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Update: MMWR and Anthrax Investigation Update with Drs. Koplan and Gerberding

December 6, 2001

CDC MODERATOR: Thank you very much for joining us today for an update on the anthrax investigation. We have Dr. Koplan, Dr. Jeffrey Koplan, the CDC director with us, and, shortly, we'll be joined by Dr. Julie Gerberding, the acting deputy director for the National Center for Infectious Diseases at CDC.

We have 30 minutes today and we appreciate you joining us. I'm going to turn it over to Dr. Koplan for some brief opening remarks and then we'll start the Q&A.

DR. KOPLAN: Good afternoon. CDC and the Connecticut state health officials continue to look for the source of exposure in the case of the 94-year-old woman in Connecticut who died from inhalation anthrax. B. anthracis spores were found in three high-speed mail sorters in the Wallingford postal processing and distribution center, and on a single piece of mail delivered to an address a few miles from the home of the patient who died.

These findings have raised concerns that this unsolved case of inhalation anthrax might be due to contact with cross-contaminated mail. CDC believes that also the risk of contracting inhalation anthrax from cross-contaminated mail is very, very low, it's not zero.

85 million pieces of mail were processed on the days after the implicated envelopes passed through both the New Jersey and the District of Columbia sorting facilities, until they were closed.

Despite the fact that both of these facilities had widespread evidence of environmental contamination with B. anthracis spores, and the fact that public health officials have been aggressively looking for anthrax cases, no new cases have been identified. If there is a risk from cross-contaminated mail, it is very low. But because some people are concerned, worried about the situation, and want to be able to do something, we've come up with some potential steps that they might take. They're not scientifically proven recommendations but they may be able to reduce one's risk, and these are, I think, easily done, common sense steps, if people would like to take them, they might do.

A continued concern and awareness about suspicious mail, not opening it, turning it over to local law enforcement authorities. Keeping mail away from one's face when you open it. Some people have a tendency to blow open envelopes. Not a good idea; shouldn't do that. Or sniff mail or mail contents.

And don't do anything that would promote potential content from floating into the air. For example, any kind of vigorous tearing or shredding of mail or an envelope. And then washing one's hands after handling the mail. Most of these items we have mentioned before. They continue to be prudent steps to take for people who have, are particularly concerned about the situation.

And a separate item, but related, CDC has now adjusted the recording of cases to 22 cases of anthrax, 18 confirmed and four suspect. That's one less suspect case. The reason is that a patient from Delaware who was suspected of having cutaneous anthrax was removed from the list after additional testing showed that this was not the case. The patient did not have anthrax.

Dr. Gerberding is not here yet but I will be happy to answer your questions.

CDC MODERATOR: We'll take the first question now.

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

Our first question is from the line of Andrew Revkin with the New York Times. Please go ahead.

QUESTION: Hi. Thanks, again, for the briefing. In your search for further clues about the Lundgren case, what are you doing in Connecticut to look for sort of--at the second square on this hopscotch board, meaning, Hamilton [?] being the first one, to look for possible simultaneous or close transmission of the Seymour letter and something that then went to Ottilie. And I have a quick follow.

DR. KOPLAN: Okay; sure. First of all, we're pursuing, continue to pursue, you know, a variety of possible exposures. We continue to have a large number of environmental specimens from that patient's home, and her clothing, and her personal effects, that are still undergoing testing. Obviously, there wasn't a lot of contamination or it might have grown sooner. But the final lab results have not come in on a number of those tests.

QUESTION: Do any of them even hint at a positive?

DR. KOPLAN: Not yet. But, you know, you can get growth further out, so we haven't given up on it. But at the moment, there is no evidence of positive growth on any of those specimens, and that is also true of, you know, other sites where she visited, where we also have specimens, some still pending.

The team there continues both to talk to people who knew the woman and to try to ascertain if there's something we have missed. As they're trying to put together a literally hour by hour schedule of her life over the preceding weeks, everywhere she went, who she was in contact with, et cetera, and were there other possibilities for exposure there, in terms of mail for this woman, we are continuing to work with the Postal Service to see of any possibilities of other mail she may have received, or what the quality of it is, and we do have, you know, specimens of the mail that were recovered from her home, which have not grown out any B. anthracis.

QUESTION: Okay. The follow is do you think you're obligated, in any way, even to basically assuage public fears, to release just how broad an area of mail from Hamilton that went through on October 9th went to? Doesn't that kind of help make your case that there's no risk?

DR. KOPLAN: Well, you know, the issue of how mail gets handled and what goes on in postal facilities is an important one, just as you say, and if we had an exact set of locations to be able to say here's where all that mail goes, it would be easier. But it is quite complicated because mail comes through these big distributing centers and goes to a wide number of sources.

I think an important thing for us is that it's a very large number of pieces of mail, and with close surveillance, we have not seen cases of illness other than two cases of cutaneous anthrax, both in New Jersey, one in a mail handler where the presumption is it's cross contaminated, one in a person who receives mail but whose occupation wasn't mail handling. The mail that goes out from that facility does go to a very wide distribution of places, once it goes out, as you said.

AT&T MODERATOR: Our next question is from the line of Aaron McLean with the Associated Press. Please go ahead.

QUESTION: Yes. I have two questions, if I could. First of all, can you report any results yet on the tests on the anthrax that was in the letter to Senator Leahy, and, secondly, based on the MMWR, you seem to be concerned about the overuse of these rapid tests, these PCR tests.

I'm wondering if you could sort of give us an assessment of how much of a problem that is.

DR. KOPLAN: I believe [inaudible] the first part of your question is we haven't received specimens at this point from the Leahy letter, and that's being tested up at the U.S. Army Medical Institute of Infectious Diseases.

On the second question, on these rapid detection units, I'm happy to give--I think that an issue with these units is, one, there are several different manufacturers, and like many pieces of equipment, they probably have different levels of sensitivity and specificity depending on the particular one. I think they are largely designed for large amounts of material such as a powder to be tested, and they do better in those circumstances rather than things like an environmental swab. I'm answering your question about the right pieces of equipment. Is that what you were talking about, these rapid detector equipment that are used out in the field? Hello?

QUESTION: Yes, that's what I'm--

DR. KOPLAN: Then, yes, that's basically what we've found. There is probably a place for them, but it's for larger amounts of material, and it's the infectious material itself in a clump that can be tested more readily rather than trace amounts, and I think the reliability of the actual test results is somewhat a function of the amount that gets tested.

CDC OPERATOR: And, Aaron, if you have any other questions, feel free to call the CDC press office after this call. Next question, please.

AT&T MODERATOR: Thank you. That's Marian Falco with CNN. Please go ahead.

QUESTION: Hi. I've got two questions for you. Number one, why was [inaudible] of mail added to the list? Did something happen? Did you learn something in the investigation? I checked the list of things that you can do to protect yourself from October 26th and that was the only thing that wasn't really on it.

And also, from all your investigations, have you learned anything about how long one might wait for a spore to grow? I mean how long can it be in the body? I know that it's been 45 to 48 days, I think it was, the longest that one thought beforehand how long it might take for the spore to grow inside and thus cause either cutaneous or I think more inhalational anthrax? What have you learned?

DR. KOPLAN: Yeah, I'm--the two parts of your question, on the first one, it really is just a kind of practical consideration, is if there are some spores on the outside of an envelope, the more vigorously you shook it around, or shake it or bang it or--they're more likely to come off, and so that the less vigorous one deals with it and--you know, you've got to be able to grab it, open it and take out the contents, but beyond that, it's probably better not to flap it around or wave it in the air or tear it too aggressively.

In terms of the spores and really the incubation period for the spores, as you're aware, the spore gets ingested through the respiratory tract in the body, goes to lymph nodes, and gets grabbed by the type of cell called the macrophagus and grows--germinates in that, and that's where the bacteria comes out.

The experiments done in this are variable. Most of them are in animals and show an outside limit to this happening of about 60 days, or below--it's under 60 days, and that's one of the reasons why the recommendation is made for 60 days of antibiotics.

CDC OPERATOR: Next question, please.

AT&T MODERATOR: Thank you, and that's from Greg Smith with The New York Daily News. Please go ahead.

QUESTION: Thanks. I have two questions, just like everybody else. The first one has to do with the barcode analysis that the postal service has done in the Trentwood facility. Can you just get into the scope of environmental testing that you have been asked to do as a result of that analysis? And that would include, I guess, sides--move just beyond the Seymour letter and the Bronx letters.

And then, number two, can you give me more information at all about any comparisons between the Lundgren case and the Nguyen case in the Bronx?

DR. KOPLAN: Sure. On the first one, of the issue of environmental testing, what we are doing now is we use methods that have largely not come out of the infectious disease area but come out of the environmental toxin area or the environmental exposure area that works oftentimes for chemicals, metals and other things. And that involves kind of a mapping out of a facility and then taking areas that are at higher risk for these things occurring, and then creating a map pattern as to where the isolates occur.

There are also various methods that you can try to stimulate growth in these--from these isolates, and that has been used as well.

That's largely the approach that our folks--because they combine--our infectious disease experts, our environmental and occupational health people have put this together, and it's what has been used when we go back in to look with extreme diligence for scattered particles that might not otherwise be picked up, and actually and may not also pose any risk to people. One of the purposes of this is to find some trace, somewhere, of a particle, and so we do it with extreme, an extreme level of scrutiny and diligence.

Your second question was the linkage between New York and Connecticut. We have had regularly, since the beginning of this bioterrorist event, at least a weekly, and, in some cases, more frequently, interchange between what we call effective [inaudible].

So early on in this, we had regular interchange between Florida, Washington, D.C. area, New Jersey and New York, and that has been very helpful to the various investigators involved in the sites, because they get insights from the other places, things get learned even on a day to day basis as to what's gone on.

For Connecticut and New York, in that these two have been very frustrating cases to all parties, we have had regular interchange between these two, literally on a daily basis, and as new news has broken, the parties have been involved together, including us, in the public health investigation side, and the FBI doing the criminal investigation, and, recently, the New York team investigators met with the Connecticut team investigators, on site, to go over, in great detail, information about both of their investigations to see if more light could be shed, and that interchange continues.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: And it's from David Kassenbaum with the National Public Radio. Please go ahead.

QUESTION: I was wondering if you could tell me how precise are the postal records. I mean, when a letter goes through one of these machines, do you actually always have the address or the zip code? I mean, how sensitive is the monitoring and tracking?

DR. KOPLAN: I speak not as a postal expert but let me just give you our understanding, and it may well be corrected. But it's variable. That in some instances, one is able on the basis of the coding, to track a letter to an individual household. In others, it can be tracked to a mailing delivery site and for a place like New York City, that can be an apartment building with many hundreds or thousands of residents in it, and in other places one doesn't get that level of detail and it's not present on every letter that goes out.

AT&T MODERATOR: Our next question is from Henry Neiman [ph] of [?]. Please go ahead.

QUESTION: Hi. I was trying to get a little better understanding on the distribution of the letters that went through either New Jersey or D.C. Some of the early reports had different cut-offs of either 15 seconds, or 90 minutes, or one day.

Do you have ball park numbers of the 85 million pieces of mail that went through the two sites, approximately how many went to Wallingford and how many went to the corresponding processing center in New York, and then to confirm that none of those 85 million actually went to the residence of either Ottilie Lundgren or Kathy Nguyen?

DR. KOPLAN: Let me try to explore with you a rather complex system and explain it as best I understand it and can explain it.

When mail comes into some of these big sorting facilities, it is--you know, there's been a focus on the sorter as the piece of equipment of particular interest, and we as well did that, early on. There are other pieces of equipment in the facility which probably have as likely or potentially have as likely a possibility of being destructive [?] to the letter or causing some amount of material to escape from it, and that includes the cancelling equipment which strikes the envelope with a cancelling mark that we're all familiar with.

And in the Hamilton Township facility, which is where a lot of our focus has been, that was the first step in which mail comes through, and there's more than one piece of cancelling equipment. So there are other equipment nearby which, in turn, can become cross contaminated in that process of when one canceler gets, you know, gets struck, the potential for the other cancelers then to get contaminated.

The mail then goes on to sorters of which there are many, and where the same crossing of potentially spores from one to another can occur. At some point in this process, relatively early on, if aerosolization is occurring from a contaminated letter, i.e., one of these letters addressed to a senator with criminal intent, then you are essentially getting-- your contaminating element is not a piece of equipment anymore, it's the air in which spores are now floating around, and can settle on different parts of the facility, and we have evidence of that from our environmental sampling of this facility.

So that the early use of this 300 letters reflected a very sort period of time in which mail comes through just one of these pieces of equipment, the sorter, or might have been the canceler, the canceler. But in any event, it is a limited focus on a much broader process that's going on, and could lead to false, I think, both reassurance and sense of risk, if one only looked at those letters, which may have no greater likelihood of being contaminated than other mail throughout the facility.

CDC MODERATOR: Next question.

AT&T MODERATOR: Thank you. That's from Sara Leak [ph] of The Wall Street Journal. Please go ahead.

QUESTION: Yes. Hi. Dr. Koplan, can you talk at all about the balance you're trying to strike with the recommendation of, I guess, the tips in the MMWR this week. You know, what is that balance, and did you go back and forth at all on the issue of how to talk to the public about this issue?

And, secondly, if the warning were more targeted at a specific population, would there have been other concerns raised? Would postal workers of, you know, who are older, or immune-compromised, for example, or who worked in certain facilities, somehow, would their risk or safety be called into question and was that something that you were dealing with?

DR. KOPLAN: Thanks. As with most public health emergencies or major events, it's just what you say, striking a balance is a key issue in this. On the one hand, and it's obvious to all of you, we don't have all the answers to this. There's large parts of this that are unknown and we're hoping to sort out and get answers to.

So in the process of that, we're trying to balance protecting people in as absolute a way as we can from any illness unnecessary, by the same token not creating undue alarm and fear where it's unwarranted. And it's that balance that we're trying to walk every day here.

And what this article we hope conveys is the mail is by and large very safe. The risk of cross-contamination is very low, but there are some elements that we can't explain well, and--which raise an issue of possibility for a couple of people of potentially of cross-contamination being the cause of their disease, even as we explore lots of other reasons for it, and it's that balance of saying to folks if you're really concerned about this, here's some extra steps you can take. And we understand why you'd be concerned about it. First it's saying but there really isn't a basis for undue alarm and fear around this.

There are billions of pieces of mail that have pressed through postal facilities in the last few weeks while this has been going on, and we've got a grand total of 18 confirmed and four suspect cases in the course of this. And we're taking those very seriously and doing a lot of work around them, but nevertheless people are getting mail at home and at work, and they're sending it.

Now postal workers, similarly, there has been great attention to both by us but even more so from the postal service, and they have taken extraordinary steps on an almost immediate basis to protect their workers from risk. And that involves changing the way they do business in their facilities from very early on in this and have continued to look at, almost daily, of how they can protect those workers better every single day. And so we are very comfortable with the efforts they're taking to protect the workers in this.

CDC OPERATOR: Next question, please.

AT&T MODERATOR: Thank you, and that's from Bob Hager of NBC Network News. Please go ahead.

QUESTION: Hi. With the new information that it's possibly easier to cross-contaminate than people had felt originally back when this began, we talked about how long the spore incubate--takes to incubate in the body. What about in the scenario where somebody got mail that was cross-contaminated some time ago in their home, and then the spore comes off and it hangs around, and then the person eventually inhales it, or something? Is that a scenario, and how long would that be something for people to think about?

DR. KOPLAN: It's a potential scenario, but--and as you are again all aware, we're learning stuff new every day. The wisdom, the conventional wisdom about anthrax spores prior to this outbreak, and it was based on research done in government facilities and in academia, was that anthrax spores are very difficult to re-aerosolize. Once they've gone in the air and settled down on something, the concept was it was hard for them to get back into the air.

That hasn't necessarily been the case in the course of this outbreak. Nevertheless, the other pieces of it are is that the bigger particle sized spores are most likely to settle down. So if you had an envelope and spores stuck to it, you know, the literature would argue that those would be the larger ones which have less of a likelihood to be inhaled. The ones that are most likely to be inhaled have been described in the past as almost having a gaseous quality and floating off.

But, you know, as we're learning new things about this, we can't make those assumptions as readily. So would an old envelope that might have been contaminated or cross-contaminated have a spore or two on it? Could it still? Yes.

Does that pose a risk to folks? It could, but there's a couple of factors going on here. One, it's probably a very small number of spores, and many of them may have dropped off, but two, we have now had a considerable period of time that's passed since these contaminated, originally contaminated envelopes passed through, and with each passing day there does seem to be a decreasing risk for more cases being seen from this initial event. So, you know, we have to both hope and assume that no new letters are mailed. But it is a positive thing to have time pass from when the last cases occurred.

CDC OPERATOR: Next question, please.

AT&T MODERATOR: And that is from Elizabeth Cohen of CNN Television. Please go ahead.

QUESTION: Hi. I actually only have one question, and that is, is there anything specific about these people who have become ill or have died that would have made them more prone to anthrax? I know that Mrs. Lundgren was very old, but the other one as well. Because, as you said, mail went from these two facilities all over the place, to seemingly, what it sounds like to me, thousands if not millions of people. So why them? Is there something about their immune systems? Was that something about them sort of biologically, physically?

DR. KOPLAN: Not that's obvious. You know, the woman in Connecticut is 94 years old. She was an active--sounded like a delightful 94-year-old woman who was kind of a model for being out in the community, doing things. Nevertheless, you know, there's I think ample evidence that as we age, and particularly as we get into the very older years, that our immune system isn't as robust as it was earlier. And so in the absence of a specific disease that would have her immuno-compromised, age can be cited as a potential factor that might have made her more susceptible.

In terms of the woman in New York whose age is currently thought to be 51 rather than the previously quoted 61, I would have to say from my own now maturing perspective, 51 seems pretty young to me, and I wouldn't invoke the same argument of a diminished immunologic system. She had some, you know, kind of aches and pains and she took some antihistamines and some anti-arthritic medications, but again no evidence of, clinical evidence of a--and she did see physicians--of a real immunologic deficiency. So we don't have a good host physiologic explanation for any increased susceptibility.

CDC OPERATOR: We have time for one more question.

AT&T MODERATOR: And that's from Dustin McNichol of The Star Ledger. Please go ahead.

QUESTION: Yeah, hi, thanks. I'm calling from Trenton, so, tomorrow will be the 60th day since October 9th, and in light of that, if you could just go over how firm you are and how confident you are in that 60-day incubation window and the prospect that people who were present in Hamilton on October 9th might be able to breathe a little sigh of relief come tomorrow. And also if you have a breakdown of the 85 million letters between how many went from Hamilton and how many went from Brentwood, that would be helpful.

DR. KOPLAN: Let me let Dr. Gerberding answer this one.

DR. GERBERDING: We're [inaudible] for the 60-day timeframe. One of the things that we're very concerned about is that people really have taken their antibiotics for the full 60 days that they have been advised to, and most of the people there need more pills because they haven't taken them for that whole period of time. So you can help us get the word out about being sure to complete all 60 days of therapy. That's the best assurance for protection.

If the experience we've had in other situations, including some of the animal research, are correct, 60 days of treatment should be enough to prevent infection. But we've never done this before, and we can't be sure, so we will be monitoring people after they stop their therapy and advising them to see the doctors if they have any symptoms of a fever or anything else that might be suggestive of an early infection. We are not expecting it, but we'll be prepared just in case.

DR. KOPLAN: And if I could just add to that, as Julie said, as Dr. Gerberding said, the basis for this are experimental studies, largely, and it involved a certain dose of anthrax spores that led to the conclusion of 60 days, and then observation from an accident in Russia. And what we're doing now is both working ourselves and talking to clinicians and outside of government as well, and not just accepting the 60 days. The 60 days has been what we used all along, but as Dr. Gerberding said, we're going to carefully monitor people when they finish, and one of our biggest concerns is people who didn't take the full course. They really need to take all of those antibiotics that were available to them, because that's what kills those lingering spores when they turn into bacteria, and so that's an important public health message for us.

CDC OPERATOR: That concludes our session for today. Thank you very much for joining us.

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

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