evidence that tells us that one hypothesis is any more likely than any other hypothesis right now. And so I would put it within that context rather than us suggesting that that's what happened.

CDC MODERATOR: Thank you. We're going to move on the second article now, "Adverse Event Associated with Anthrax Prophylaxis Among Postal Employees." And Dr. Nancy Rosenstein is going to give some brief remarks.

DR. ROSENSTEIN: Thank you. It can be hard for people to take a full 60 days of antibiotics, but it's very important that people who were exposed to anthrax related to these bioterrorist attacks complete the full 60 days. We found that the side effects associated with these antibiotics were similar to previous reports and were mostly mild.

And CDC and state and local health departments continue to work to help people who are having difficulty taking their antibiotics.

CDC MODERATOR: Thank you. First question.

AT&T MODERATOR: And once again, ladies and gentlemen, if you have a question on this topic, please press the 1. And we have a question from Seth Borenstein with Knight Ridder. Please go ahead.

QUESTION: Thank you. And not to rain on your parade, but if Dr. Ostroff is still there, 15 minutes really isn't enough, so this is going to be more for Dr. Ostroff and Swerdlow. But sort of crosses all lines.

In terms of the purity, we keep hearing about the purity of the anthrax that was found. I know you don't regulate how much--regulate the labs, but you do regulate the transfer. How unusual is this purity in what you see in transfers and how much technology and know-how do you have to have in terms of this type of purity?

DR. OSTROFF: Well, what we regulate is the transfer of the bug itself. Most of the time what researchers are doing is moving, you know, a small amount of the bug from one laboratory to another, and so that says nothing about the purity of the material or anything like that. We don't do that type of work within our laboratories, and so I don't think that I'm in a position to really be able to comment about it.

CDC MODERATOR: And keep in mind that if you have additional questions about the Connecticut investigation, feel free to call the press office today at 404-639-3286.

Next question.

AT&T MODERATOR: And that's from Kim Dixon with Bloomberg News. Please go ahead.

QUESTION: Thanks. I have a couple--triple questions. First is on adverse events. Is the 19 percent--it seems a little bit high when I look at the PDR and look at Cipro, that seems a little bit high, the 19 percent for severe nausea, vomiting, diarrhea and abdominal pain. Is that because many of these people probably haven't take it before? That's my first question.

The second question is any sort of update on the University of Connecticut samples of the suspicious--looking into suspicious deaths in Connecticut?

And the third question is if you can confirm that you're not--you don't definitely think that the Chile anthrax is a case of lab contamination, that that's still an open question as well?

DR. ROSENSTEIN: Well, about the 19 percent. One thing to keep in mind is that the way that this surveillance is conducted, it's really twofold. We do have continuous surveillance to detect severe adverse events, but what we're reporting in this MMWR is a cross-sectional survey that was administered and that the individuals themselves reported how much nausea that they were having. And so while that number may be slightly higher than what's in the PDR, it still is within the realm of the same as other reports.

CDC MODERATOR: The second question on Connecticut. Dr. Swerdlow?

DR. SWERDLOW: We would defer to the Connecticut Department of Public Health for that answer. Local law enforcement, Connecticut Department of Public Health is looking into that possibility and to find out what was happening at the university.

DR. OSTROFF: Right. And as far as your question about the Chilean situation, we're working very closely with our counterparts in Chile to examine those circumstances. The one thing that I can say is that we know that it's not linked to what's going on here in the United States, and we're working with them to explain what happened there. Certainly what you mentioned, which is contamination within the laboratory, is one potential explanation.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Thank you. That's from Jill Carroll, Wall Street Journal. Please go ahead. 

QUESTION: I was wondering, on the anthrax quickie test a while back that the CDC mentioned that they didn't want people to use them any more. I wonder if you could be specific about which--is it all quick anthrax tests should not be used until they can be validated? Which ones I guess?

CDC MODERATOR: I don't have someone here to answer that question for you. If you want to call the press office later.

DR. OSTROFF: Yeah, I'm certainly not the right one to be talking about laboratory tests.

CDC MODERATOR: Okay. Next question on the prophylaxis.

AT&T MODERATOR: And that's from Aaron McClain with the Associated Press. Please go ahead.

QUESTION: Yes, hi. The MMWR says there are essentially two groups of New York postal workers who were offered antibiotics: the ones who were at increased risk and the 2,600 who were at lower risk for anthrax. It also says that 1,786 in this survey are actually taking the drug. Do we know whether those come mostly from the group at increased risk or lower risk?

DR. : I don't specifically have that information. What I can say to you is that there were groups of individuals in New York in which we recommended--we, being CDC as well as the U.S. Postal Service, recommended should be on antibiotic hemo-prophylaxis. However, we had a very permissive policy for other workers that were within that facility that might have concerns about their potential for having been exposed to anthrax, and we made the drug very readily available to those individuals. Some chose to take it. Some did not.

Probably I would turn to Dr. Rosenstein to comment on how many fit into each group.

DR. ROSENSTEIN: We're still working to compile the numbers that would give the exact percent that fit into each group. In addition to that, what we're doing is we're actually sending a team back up to New York this weekend or early next week to help work with the post office to promote adherence to the antibiotics among the group at highest risk and also to answer whatever questions anybody else has about what their risk is and whether they should be taking antibiotics or not.

CDC MODERATOR: Next question.

AT&T MODERATOR: Thank you. That's from Dan Davidson with the Federal Times Newspaper. Please go ahead.

QUESTION: Yes, one of the presidents of one of the postal workers union has expressed concern about the long-term effects of Cipro, what might happen to these people who are taking it five or ten years. Is there reason for this kind of concern?

DR. ROSENSTEIN: I think you're talking about not taking it five years, but five years from now if there's any concern about long-term side effects, and what I can say is that there is no data that suggests any long-term side effects five to ten years out.

Also, the majority of people--and this is especially true for the postal workers--actually only received a short course of ciprofloxacin. By 10 days or 14 days after the onset of therapy, most people had been switched over to doxycycline, which is an equally effective antibiotic. And there is a lot of data suggesting people who have been treated with antibiotics--I'm sorry. There's lots of data that people who are treated with 10 to 14 days of ciprofloxacin don't have any long-term side effects.

CDC MODERATOR: Thank you. Next question?

AT&T MODERATOR: And that's from Emma Hitt (ph) with Reuters Health. Please go ahead.

QUESTION: Yes, hi. Let's see. I wanted to know if somebody has an adverse event reaction to ciproflox--Cipro, are they counseled about continuing to take it, or are they given doxycycline? And how are they dealt with? And, also, are the same people that are allergic or have adverse events to Cipro, are they the same people that are likely to respond poorly to doxy?

DR. ROSENSTEIN: Let me take the first question first. People who have had adverse events--people who have adverse reactions to their antibiotics and are at risk for anthrax, they are both switched to another antibiotic, if that's appropriate, and also counseled about taking antibiotics. 

In many cases, the side effects associated with an antibiotic can be managed, and the individual actually doesn't have to be switched in terms of their antibiotic. And in terms of whether the individuals who are having side effects to Cipro are more likely to have side effects to amoxicillin, in general we haven't found any specific characteristics that allow us to predict who's going to have side effects associated with the medication.

It's still a little too early in the course to tell you yet specifically if people had the same reactions to both antibiotics. The data that we're reporting is really only ten days after people started their antibiotics. We're going to continue to monitor people for side effects throughout the course of their antibiotics, and there will be more data on that in the next couple months.

CDC MODERATOR: Next question?

AT&T MODERATOR: And that's from Karen Kirn (ph) with News Max. Please go ahead.

QUESTION: Thank you. First question would be: How are you deciding when to switch people from Cipro to doxycycline? And the second question is: Are you looking to see if the 60-day regimen will be adequate or might you consider extending it?

DR. ROSENSTEIN: Let me answer the first one first. Initially, people were provided with ciprofloxacin through the stockpile. In many cases, the change of ciprofloxacin--the change from Cipro to doxycycline was not made on the basis of adverse events, but merely made as we discovered that the antibiotics were similarly effective. And so when moved over to doxycycline, that was not primarily, again, made on the basis of adverse effects.

In general, however, though, when a person has an adverse effect associated with their antibiotic, what we recommend is that they talk to their physician or their health care provider or the health department to get counseling. And it's really a clinical decision, a one-on-one decision as to whether those antibiotic side effects are severe enough that a person's antibiotics need to be changed.

As I'm sure you've heard before, the Bacillus anthracis spores can stay in the body for several weeks before they start growing and causing illness, and they can develop into this very serious form of anthrax, inhalational anthrax, for up--for any point--at any point up to 45 days after the exposure. And it's for that reason that we're recommending taking the antibiotics for a full 60 days, which is 15 days after that. Right now our recommendations are for 60 days. Of course, we're going to continue to monitor people to make sure that there are no cases of anthrax either among the people who are taking antibiotics or among individuals who have elected not to take antibiotics.

CDC MODERATOR: We have time for one more question on the prophylaxis article.

AT&T MODERATOR: And that will be from Sara Leek (ph) of the Wall Street Journal. Please go ahead.

QUESTION: Yeah, hi. I was, first of all, wondering if the numbers in the table in this article reflected the number of people who are on Cipro versus doxy any longer. And the other question I had is whether anyone--any non-postal workers are being monitored or interviewed on their antibiotic intake.

DR. ROSENSTEIN: The MMWR reports some very early data, and so at the time of this survey, you'll see that the number of people on prophylaxis, there were about 3,400 in ciprofloxacin and about 200 on doxycycline. But, again, this was done at about seven to ten days after antibiotics were initiated in these individuals, and in many cases people at seven to ten days were changed over to doxycycline. I don't have the exact numbers in front of me, but, yes, you are correct. Currently, there are many more people on doxycycline and many fewer people on ciprofloxacin.

In answer to your second question, we're reporting in this MMWR about the monitoring for adverse events among postal workers, but similar activities are taking place among any individuals for whom we've recommended 60 days of antibiotics.

CDC MODERATOR: Okay. I'm going to move on to the next article, "Alcohol Involvement in Fatal Motor Vehicle Crashes," and we have Dr. Ruth Shults to give some brief opening remarks.

DR. SHULTS: Thank you. This is Dr. Ruth Shults. The last name is spelled S-h-u-l-t-s.

I know that our nation has been focusing on the tragic events of September and anthrax, but as that goes on, CDC has continued to work on other important public health problems. And with the holiday approaching, one of those that concerns us is drinking and driving.

Today's MMWR releases the number of alcohol-related traffic fatalities in the year 2000, and those numbers indicate that drinking and driving continues to be a serious public health problem for our nation.

Last year, about 16,500 people were killed in alcohol-related crashes, and the burden to the families and friends of these individuals who lose their lives is tremendous. And all of those deaths are preventable.

As we approach the holidays, we'd like to remind everyone that December has been designated National Drunk and Drugged Driving Prevention, or 3D Month, and CDC, along with the National Highway Traffic Safety Administration and our other partners, want Americans to have a safe holiday.

We'd like to remind each and every driver that choosing to--not to drink and drive is a personal responsibility for each of us.

I'd be glad to take any questions.

AT&T MODERATOR: And, ladies and gentlemen, if you have a question on this topic, please press the 1 at this time.

CDC MODERATOR: First question?

AT&T MODERATOR: And no questions in queue.

CDC MODERATOR: Okay. Is there anything else you would like to add, Dr. Shults?

DR. SHULTS: Looking at the number of alcohol-related traffic fatalities from 1999 to the year 2000, we saw a 4-percent increase. There's no easy way to answer why alcohol-related fatalities increased from 1999 to 2000, but if we look back over the past two decades, it's clear that as a country we've made steady progress in reducing alcohol-related traffic fatalities, that is, until the last few years. And these numbers from the year 2000 emphasize that we're going to have to step up our drinking and driving prevention and enforcement nationwide.

CDC MODERATOR: Okay. Any questions in the queue at this point?

AT&T MODERATOR: We do have a question from Seth Bornstein with Knight Ridder. Please go ahead.

QUESTION: Forgive me, but 4 percent in one year does not seem like a statistically--you know, I haven't obviously done the math. Is it--have you looked to see if that is a statistically significant number, or are we looking at just, you know, the random up-and-down variations? If I recall, reading the article, wasn't there a decline beforehand? So is this a burp or is this a change in trends or what?

DR. SHULTS: It's not easy--it's not easy to say. It's likely that it is just fluctuation. These are--these are just raw numbers, and they do fluctuate.

We like to look at longer trends, and as I said, if we look back over the last couple decades, we're confident that the numbers have declined steadily until a couple years ago. Now we seem to be kind of at a plateau.

CDC MODERATOR: Next question?

AT&T MODERATOR: No further questions at the moment.

CDC MODERATOR: Okay. We can open it up to questions on the other two articles, if there are still questions on those topics.

AT&T MODERATOR: We do have a question from Robert Bizell (ph) with NBC News. Please go ahead.

QUESTION: Hi. On the anthrax issue, and this is something you've undoubtedly thought about many times, as have we all, but what are the arguments for and against the Connecticut case and the New York inhalational case not being related to the Postal Service and the other bioterrorist events?

DR. OSTROFF: Bob, this is Steve Ostroff. I don't think that we've stated that they're not associated with the Postal Service and any of the other bioterrorism events. We know that based on the microbiologic information all of the human cases have been associated with an indistinguishable strain of anthrax, which suggests to us that they're all linked to each other.

The potential that we know, as is stated in the MMWR article, that in all of the other cases, with the exception of these two, we have a ready explanation related to either postal facilities themselves or end recipients of letters. And so it is certainly tempting to try to determine whether or not that may be the explanation for these two, what we refer to as outliers.

However--excuse me--I don't think that it's reasonable to jump to that conclusion, and certainly we would need some scientific information, and certainly law enforcement would need far more information than is currently available to come to a conclusion that that's the likely route of exposure.

CDC MODERATOR: Next question.

AT&T MODERATOR: And that's from Eunice Moscoso with Cox Newspapers. Please go ahead.

QUESTION: Yes, hello. I was wondering if anyone there could talk about the--when they're going to start to try to look at the Leahy letter, and is that going to happen today or tomorrow, they are planning to open that letter? And sort of what that--any details on that?

DR. : We're not involved in that, and so I don't think it's appropriate for us to be commenting on that.

CDC MODERATOR: Next question.

AT&T MODERATOR: And that's a follow up from Rick Weiss of the Washington Post. Please go ahead.

QUESTION: Thanks. For Dr. Rosenstein, you had mentioned that there will--that well beyond the 60-day period the people who have been taking Cipro will be followed. I understand that one of the things you want to know is to make sure that germination doesn't in some cases happen beyond that window of time. What kind of follow up are you talking about? Are you talking about active follow up? Are you going to be calling these folks in for periodic x-rays or something, or are you just hoping that they'll--you know, telling them to make sure to go to the emergency room if they ever start to feel sick after this or what?

DR. ROSENSTEIN: I just want to clarify that follow up is not just for people who received 60 days of ciprofloxacin. It's for any of the groups who we think were exposed to anthrax associated with these bioterrorist events.

And I guess I have to tell you that in each of the different sites, there's a different system set up to monitor for people who might have clinical illness that's associated with anthrax. We have cooperation with the Postal Service, and there's a lot of monitoring that's being done actually through the Postal Service for those groups of people.

In other groups it's being done differently, but there's an active surveillance going on to look for anybody who might have clinical symptoms.

CDC MODERATOR: Next question.

AT&T MODERATOR: And that is a follow up from Henry Nyman of Net Cox. Please go ahead.

QUESTION: I was just following up on your comment about the large number of COPTN elderly patients. Did Kathy Nguyen have any respiratory kind of conditions? 

DR. : Well, the information is also probably better to come from the New York City Health Department than from me. You know, we're there as technical advisers to them. All I can say is that, you know, all possible explanations are being examined. They could provide you more information about that.

CDC MODERATOR: Next question.

AT&T MODERATOR: And that's from Laura Meckler, Associated Press. Please go ahead.

QUESTION: Hi. I wanted to follow up on two of the things he said relating to Connecticut or--well, one in Connecticut. The first one in Connecticut is you said that the trail has not gone cold, you still have more that you can do there, but since this is not the same sort of situation as you faced in New York, this person did have friends who knew what she did, her life isn't quite as much of a mystery, and you've done the sampling in all the places where you were able to determine where she went. If you could just give me a sense of where you go from here, what else there is to look for. I'm sure there are other things. I'm just wondering how you approach it at this point now that you've done all the places presumably that seemed likely from the start?

And then secondly, in terms of comparing--you said the two teams are comparing notes, the New York team and the Connecticut team. I just wanted to be clear whether they found any comparisons beyond what you detailed?

DR. SWERDLOW: This is David Swerdlow. I just want to say that we have done a lot of environmental testing, but we are still in the process of doing more testing, and I wouldn't say that we're complete and we haven't had any, you know, any clues. We're still looking into possibilities. It takes time to visit every single place that she has been, and again, we've cultured--you know, we think we're almost at the point of having cultured every place that she's been in the last 60 days, and we've talked to every single person that we could possibly talk to, but it's still an ongoing investigation, and there are still more laboratory results that aren't even back yet from the culturing we have done, and we're still going to try to find every possible clue.

In terms of the other question, the New York team participates in our conference calls and actually one of the epidemiologists who investigated the New York case is actually going to join the Connecticut team, and we really want to try to explore all possible connections.

DR. OSTROFF: What I would say, in follow up to that, is that while I realize it's almost December in Connecticut, and so it's getting cold in Connecticut, I really wouldn't use the term that the trail is going cold because this is still a very active investigation, and while to you it may look like it's in its late stages, to us it certainly does not.

CDC MODERATOR: Next question.

AT&T MODERATOR: And that's from Michael Okule with CNN. Please go ahead.

QUESTION: Hi, yes. Several questions really. I wanted to follow up. I think it's something that Dr. Rosenstein might have mentioned. I just want to be clear about it, the fact that the bacillus can stay in the system for several days if not weeks and then finally develop. Could you just be clear about what it is you were saying there again, if you can, just repeat that for me?

And secondly, generally speaking I suppose for all of you, could you talk to me a little bit, and talk to us a little bit about whether or not you have a higher learning curve than you thought you might have regarding anthrax and how it behaves, and how people might get exposed to it. I know you don't have anything conclusively yet, but if you can talk to us about your learning curve on all of this and be as specific as you can if possible.

And then thirdly, I know that more sensitive machinery was used to conduct some of the environmental tests in Connecticut. I think I know the answer to this, but I'm curious as to why it is those sensitive machines aren't used initially? If you can speak to that a little bit as well, thanks.

DR. ROSENSTEIN: This is Dr. Rosenstein. I'll say it again, and then let me know if there's something that's unclear. The bacillus anthracis spores can stay in the body for several weeks before they start growing. The spores can germinate, which means grow and develop into this very serious form of anthrax, inhalational anthrax, for any point up to 45 days after exposure. And it's for that reason that we're recommending antibiotics for even 15 days more, which makes a total of 60 days to prevent this germination and growing of anthrax spores.

CDC MODERATOR: Second question.

DR. OSTROFF: In regard to your second question about the learning curve, what I would say in response to that is that in the same way most clinicians in this country had never seen a case of either cutaneous or inhalation anthrax, it's been a long time since our agency had actually investigated a cluster of cases of inhalation anthrax. And based on that, obviously, we have been learning a fair amount as we go through this particular investigation, and we are constantly mining the information that we're collecting, so that we, in terms of both what we do as well as what we recommend, is using the most up to date scientific information that's available, and so I think there's little question that yes indeed we do have a steep learning curve.

DR. SWERDLOW: In regards to the third question about the methods we're using for testing, I wouldn't say that we're using any new types of testing in Connecticut. However, we are trying to be as exhaustive as we can in our search for spores, and so we are using methods such as vacuum sampling and swipe sampling and swabbing, and we're just trying to be as exhaustive, searching for spores, as we possibly can.

I have to say that if there was a facility that had just--you know, some of the facilities that received contaminated mail early in October, it may have been much easier to identify spores than--and because a large number of spores were released in that immediate environment. And we may not be having that situation here. So we really have to be more exhaustive in our search for spores, and so we are trying to use the best possible methods to sample and to culture in order to be sure we can identify any spores.

CDC MODERATOR: Thank you. And that concludes our telebriefing for today.

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