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 States 2002.

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.

Thank you.

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 60,000.

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 this condition.

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 30-percent range.

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?

[Simultaneous conversation.]

DR. MANNINO: That is entirely possible.

QUESTION: Thanks.

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 very much.

DR. MANNINO: You're welcome.

AT&T MODERATOR: And we do have a follow-up from Seth Bornstein [ph]. Please go ahead.

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 is this--

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 and answers.

Dr. Marfin.

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 areas.

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 ahead.

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 Communications.

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 Texas.

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 cases, or--

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 control.

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 the year.

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 of Texas.

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 particular area.

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--

[Simultaneous conversation.]

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 these samples.

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 South.

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 they've had.

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 Control?

QUESTION: Yes.

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, yes.

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 animal.

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 health officials.

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 is www.cdc.gov.

Thank you all again.

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