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CDC Telebriefing Transcript
MMWR, "Chronic Obstructive Pulmonary Disease
Surveillance--United States, 1979-2000" with
Dr. David Mannino, CDC Pulmonary Disease Expert; and,
"West Nile Virus Activity--United States, 2002" with
Dr. Anthony Marfin, CDC West Nile Virus Expert
August 1, 2002
CDC MODERATOR: Thank you all for joining us. My name is Elwin Grant, and I
am a press officer assigned to the CDC's Office of Communication.
Today, we will be discussing two articles. One is a surveillance report.
First, we have Dr. David Mannino, and that is spelled M-a-n-n-i-n-o, who is
CDC's pulmonary disease expert with the CDC's National Center for
Environmental Health. He will be discussing a report which summarizes
obstructive pulmonary disease surveillance in the United States for the
period of 1971 through 2000.
And then we have Dr. Anthony Marfin, and that's spelled M-a-r-f-i-n, who is
CDC's West Nile Virus expert assigned to CDC's National Center for
Infectious Diseases. He will be discussing West Nile Virus Activity, United
Dr. Mannino will now make some opening remarks, and then we'll open up to
questions and answers, and then we'll move to the second topic, which will
again be West Nile activities in the United States.
DR. MANNINO: Thank you, Elwin.
Chronic Obstructive Pulmonary Disease, which is also known as COPD, includes
patients who have chronic bronchitis, emphysema and some people with asthma.
COPD is the fourth leading cause of disease in the United States. Some have
described COPD as an asthma attack that never stops. Tobacco use is a key
risk factor for COPD, although other risk factors include occupational
exposures, infections, air pollution, sensitive airways and genetic factors.
Lung function testing is needed to diagnose COPD.
The report that's being released today reports on trends and different
measures of COPD in the United States over the past 30 years. In 2000, for
the first time, the number of women in the U.S. dying from COPD surpassed
the number of men. This report also finds that women visit emergency rooms
and are hospitalized more often for COPD than are men. These data confirm
that COPD is now a women's health disease.
The increase in these trends for women probably reflects the increase in
smoking by women in the United States since the 1940s. People with COPD are
twice as likely to report activity limitations as people without COPD. In
addition to taking away years from a person's life, COPD also takes life
away from a person's years.
The good news is that the number of men and women, age 25 to 54, with mild
to moderate COPD has actually decreased over the past quarter century,
suggesting that the increases that we're currently observing in
hospitalizations and deaths may not continue indefinitely. We believe that
this observation is a result of the overall decrease in smoking in the
United States since the 1960s.
The main message from this report for physicians is that they should
consider measuring pulmonary function in order to detect COPD in current and
former smokers, age 45 and over, and anybody with respiratory problems.
The main message for members of the general public who have a history of
smoking, asthma or respiratory symptoms is that they should discuss COPD
with their physicians.
CDC MODERATOR: Thank you Dr. Mannino.
I think we are now ready for questions for Dr. Mannino.
AT&T OPERATOR: Once again, ladies and gentlemen, if you do have a question,
please press the one at this time.
We do have a question from the line of Seth Borenstein [ph] with
Knight-Ridder. Please go ahead.
QUESTION: Yes, Dr. Mannino. Unfortunately, the summary of the surveillance
wasn't sent out with the rest of the packet. So how much of a difference are
we looking at between men and women? Is it statistically significant, and
could it be related to the fact that there are more, I mean, we're talking
older people at this point when you're talking dying, how related is it to
the fact that you have more older women at that age because of survival?
DR. MANNINO: That's an excellent point. And actually I believe, and perhaps
I will further address this after I finish the response to that, the full
report will now be available on our website because the embargo is off, so
you'll have access to the entire report.
Many of the measures actually are significantly higher in women. Prevalence
of the number of people who report they have COPD is significantly higher
than women, as are I believe emergency room visits. I'd have to look at the
various specifics of the report, but it is all in there. Because our measure
of deaths actually counts every death in the country, women have about I
think there are 7- or 800 more deaths among women than among men, and that
of course is statistically significant, although both were right around
Part of this is related perhaps to women living longer, and the evidence for
this is that if you actually look at the age-adjusted mortality rates, they
are still slightly lower among women than they are men, although the actual
numbers are higher in women.
QUESTION: They're slightly lower among women?
DR. MANNINO: Yes, the mortality rates, although the actual number of deaths
is higher in women.
QUESTION: In the deaths, are we talking about predominantly in the over
60/over 70 age group?
DR. MANNINO: Yes, COPD deaths predominantly occur in older people. Again,
the specific numbers are all in the report.
CDC MODERATOR: You can get a full copy of the report by going to our
website, which is www.cdc.gov. And if you select "In the News" on the
left-hand corner of your screen, it will be listed under content. That will
take you to a summary of the surveillance report, and then you can also
obtain the full copy.
AT&T OPERATOR: Our next questions are from the line of Megan Brooks with
Reuters Health. Please go ahead.
QUESTION: Hi. Can you just address a little bit about the underdiagnosis of
DR. MANNINO: Yes. Thank you for that question.
We have evidence from other reports that we have published, and it's briefly
addressed in this report, that a substantial proportion of the population
has objective evidence of COPD. In other words, in some of our national
surveys, if you actually go out and measure lung function, you'll find a
certain percentage of the population that has evidence of COPD. In our
report, I think it was somewhere around 14 percent that had either a mild or
a moderate COPD.
If you actually then look and ask those people who have been diagnosed with
COPD, it's a relatively small proportion. Generally, it's in about the
QUESTION: Thank you.
AT&T OPERATOR: We have a question from the line of Adam Marcus with Health
Scout. Please go ahead.
QUESTION: Hi, Dr. Mannino. Just a question about asthma and COPD.
Asthma rates have been increasing in the last decade or so or two, and I'm
wondering whether there's any link between asthma and COPD biologically.
DR. MANNINO: Yes, actually, there is. Within the pulmonary community, one
typically sees diagrams of overlapping circles, with emphysema, chronic
bronchitis and asthma. Clearly, the definition of asthma is variable air
flow obstruction and the definition of COPD is fixed airflow obstruction.
One of the problems that one can see with asthma, particularly if it exists
for a long time, is that some of the variation diminishes over time,
particularly it is thought in people that aren't being adequately treated.
And some evidence we have for this that isn't in this report, but we have
another paper that's coming out shortly is that if you look at COPD deaths
in the country, that somewhere between 15 and 20 percent of these occur in
people who have never smoked, and of those, a history of asthma was one of
the most significant risk factors for having a COPD-related death.
QUESTION: So part of the increase might be due to the increase in asthma?
DR. MANNINO: That is entirely possible.
AT&T MODERATOR: And we have a question from the line of Ann Kerns with Wall
Street Journal. Please go ahead.
QUESTION: Hi. Thanks. One of my questions has already been answered but I
was wondering if you could elaborate a little bit on the overall trend and
diagnosis of COPD. I understand it's the fourth leading cause of death and
that in 2002 ten million adults were diagnosed by doctors.
Has that been stable? Is it going up or down? Can you give us any trend? I'm
assuming this might be in the report but I don't have that yet.
DR. MANNINO: Yes, that is in the report. If you actually look at the report
that they've been diagnosed with either chronic bronchitis or emphysema,
that has stayed relatively stable over the 20 years that we report for that
measure in this report.
QUESTION: Okay. All right. And the report's on the Web site. Okay; thanks
DR. MANNINO: You're welcome.
AT&T MODERATOR: And we do have a follow-up from Seth Bornstein [ph]. Please
QUESTION: Yes. Dr. Mannino, now that I've got a chance to quickly look at
the report, first, following up on the question earlier on the 15 to 20
percent of those who have never smoked, is that an increasing trend?
I mean, among those, are you seeing in that giant line that goes up, an
increase in nonsmokers who are dying of COPD?
DR. MANNINO: Unfortunately, with the current mortality data that we have
available, which does not ask specifically about smoking, we cannot tease
that out, and we're currently working on some other databases where we may
be able to get an answer to that; but we simply can't answer that.
QUESTION: Okay. And then looking at the data on your report, I mean just
that first deaths, you, it seems that you almost quadruple the deaths in
women from 1980 to 2000.
DR. MANNINO: Yes, that--
QUESTION: And I mean that's purely smoking? You're saying it's mostly
smoking. I mean, that would be considered alarming in other places. I mean
DR. MANNINO: I consider, we consider it alarming, and that's why we're
reporting it, and that's what we feel is one of the messages of this report.
QUESTION: But most of that is smoking. You can't attribute--I mean--
DR. MANNINO: Yeah, we believe most of it is smoking. There's a little bit in
the report that tries to talk about this. That, you know, generally ,the
life history of COPD development, or, actually, if you just look at
cigarette smoking, people start smoking in their teens or early twenties,
and they start developing COPD in mild cases, probably in their 40's and
50's, and start dying in their 60's and 70's.
So in that sense I think we're seeing here, is really related to the uptake
of smoking by women in the United States in the 1940's and '50s, and then
that continuing increase that has occurred through 1960's.
AT&T MODERATOR: And no further questions.
CDC MODERATOR: Thank you, Dr. Mannino.
DR. MANNINO: Actually, can I make a--just one little final statement. I've
also sent, and our Press Office has available a list of some other of our
key partners and contacts in dealing with COPD, and I guess that can be
faxed or e-mailed to anybody that wants to get perhaps a different
perspective. Our key partners are the National Heart, Lung and Blood
Institute, the U.S. COPD Coalition, the Global Initiative on Destructive
Lung Disease called GOLD, and the National Lung Health Education Program and
all these have available contacts and also Web sites that you would look at.
CDC MODERATOR: Once again, thank you, Dr. Mannino, for your presentation.
Let's now move forward to the next portion of our briefing to discuss West
Nile virus activities in the U.S.
Dr. Marfin will now make some remarks which will be followed by questions
DR. MARFIN: Thank you. During the past week, the Centers For Disease Control
has received reports of about 30 cases of West Nile encephalitis from three
states--Louisiana, Mississippi, and Texas. This brings the total reported
cases to forty-four in 2002. But these states and CDC continue to work
closely together to identify new cases, so these numbers may change.
These three states have already started their increasing surveillance for
human cases to identify counties where people are acquiring infection, and
they're doing this primarily to intensify vector control in several of these
In addition, all three of these states have increased their public health
messages that emphasis personal protection from mosquitoes, such as the use
of insect repellents such as DEET, and the behaviors that would lead to
avoidance of mosquito bites.
Although during 2001, sporadic cases were reported from many states, this is
the first outbreak in a relatively small area since the 1999 outbreak when
West Nile virus was introduced into New York City.
In addition, CDC is working closely with these states to identify ways to
optimize mosquito control that is being done by assisting these states in
case investigations as well as providing some entomologic teams for ongoing
investigations as to which mosquito species are causing illness.
In addition to the human cases, we've seen a increase in the number of
positive mosquito pools in many, many states, and new states have reported
activity for the first time in 2002, and for several states it's the first
evidence of West Nile virus activity in some of these states, forever.
States such as Minnesota, South Dakota, West Virginia, have all identified
activity for the first time ever.
We are in contact with many of these states and assisting in many, many
ways, but currently we have an investigation team in Louisiana assisting the
Louisiana Department of Health and Hospitals in the investigation, and again
with the intention of improving our vector control operations, and to bring
an end to this current outbreak.
CDC MODERATOR: Okay. We're now ready for any questions.
AT&T MODERATOR: And once again, ladies and gentlemen, if you do have a
question at this time please press the one. And we do have a question from
the line of A.J. Hufstedler [ph] with the Richmond Times-Dispatch. Please go
QUESTION: Hi. Good afternoon, Dr. Marfin. Thanks for taking time to speak
with us today.
I just wanted to clarify, did you say the number of human cases so far this
year is up to 44 or thirty-four?
DR. MARFIN: It is forty-four.
QUESTION: Forty-for. And can you provide a breakout of those?
DR. MARFIN: Actually, I do not--let me look. The majority of the cases are
coming out of Louisiana, and we are, again as I said, we are working closely
with them to identify new cases, and so these numbers are changing.
In addition, we do a lot of laboratory confirmation for these states, so
cases where there's some question as to whether it's West Nile virus or some
other mosquito-borne virus are still being answered for a lot of these.
CDC MODERATOR: And A.J., feel free to give us a call at the Office of
QUESTION: Okay. I'll do that.
DR. MARFIN: But I do have--
CDC MODERATOR: Oh, okay; sorry.
QUESTION: Oh, okay.
DR. MARFIN: We are talking about, of the cases that have been reported to
us, there's been 32 cases in Louisiana, five in Mississippi and eight from
QUESTION: Okay, and if I may ask a follow-up. We've got, in some parts of
the country, another three or four months of the mosquito season. What do
you expect to see? Do you expect to see an increase in the number of human
DR. MARFIN: That is an excellent observation because these are--the human
cases that occurred this year, the first one had an onset of illness in the
beginning--or the middle of June, which would have been the
earliest-reported case with regards to earliness in the year.
And as you may know from looking at the human cases in 1999 through 2001,
human cases up in the Northeastern states as well as other Eastern states,
have usually occurred in August and September.
So we think that there is still the potential for human cases in other
states and that it is still very, very important for people to be involved
in personal protection from mosquitoes and for state health departments,
local mosquito control, just to continue their activities in mosquito
QUESTION: Thank you.
AT&T MODERATOR: And we have a question from the line of Jerry Snook [ph]
with Metro Source. Please go ahead.
QUESTION: All right. Thank you very much. I've got a--in Indiana here, the
local health department in Indianapolis had mentioned in a recent release
that they expect that West Nile virus will reach California by the end of
Is that something that you can talk about or confirm?
DR. MARFIN: There has been a great deal of speculation as to how far West
the West Nile virus will spread. I think that a lot of people are expecting
great movement because of what we've seen in the past year. We now have
animal infections identified in North Dakota, South Dakota, Nebraska,
Oklahoma, and in Texas, and then we have human infections being reported out
And so what we've seen is a great leap forward, and it appears that that
would be a leap to the West.
The difficulty, though, is accounting for what's causing that move. It could
be caused by birds that are making their north-south migrations, and some of
them start to veer a little further west.
So when we don't completely understand the reasons for the movement to the
left, it's very hard to speculate sa to when it will show up in states
further to the west.
In addition, the real factors that are important in terms of the spread of
this particular infection are the vectors, the mosquitos that actually
spread the disease.
So you have to have a vector that can accommodate the virus, that can spread
the infection within bird populations, that can increase the number of
infected birds, before you start to see that virus becoming established in a
As to whether states further to the West are going to have a hospitable
environment for some of these vectors, it's very, very unclear. But I can
tell you that the people in the State of California have lots of experience
in terms of looking for mosquito-borne viruses.
They've been doing it for many years, and they have added the West Nile
virus to their list of agents that they are searching for, and they have not
found it to date.
QUESTION: All right. Thank you.
AT&T MODERATOR: And we have a question from Seth Bornstein, Knight-Ridder.
Please go ahead.
QUESTION: Dr. Marfin, given that as you said earlier, August and September
are the more mosquito-prone and West Nile virus-prone seasons from the past,
can you help us compare the 44 cases--and by the way, you said there were 32
cases in Louisiana, five in Mississippi and eight in Texas. That adds up to
forty-five. So I'm just won--I'll have a editor who's going to complain
about the math.
DR. MARFIN: Oh, I'm sorry.
QUESTION: Is it 45 or is it 44?
DR. MARFIN: In the MMW article, it speaks--
QUESTION: It says actually forty.
DR. MARFIN: --there will be 36--there'll be 44 cases that are mentioned. As
I mentioned earlier, many of these cases are still being investigated, and
that investigation goes on with regards to where the person lived, where the
person likely received their infection. But probably more importantly, it's
the laboratory confirmation that is done at several state health
departments, and here at CDC, to help them determine which virus is actually
causing the encephalitis.
And so sometimes there are discrepancies between the numbers that we have
reported to us ,and the numbers that are reported on state Web sites, and a
lot of that has to do with making sure of the diagnosis and very often it
has to do with increasing the laboratory investigations that go on with
QUESTION: Okay. Well, I'll try to get through that another time.
In terms of trying to look at this compared to, for example, '99, or even
'99, 2000, 2001, at this time of year, how does the 44 or 45
cases compare for the end of July?
Is this more than the previous years? How much more ? Less than other years?
DR. MARFIN: No; this is more. These are the earliest cases that have, of
West Nile encephalitis, that have been reported in the country, and part of
that may have to do with different mosquito vectors that are present in the
It may have to do with weather that is more conducive to year-around
transmission in the birds. It may have to do with some of the drought
conditions that a lot of states have been experiencing. But these are the
earliest cases of West Nile encephalitis that we have seen since its
introduction in 1999.
QUESTION: So in the past years, we haven't seen any at this point?
DR. MARFIN: We've never seen a case with illness onset as early as June.
QUESTION: What was the previous earliest?
DR. MARFIN: I'm sorry, I don't have that in front of me right now.
QUESTION: Then can you say that bodes--
DR. MARFIN: It would probably be the middle of July, though.
QUESTION: Then obviously bodes very poorly for September and August?
DR. MARFIN: I think that what we have done is that we have incredible
surveillance with regard to West Nile virus, better surveillance than we
have established for any of the other mosquito-borne virus diseases, and so
we have states that are out there, that are working very, very hard to first
identify any activity by identifying infected birds, infected mosquitoes,
infected horses, and as a result, when they see those infections in animal
populations, what they do is they intensify their investigations for human
cases. So I think part of that is that states are doing just an incredible
job in terms of finding human infections, and I think that's contributing to
some of the increase. But you are correct that these are very, very early,
and I think that we have to be very aggressive with regards to our vector
control operations, our personal protection, pushing those things to end
this outbreak or to greatly reduce the number of infections that are
occurring. That's for this particular area that we talked about today with
regards Louisiana, Mississippi and Texas.
Now other states who are also equally intensive in their investigations for
human cases, they may identify cases later on, but those will be due to
local conditions. There's not some sweeping generalization that you can make
for the entire country.
QUESTION: One last thing. In terms of the prevalence we're seeing among
animals--birds, horses, whatever--all across, all the way West how is this
compared, in terms of time frame, to the prevalence in '99, 2000, and 2001?
Are we seeing more in birds and horses, et cetera, than we did in previous
years, too, and we're spread out more?
DR. MARFIN: That is subject to the same factors that I was discussing for
the human cases. The states with which we work have incredible animal
surveillance programs going now, and so they are finding cases much earlier.
There's a lot more activity in terms of animal surveillance now than there
was in 1999, when there was essentially none, because that was when the
virus was introduced.
QUESTION: So it might have been there like all of the time, and we're just
noticing it more.
DR. MARFIN: I think that when we're talking about new cases in the West, I
think that a lot of it has to do with the actual spread of the virus through
the animal population, but I think some of that does have to do with the
greatly intensified surveillance that the states have incorporated.
QUESTION: Thank you.
AT&T OPERATOR: We do have a follow-up from A.G. Hostetler. Please go ahead.
QUESTION: Hi, Dr. Marfin. Thanks again for taking the time.
I wondered--I have two questions--I wonder if you could comment, please, on
the importance of the seroconversions in the Sentinel chicken flocks in
Florida and also if you could comment on what, if anything, the CDC is
telling physicians to do in terms of their patients, if they are supposed to
be more suspicious if they have got an elderly patient with flu-like
symptoms and mental confusion or something.
DR. MARFIN: Let me address the chickens first.
The State of Florida has been working with what are called Sentinel chicken
flocks for many years. They have had problems with a very closely related
virus, the St. Louis Encephalitis Virus, for many years, and so they have a
well-developed system in which they can identify a bird that becomes
infected. Because these birds have never traveled elsewhere and because
they're kept in a particular area, that tells them that, in fact, there are
infected mosquitoes in the area.
Last year, there were a few counties in Florida in which the very first hint
that there was any West Nile Virus activity was because of a chicken that
seroconverted. So that tells us two things:
One, there is infected mosquitoes in the area; two, it tells us that the
risk for human disease is now increasing because we're having local
transmission, and the State of Florida has a response system in which they
will kick in intensified vector control operations for those chickens. So
they have been very happy with it. It's helped them out. As I mentioned, in
some counties, it has been the very, very first sign of activity that
With regard to the second question, what this means to physicians, I think
that it should be considered, in all of these areas in which there is animal
activity being reported that one has to consider that as part of the
differential diagnosis for encephalitis.
Unfortunately, at this time, there is no treatment for West Nile Virus
Encephalitis. The care is primarily supportive; meaning that if ventilation
is required, that they would be put on a ventilator. It requires good fluid
balance, it requires good salt balance, and those things are maintained by
physicians and nurses in intensive care situations very often, but there is
no specific antiviral that is out there. As a result, sometimes people not
pursue the diagnosis of West Nile Virus as readily as they might.
But the one thing to think about that's a little bit different is that, when
you identify a case of West Nile Virus Encephalitis, that diagnosis may not
be of utmost importance to that particular individual because you're going
to treat them in the same way anyway. You're going to support them in every
way that you can.
But what it does do is it tells you that there is a community out there
where human infection and human cases of encephalitis are occurring. So, in
that way, it is extremely helpful to the communities that are collecting
this information so that they have some idea of what they need to do in
terms of vector control.
AT&T OPERATOR: We do have a question from the line of Karen [inaudible] with
National Public Radio. Please go ahead.
QUESTION: Hi. Thank you for taking my question.
I was wondering if you can confirm a report that a Louisiana woman died on
Monday from West Nile Virus.
DR. MARFIN: I was told yesterday by the State of Louisiana that one person
has died from West Nile Virus Encephalitis, and I have not seen the
particulars of that case yet.
CDC MODERATOR: Yes, we encourage you to call the Louisiana Health Department
on any details concerning that case.
QUESTION: If that is the case, would that be the first U.S. death this year?
DR. MARFIN: Of the ones that have been reported to the Centers for Disease
DR. MARFIN: Yes.
QUESTION: Thank you.
AT&T OPERATOR: We do have a follow-up from Seth Borenstein. Please go ahead.
QUESTION: Sorry to bother you with one more follow-up.
Just to confirm, the White House one, was that confirmed, the crow found at
the White House I think it was last week?
DR. MARFIN: I spoke with the people in Washington yesterday, and they said
there was a report of a confirmed I think it was a crow that was infected,
QUESTION: And it was in the White House. When was that found?
DR. MARFIN: I'm sorry. I don't know the particulars of that particular
QUESTION: But it was confirmed infected.
DR. MARFIN: Correct.
QUESTION: Has the White House or any of the Washington power elite called
for any additional things because it's gotten so close to them?
DR. MARFIN: I'm sorry. You would have to direct your questions to them. Most
of my activity over the past two/three days has been spent with receiving
the surveillance data from the states.
CDC MODERATOR: Normally, the procedure is to work with the local and state
AT&T OPERATOR: No further questions.
CDC MODERATOR: Since there are no further questions, I wish to again thank
you all for participating in today's media telebriefing. If you have any
follow-up questions, feel free to call our main press office, and that
number is 404-639-3286.
The transcript for today's telebriefing will be available on-line this
afternoon, and you can obtain by visiting our website. Again, that address