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CDC Telebriefing Transcript

Updates: Smallpox Educational Activities and West Nile Virus

December 19, 2002

CDC MODERATOR: Thank you, Mary Sue, I appreciate it, and thank you to all the reporters who have taken time out today to join us on our weekly teleconference.

Today, we're going to cover several subjects. One, we're going to have the director of CDC, Dr. Julie Gerberding, provide an update on where we are in regards to implementing the policy that the President announced last week regarding smallpox, and in the second half of our teleconference we'll be joined by Drs. Lyle Peterson and Dan O'Leary from our laboratories in Fort Collins, Colorado, who will be joining us to discuss the series of articles that's published today in the MMWR on West Nile virus.

So with that said, I'd like to turn it over to the director of CDC, Dr. Julie Gerberding.

DR. GERBERDING: Thanks, Tom, and thanks to all of the reporters who are online. I'm going to keep my remarks brief so we can answer as many questions as possible. I'm just going to hit the highlights here.

HHS and CDC are continuing to work with state and local health departments to implement the policy announced last week by the President. I'm sure most of you are familiar with it but we can review it during Q&A, if that would be helpful.

What I'd like to do is update you on where CDC stands in regards to reviewing the smallpox preparedness plan that have been coming in since the beginning of December.

Now, to date, we have received plans from all 50 states, plus LA County, Chicago, New York City and Washington, D.C. Our review reveals that approximately 440,000 people who would serve on smallpox public health response teams or smallpox medical response teams may be offered vaccines and over 3,600 medical facilities that may participate have been identified.

The review of the plans is still in progress, but so far, over half of those submitted have been reviewed and have met the criteria necessary to begin vaccinating public health and medical response teams early next year. We don't anticipate any significant problems in the remainder of the plans meeting criteria. We're just still in the process of reviewing them and checking on some details.

CDC is continuing on a number of fronts to educate clinicians and the public about smallpox and we know that educating clinicians is extremely important because most members of the general public will refer to their clinicians for information and advice.

Just this week, we've hosted over 200 public health workers from states across the country to come in and get training on how to administer the smallpox vaccine. These health workers, in turn, will go back to their states and train others who will be administering the vaccine.
So sort of a "train the trainer" program.

In addition, we're hosting satellite broadcast tomorrow entitled "Smallpox Preparedness: Considerations For Response Team Volunteers," which is a program specifically designed to provide information to people who are making their decision about whether they want to volunteer to participate in this initial stage of the immunization program.

We hope the information in the video will address their questions. We've actually solicited questions from members of groups that would be included in those response teams, so that we are hoping to be as responsive as we can to the actual concerns from these informed volunteers.

We also continue to update our website of course. I think there's a lot of valuable information on it, and our hotline is continuously available, so that people can call with questions about smallpox and information about the hours of the hotline and accessing the hotline can be made available to you, if you're interested.

I'd really just like to close by emphasizing what this program and policy is all about.

First of all, CDC definitely supports the President's policy. We think this is a measured response to the information that is available about the current smallpox threat, and we know that protecting our public is the highest priority for all of us. The President's policy ensures that we can quickly and effectively respond to a smallpox attack and that by offering the vaccine to the first people who respond to an emergency, we strengthen the ability of the whole system, including states, communities and hospitals, to protect the general public. We also recognize that this is a policy that we're in the initial stages of implementing.

We're going to learn, as we go forward with it, and we will keep you updated with information as the implementation criteria and experience informs us about modifications or changes that we want to make in the overall program, and we appreciate all the help you've given us in putting the accurate information out about smallpox and vaccine, and the risks and benefits of the program.

CDC MODERATOR: Okay, Mary Sue, I think we're ready for questions, please.

AT&T MODERATOR: And ladies and gentlemen, if you wish to ask a question, please press the one on your touchtone phone. You will hear a tone indicating that you've been placed in queue.

If you pressed one prior to this announcement, we ask that you please do so again at this time. You may remove yourself from queue at any time by pressing the pound key. If you are using a speaker-phone, please pick up the handset before pressing the numbers.

Once again, if you have a question, please press the one at this time.

Our first question comes from Ann Carrns [ph] with The Wall Street Journal. Please go ahead.

QUESTION: Hi. Good morning, Dr. Gerberding. My question relates to the handful of hospitals this week who have announced that they don't plan to offer the smallpox vaccine to their employees.

I was just wondering how significant this is in terms of the emergency planning that's going on, and if a lot more hospitals opt out, what that will mean to their response plan.

DR. GERBERDING: CDC fully expected some variability in the hospital's decision about participating. Now, this is a voluntary program, and we know from our long experience in working with the public health system that implementation varies from jurisdiction to jurisdiction. So, it's really not surprising that some hospitals would have chosen not to vaccinate. In fact, we had included that in our planning estimate for the amount of vaccine that would be allocated to this program.

What is important, I think, is that we have a large number, 3,600 hospitals, that have been asked to consider participation, and we know that we're going to be far more prepared with the response teams that are stepping up to the plate than we are today. So we're very optimistic, and I think confident that we will be able to get this job done right.

CDC MODERATOR: Next question please.

ATT MODERATOR: And our next question comes from Anita Manning with USA Today. Please go ahead.

QUESTION: Hi. Thanks for doing this.

Dr. Gerberding, I just had a question about the expected adverse events that we'll see related to the vaccine. Is there going to be a central reporting place, or how will that be reported? Will it be just within the states, or will the CDC have all that information and be able to tell us about those adverse events?

DR. GERBERDING: The monitoring of adverse events is the critical component of this program. CDC and the Department of Defense are working together to share information as we go along with the kinds and frequency of the adverse events that are being reported. And that information will be collected and organized by CDC. We are already working with states on the tools and the methodology for that reporting, and it's a really critical investment.

In addition, the Institute of Medicine is working this week to provide input into the process of monitoring the safety of the program so that we're sure that we are doing everything we can to get accurate information back to people as quickly as possible.

CDC MODERATOR: Next question, please?

ATT MODERATOR: And our next question comes from Laura Meckler with the Associated Press. Please go ahead.

QUESTION: Thank you. I have two parts to my question.

The first is do the 3,600 hospitals that you mentioned in terms of potentially participating, are those hospitals that have already agreed to participate, or just ones that have been identified by the states as potential participants?

And secondly my question is about transitioning into stage 2. Where are you? Have you prepared the guidance for the states yet? And if you could just give us an update on how you transition from stage 1 into stage 2.

DR. GERBERDING: With respect to your first question, states have used different methods for reporting on the number of hospitals included in the initial phase of the program. Many states have pre-identified hospitals that have agreed to participate. In fact, the majority of the hospitals included in that 3,600 have already agreed to participate.

With respect to your second question about transitioning into the expanded access for the police, the firemen, and the other broader category of health care workers, we don't expect to have the guidance for that developed in a short time frame, because we're going to need to get input from the stakeholders in those communities, and work with our partners in state and local health agencies to get out a guidance that makes sense and is a feasible implementation time line.

So I'm not prepared to tell you the date of the guidance release, or the date on which we would expect the plans for that to be returned. But obviously we want to do it as expeditiously as we can, but we're certainly not going to do it in a crash course, because our highest priority right now is get the smallpox response teams prepared and immunized.

QUESTION: Thank you.

CDC MODERATOR: Mary Sue, next question please. And if a reporter has a follow-up that they'll indicate, we'll try to get to the follow-up question as well. Mary Sue, next question please?

ATT MODERATOR: Our next question comes from John Lauerman with Bloomberg News. Please go ahead.

QUESTION: Hi. Thanks for taking my question. When will we know, or how will we know that health care workers have volunteered? That is, what's the mechanism for them to volunteer? Is it a public mechanism, or is it private? And how soon will we know what the rates of volunteering are?

DR. GERBERDING: Yes. The actual management of these programs is of course handled at the level of each individual state and local jurisdiction, and so the mechanisms that they're going to adopt to get people involved and initiate the immunization program will really be up to their discretion. And I'm sure they have a strong incentive to protect the privacy of the individuals who are involved in the program. But we will be able to report on some summary information about the numbers and so forth, as we go forward.

QUESTION: Do you know when that might be?

DR. GERBERDING: But it wouldn't happen until after the program was implemented.


CDC MODERATOR: Next question, please?

ATT MODERATOR: Our next question comes from Ceci Connelly, with the Washington Post. Please go ahead.

QUESTION: Thank you. Hi, Dr. Gerberding. I was wondering if you could help us with as many of the specific details of phase I as possible. A couple of the things that come to my mind are: We know that the vaccine comes in 100 doses per vial. So will you have some sort of requirements for state that when they start phase 1 they have at least groups of 100 readily available?

Also wondering, have you got all of the various forms and information packets already prepared to begin that phase 1, or they still in development?

And also on a question about children, I know I just heard from individuals, they've read that children shouldn't be vaccinated, but is there an actual age cut-off?

DR. GERBERDING: Let me start with the first part. You're quite right, Ceci, that the vaccine comes in 100 doses per vial when it's diluted. We're working with our expert logisticians from the National Pharmaceutical Stockpile, who are really the world's experts in deploying these kinds of assets, and they have an enormously comprehensive strategy for ensuring not only are we avoiding waste of vaccine as it gets distributed locally, but also that it's protected in special containers that keep it at the ideal temperature, so that its potency is maintained. And finally that it's stored and maintained in a secure environment, so that it's not lost or stolen or in some other way interfered with.

So this is actually a place where CDC's planning has taken us, quite far along the road, and we will be working out the solution to distributing the vaccine in individual jurisdictions, depending on how they plan to implement their policy. Our priorities are certainly efficiency in use of the vaccine, but also safety and security of the product.

The question about use of the vaccine in children. The vaccine that we're using for this stage of immunization is a licensed product. Obviously we don't expect any children to be included in the emergency response teams that we're talking about. But in the case of an emergency, children would be included in a mass vaccination program, and if they were exposed, they would be immunized regardless of their age.

And I'm sorry, I didn't remember your middle question.

QUESTION: Oh, well, I was just asking in terms of if CDC has already prepared the various information packets or any kind of forms that this first group of vaccines would respond. And that also reminds me that I wanted to ask procedurally, are you vaccinating your first group of trainers? Or in other words, is there going to be sort of a domino process when you get started?

MR. : Ceci, we've been joined by the Associate Director here at CDC for terrorism preparedness and Response, Mr. Joe Henderson. So I'm going to let him take a crack at that one.


As far as the documents that you refer to, we have initially posted a number of documents that we would use on our website back in November, and we have been working day and night with the states to make sure these documents are appropriate. So what you'll see on the website now if you were to look are samples of those documents. But there's an awful lot of specificity that we need to add to ensure that those documents can work in a clinic setting, especially as it pertains to the first stage of this program.

The other question that you had about the trainers, Dr. Gerberding talked about the fact that this week in Atlanta we've trained a number of folks, and the idea of the training was, in fact, train the trainers. So it is a domino effect. We're training these individuals to go back to the states, then train their own folks in their states. So we think in a relatively short period of time, we'll have an awful lot of folks trained.

CDC MODERATOR: The next question please.

ATT MODERATOR: Our next question comes from Mariam Falco with CNN. Please go ahead.

QUESTION: Hi, Dr. Gerberding. This is indeed Miriam. I have two quick questions. Number one, following up on an earlier question, do you expect that we will have listings of people with adverse effects, state by state, similar to the way the West Nile virus was reported this summer? And some of the folks that I have talked to in hospitals have concerns about the needles that were being used, the 50 million dosages using 1970s antiquated, not-so-safe technology. Do you have any response to that?

DR. GERBERDING: Well, first of all, with respect to how we will be reporting out the progress of the program as it goes forward, this is a situation where obviously the domain of control of the information is at the state level, and CDC will reporting out summaries that indicate how many people have been vaccinated, and what kinds of adverse events are being experienced, and how many people are experiencing them. But we will not necessarily be reporting things by location, in part because we want to protect the privacy of the individuals who are involved in those situations. So we will defer to our state partners to provide the details about the experience in their own jurisdiction. CDC's role is to summarize it and to present it in terms of numerator/denominator context. With respect to this needle issue, the bifurcated needle is the needle that was used to eradicate smallpox off the face of the Earth. So it's a completely effective needle for accomplishing its stated purpose and it works quite well.

The products that have been evolved to reduce the opportunity for someone to sustain an accidental puncture with this needle, Unfortunately, do not fit in the vial of smallpox vaccine that we are using, they're too short, and so they are not appropriate for use at the current time. We're hoping that products that meet those specifications may become available, but, for right now, we know this needle can be used safely.

We're going to be emphasizing the proper disposal and use of the needle and I think we'll be able to get this immunization program safely initiated with the products that we have now.

QUESTION: Thank you.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Our next question comes from Larry Altman with the New York Times. Please go ahead.

QUESTION: A couple of questions here. First, to clarify something earlier, were Grady [ph] and Virginia Commonwealth among the 3,600 hospitals that were designed and then declined, or did they decline beforehand, if you know that?

DR. GERBERDING: Larry, I have to defer that question to the involved hospitals to respond to, or the involved states.

QUESTION: All right. The second question is, What do we know about the complications from smallpox vaccinations that have gone on in Israel and England in recent weeks?

DR. GERBERDING: We're getting that information from various sources and we haven't fully been able to verify the numerator/denominator data that we have, so I don't have an estimate for you. But we are planning to make a site visit to Israel. Mr. Henderson will be going there in the very near future to meet with clinicians there and to really get, firsthand, a look at that data, so that we can get it back and out as quickly as we can.

QUESTION: But Britain, at least there's a report from Britain that there have been at least four hospitalizations from contacts. You don't have any of that information?

DR. GERBERDING: We have the same sources of information that you probably do but we haven't been able to validate that. So we will get back to you as soon as we can with confirmation.

QUESTION: Thank you.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Our next question comes from Marin [ph] McKenna with the Atlanta Journal-Constitution. Please go ahead.

QUESTION: Hi; thanks for doing this briefing. Could you be a bit more specific about what the plans are for releasing vaccine to the states. Earlier on, you had said that once the plans were reviewed and approved by CDC, vaccine would be released to the individual states, and you said at the start of the briefing that more than half have been. However, since, I think that statement was first made, that after the plans were approved the vaccine would go out, the Homeland Security Act has been passed and states have said they're not going to start vaccinating until after the 24th of January because of the liability provisions. So could you clarify and give us some more specifics on this.

DR. GERBERDING: Well, first of all, approval of the plan is a first step to initiating the program, but the states have a lot of activity to go on between the point at which the have a plan that meets criteria and the point at which they're able to immunize people safely, and so we're not pushing them to start started at the point that their plan meets criteria. We've actually always said that they would have at least 30 days from the point that that occurred, before we would even realistically expect them to begin any kind of immunization program.

So vaccine is going to be made available o them when they're ready to receive it, when they want it, and when they're ready to go with their program.

AT&T MODERATOR: And our next question comes from David Brown with the Washington Post. Please go ahead.

QUESTION: Hi. I missed the first ten minutes, so if you answered this question, then ignore it. I'm wondering if there is a specific protocol that CDC is going to prescribe for both informing and getting consent from health care workers, specifically whether the question that there should be two visits, which came up in the last ACIP meeting. Is that going to be a requirement, that they be shown photographs of the adverse events, and also, is there going to be a standard consent form?

CDC MODERATOR: Mr. Joe Henderson will answer that question.

MR. HENDERSON: There's a number of things that we're working with the states on right now. We want to do everything we possibly can, working with our state and local health colleagues, to ensure that we provide the information to the candidates for this vaccine so they can make an informed decision, and clearly understand the risks and benefits of the vaccine.

One thing we're doing is we're working on a videotape that they could watch, that clearly provides information for them as to the risks and benefits. We're also going to have materials that we've developed and we're continuing to develop working with state and local health agencies, that would be given to an individual prior to them coming to the clinic, so that if they have questions or concerns about the vaccine, they have an opportunity to be educated and then they can talk to individuals in the clinic to get clarification on some of their concerns or issues.

Then, again, there'll be the process in the clinic where they once again review the materials that talk about the risks and benefits of the vaccine, and we actually have a number of states that are looking at these materials right now with individuals who can give us some feedback as to whether or not this information is even written at a level that various educational levels could absorb. So I think we're doing an awful lot, here, at CDC, to make sure we're passing this information on as effectively as possible.

DR. GERBERDING: I'd just like to add that tomorrow we're hosting a satellite broadcast to provide information to the people who might be volunteering to receive the vaccine. This satellite broadcast will occur at noon tomorrow and it's going to be rebroadcast on January 9th. But of course it'll also be available on our Web and we'll be making it in video format, and so on and so forth, so that we keep it out there, in the hands of the people who need the information.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Our next question comes from Jamie Tallon [ph] with Newsday. Please go ahead.

QUESTION: Yes. Hi. What about people who were vaccinated decades ago, even health care workers? Do we know anything more about residual immunity?

DR. GERBERDING: We know that some people probably have residual immunity but it's impossible to say who, and so when we're--if our goal is to provide protection to a group of people, we have to assume that all of them need immunization, and even if they have some residual immunity on the basis of laboratory information, there is no known relationship between what you might see on a laboratory test and clinical protection.

So for purposes of a vaccine program, we have to assume that no one is currently protected from smallpox.

QUESTION: Thank you.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Our next question comes from Michelle Myer with AARP Bulletin. Please go ahead.

QUESTION: Hi. Thanks. I was wanting to find out the phone number for the hotline to CDC.

DR. GERBERDING: Yes. The hotline number is, in English, [888] 246-2675. And in Spanish, [888] 246-2857 and TTY [866] 874-2646.

QUESTION: Could you repeat that TTY for me, please.

DR. GERBERDING: Yes. TTY is [866] 874-2646.

QUESTION: And what people be able to find out with the hotline?

DR. GERBERDING: This provides public information that people can access to just ask general questions about smallpox or other issues related to terrorism preparedness and response. It also relates directly to our website, where we have a huge amount of information. And as we get questions into the hotline, we repost that information on our website, so that we have an evolving library of knowledge to help people get their questions answered.

QUESTION: Okay, thank you.

CDC MODERATOR: Next question please?

ATT MODERATOR: And our next question comes from Bob Lamindolo with the Sun Sentinel, Fort Lauderdale. Please go ahead.

QUESTION: Hi, Doctor, thanks for taking the question. I just wondered if you could elaborate more on deciding about who should pay for the adverse reactions in the workers' comp, and that sort of thing.

DR. GERBERDING: First of all, just for those who haven't been following this particular issue, let me try to make sure that everyone understands the distinction between liability and compensation, because these are two completely different phenomenon.

Section 304 of the Homeland Security Act was a very narrowly tailored part of the legislation, and it specifically addresses liability coverage that would have presented obstacles to immunization. So the bottom line is the law was intended to give protection to the companies that make vaccine, to those who are in the administration program, and the institutions where it's administered. In order for individuals to recover damages under this liability act, they would have to prove negligence on the part of any of the covered entities. So the liability coverage allows the program to delivery vaccine without risk to the people who are participating in the program administration.

Compensation is a very different issue, and that has to do with the benefits that someone receives if they are injured as a consequence of the vaccination program. The program that the President has approved is a voluntary program, and we are encouraging the prospective volunteers to know how their workers comp programs, their health benefits, or their other insurance plans cover adverse events related to the vaccine.

And I think it's important to appreciate that in these initial stages of immunization, all of the people we are recommending vaccine for are, in fact, workers. But we also recognize that the workers compensation mechanism varies from state to state, and there are a lot of answered questions about the scope of coverage.

So Congress is in recess right now, and we're not aware of any formal legislative proposals to address any gaps in coverage. But HHS will continue to work with Congress as this process unfolds.

CDC MODERATOR: Next question please?

ATT MODERATOR: Our next question is a follow-up question from Laura Meckler with the Associated Press. Please go ahead.

QUESTION: Hi. Thank you. Just two really quick things that came up from others.

One was asked previously, but I didn't hear the answer, about whether you specifically will be showing people who may volunteer to get the vaccine photographs of adverse events, and/or photographs of smallpox cases. Will they actually see those pictures when they're making their decision.

And secondly, will you have VIG available at all of your [inaudible], or will that be just distributed from Atlanta? How is that going to work?

DR. GERBERDING: With respect to the pictures, we're certainly, those pictures are out all over, including on our internet and everywhere else, and the brochure that we're using to describe smallpox has a very, I think, candid photographs of both the smallpox infection as well as some of the vaccine side effects. And I will be using some photographs tomorrow when we provide the information to the smallpox volunteers.

So I think it's part of an informed process. People need to have an understanding of what these side effects are. But we want to get the right balance here, so that we're not horrifying people in one direction or another. We want them to understand that there can be very serious complications, but also there are mild complications, and to have a realistic understanding of what to expect.

Presenting the worse-case scenario is an important part of informed consent, but it needs to be balanced with information about the probability as well as the severity of that exposure.

I'm going to ask Joe Henderson to answer their question about VIG.

MR. HENDERSON: The process that we're working with the states on now, as far as assuring they have access to VIG, because there are, you know, manageable quantities of the VIG right now that we feel we have plenty to satisfy states running the program. But we want to be careful about how we distribute VIG to help manage the adverse events that we might see. So the process that we're putting in place with the states is that upon an individual receiving an evaluation from their personal physician or from the physician in the clinic where they received the vaccine, there will be rapid consultations done to determine if VIG is warranted. And if it is, by access to the National Pharmaceutical Stockpile program, we'll provide VIG to that health care provider to address those issues within 12 hours.

QUESTION: So you can get it from the central location


QUESTION: And Dr. Gerberding, if you could just expand a little bit more on your point that balancing, showing people what the realistic potential effects are with not, scaring people unnecessarily--how do you do that? I mean, I've seen those pictures, and they're obviously quite disturbing. So, could you just expand upon that a little bit, of how you do you get that balance right?

DR. GERBERDING: Yes, I think that first of all the communication is best delivered by a clinician who is in face-to-face contact with somebody who's making their individual decision. But I'm speaking as a clinician, if I were in that situation, what I would try to do is to first of all make sure that there's an understanding of why immunization is being recommended, make sure that the person understands that their choice is completely voluntary. Importantly, make sure they understand that the most important aspect of reducing their risk of any complication is to not get the vaccine, if they have one of the contraindications or if someone in their home has the contraindication, and then present them the spectrum of what they can expect if they get the vaccine, which most commonly is the local soreness and discomfort and inflammation that occurs at the injection site. But also, then, to explain, and I think realistically a picture is worth a thousand words, what some of the more severe reactions do look like, and then to present the frequency of those reactions with some context about the data are old, and some of the populations who are experiencing those adverse event rates were not as carefully screened as we intend to screen the population we're recommending vaccine for right now, and secondly that we do have treatments available for the side effects.

CDC MODERATOR: Mary Sue, we're going to move to the portion of the briefing on West Nile shortly. So we have time for maybe one or two more question, please.

ATT MODERATOR: And then our next question comes from Anita Manning with USA Today. Please go ahead.

QUESTION: Thank you and I'll be fast. I just wanted to clarify that the 200 health care workers who were there, Dr. Gerberding, to learn how to give these vaccinations, is it correct that all people giving the vaccinations will themselves have to be vaccinated?

DR. GERBERDING: The current recommendations, even before the President's policy, are that anybody who handles Orthopox viruses should have the vaccine. So someone who's administering vaccine is obviously handling an Orthopox virus, and they need to be vaccinated. And so part of the ruling up of the program is that the vaccinators will likely be vaccinated in the first wave, so that they're prepared to then vaccinate other people. And the state plans address that.

QUESTION: Thank you.

CDC MODERATOR: And Mary Sue, let's make this our last question on smallpox, please.

ATT MODERATOR: And our question comes from John Lowerman with Bloomberg News. Please go ahead, sir.

QUESTION: Yes, just a quick follow-up on the bifurcated needle. Are you saying that the needles that we have now are too short?


QUESTION: I guess I misunderstood.

DR. GERBERDING: Yes, it is a misunderstanding. The bifurcated needle that we are using now is identical to the needle that was used to eradicate smallpox. It's the tried and true needle. We're using it in the clinical trials that are underway to evaluate the dilutions of vaccine in the new vaccine products. And we know how to use this needle and we know that it can be an extremely effective way of administering the vaccine. There have been some new needles that have been developed, and the one that had certainly tweaked our interest as potentially being able to cover the sharp part of the needle, once it's been used, is unfortunately too short to reach the bottom of the vaccine vial, and if we used it we would end up either potentially wasting vaccine because we couldn't get it out of the vial, or if we tipped the vial, then we would run the risk of spilling the vaccine out and wasting it that way.

QUESTION: And who makes that needle, quickly?

DR. GERBERDING: I don't comment on that.

QUESTION: Okay, thank you.

CDC MODERATOR: Okay. Thank you, Dr. Gerberding and Mr. Henderson.

And now we'll move on to the second portion of our telebriefing today, in which we will cover a series of articles that are published in today's MMWR, on West Nile Virus infection. Do we have Drs. Petersen and O'Leary with us, please?


DR. O'LEARY: Hello.

CDC MODERATOR: Hi, great. Drs. Petersen and Dan O'Leary are our West Nile virus experts out in our division of Vector-Borne Infectious Diseases in Ft. Collin, Colorado. And if they have a brief prepared remark, I'll ask them to give that at this time. If not, we may proceed to the session, the Q&A session on West Nile Virus infection. So I will at this time turn it over to Dr. Petersen.

DR. PETERSEN: Yes. What we'll do is we will give a brief remark about all three of the articles. Dr. O'Leary will give a remark about the surveillance article and the transuterine infection article, and I will follow up with a brief statement about the occupational risk article.

DR. O'LEARY: Okay, this is Dr. O'Leary.

I'll start off with a brief summary of the provisional surveillance for West Nile Virus in 2002 in the United States. Between January 1st and November 30th of 2002, West Nile Virus activity was reported to the CDC from 44 states and the District of Columbia. It spread for the third consecutive year into new areas of the United States as far west as Washington State. In 2002, there were nearly 3,400 human West Nile Virus illness cases, reported from 37 states and D.C. And over 2,300 of these cases were infections of the central nervous system, otherwise termed "West Nile meningoencephalitis." And these cases represented the largest epidemic of meningoencephalitis caused by West Nile ever documented.

In addition to meningoencephalitis cases, there were over 700 cases of West Nile fever, a milder form of West Nile infection, that affects relatively younger age groups. The states have reported the most human West Nile Virus cases were Illinois, Michigan, Ohio, Louisiana, Indiana, and Texas. The first human cases in the southern states proceeded those in northern states by about one month. While persons at any age can develop neurologic disease from West Nile infection, persons in older age groups are at higher risk for West Nile meningoencephalitis and death.

In 2002 we also reported person-to-person West Nile Virus transmission by blood transfusion, organ transplantation, intrauterine transmission, and possibly by breast feeding. In 2002, numbers of reported West Nile cases in animals were unprecedented. There were over 14,000 reports of West Nile infected dead birds from 42 states and D.C., and over 9,000 reported equine cases, representing a twelve-fold increase over 2001 from 38 states. Bird and horse-based West Nile surveillance continued to be the mainstay for monitoring the activity of the virus and its spread in the United States.

Also the capture and testing of mosquitoes for West Nile infection is an augmentative mainstay for the state level surveillance programs.

That concludes my summary on the West Nile surveillance. And what I'd like to do now is move on to the article that was published on intrauterine West Nile infection.

The Onondaga County New York Health Department, the New York State Department of Health, and the CDC present in this week's MMWR the first report of intrauterine West Nile virus infection. West Nile Virus has not previously been associated with infection of the fetus or adverse birth outcomes. In 2002 a pregnant woman developed West Nile Virus infection and she gave birth after a full-term pregnancy to an infant who was diagnosed with brain abnormalities. Laboratory tests confirmed the infant's recent infection was West Nile Virus.

Intrauterine infections with other mosquito-borne viruses related to West Nile have been associated with miscarriage or severe illness in infants, but the frequency of these adverse events is unknown. This single case that we report does not prove that West Nile Virus infection causes adverse birth outcomes. Pregnant women should take precautions to reduce their risk for West Nile Virus and other mosquito-borne viruses by avoid mosquitoes when possible, using protective clothing and repellants containing DEET, per manufacturer's directions. There is currently no effective treatment for West Nile Virus infection.

Pregnant women living in areas of current West Nile Virus activity, who develop illness with fever should seek professional health care, and if it's deemed appropriate, they should be tested for West Nile infection. However, pregnant women without illness should not be screened for West Nile infection.

And that concludes my summary of these two articles. Thank you. And I'll hand it to Dr. Petersen.

DR. PETERSEN: Yes. Good afternoon or morning, depending on where you are.

We report two recent laboratory-acquired West Nile Virus infections in the United States. West Nile Virus infection in two microbiologists resulted from exposure through percutaneous inoculation in laboratories. One was from a needle stick exposure to a person handling live virus, and the other person was a person who received a scalpel injury while handling a West Nile-infected dead bird.

Illnesses in both laboratory workers were mild and self-limited, which is typical of illnesses in West Nile virus infected persons.

These cases confirm that laboratory workers are at risk for occupationally-acquired West Nile virus infection, including West Nile virus meningoencephalitis.

Employers and workers should follow procedures to minimize the risk of injuries from sharp instruments and to minimize airborne exposures.

Workers should clean and treat wounds immediately and thoroughly, if they occur, and should report any injuries to supervisors for further monitoring.

Employers should report any cases of infection to public health authorities. That concludes my statement.

CDC MODERATOR: Okay. I think we're ready for questions, please.

AT&T MODERATOR: And, once again, ladies and gentlemen, for questions please press the one at this time.

We have a question from Dietra Henderson with the Denver Post. Please go ahead.

QUESTION: I have two questions on the interuterine West Nile virus infection. The mother's age is twenty years old, and she is described as previously healthy. Would you expect such severe illness in that case or does pregnancy or the herpes add another layer of risk for her?

A second question is I'm trying to get a sense of the significance of the congenital abnormalities for the infant.

DR. O'LEARY: About the first question, Dietra, as stated in the other, the summary article, age, increasing age is a risk factor for more severe West Nile viral disease. However, we have documented meningoencephalitis or central nervous system illness in younger age groups as well, and although it happens less frequently than in older age groups, it is not unheard of, that this young woman developed a central nervous infection of West Nile virus.

The fact that she is pregnant, you know, I don't want to speculate on whether her pregnancy was a risk factor for additional severity of illness, and if Dr. Petersen wants to comment, that's fine. But I don't want to speculate. We don't know if pregnancy is an additional risk factor for severity of West Nile illness.

I'm sorry. The second part of your question was...?

QUESTION: It's hard for me to tell from the description exactly what's going on with the infant. Is the infant still alive?

DR. O'LEARY: Yes. The infant is still alive. The infant did have extensive pathology, pathologic changes to its brain that were revealed on magnetic resonance imaging, or MRI, and its development is being monitored by its doctor, and--but yes, the infant is still alive and is getting regular checkups.

DR. : Next question, please.

AT&T MODERATOR: Our next question comes from Rita Rubin [ph] with USA Today. Please go ahead.

QUESTION: Hello. Thanks for taking--actually, I have two questions. Are there other possible explanations for the problems the baby was born with? I mean, are these a typical combination of problems?

I also wondered, is the baby blind? because I know there was a problem with the baby's eyes at birth. And my other question is, is it possible that there have been many more cases of interuterine transmission from women who did not get sick and still could have passed it on to their newborns?

I know you're developing a registry but it seems like that might be a little--you might be a little limited because a woman may give birth to a baby with a number of problems, like this baby, but, you know, she didn't have anything striking during her pregnancy. So I just wanted your thoughts on that.

DR. O'LEARY: As far as your first question, addressing other explanations for the baby's neurologic illness, other high-suspect infectious agents were ruled out as the cause of the baby's abnormalities. There are certainly birth defects that occur for reasons that are unknown and other high suspects have been ruled out in this case.

QUESTION: You mean besides infectious agents?

DR. O'LEARY: Well, the woman's history doesn't indicate risk factors for any other type of abnormalities, toxicologic, those sorts of things. But, yes, other infectious agents were ruled out. She was otherwise healthy and there's nothing in her history that would raise a red flag as far as a risk factor for the baby's problems.

The baby did have chorioretinitis at birth. I do not know if the baby is blind at this time. As far as reports of illness from asymptomatic, in babies born to asymptomatic women, that is very difficult to assess because the cases reported to us are cases of West Nile viral illness, and asymptomatic women often do not know that they were infected during pregnancy.

So, right now, we wouldn't have a way of assessing that. So I hope that answers your second question.

QUESTION: Well, some just say it could be a more common problem than recognized because if these are--you know, there could be women transmitting infection who themselves did not have any signs of illness.

DR. PETERSEN: This is Dr. Petersen. I'd like to just comment. One is on the explanation of the baby's neurological deficits. It's very possible that West Nile virus was the cause of this baby's neurological deficit, but with only one case it's impossible to really determine cause and effect. Other known causes of similar neurological deficits were ruled out.

As far as other cases of interuterine infection, your comment that many of the women infected with West Nile virus may have transmitted the infection of their baby and not even known it because the baby may not have any symptoms is a very good comment.

We, undoubtedly, with the hundreds of thousands of people infected this year, many of the women, many pregnant women were undoubtedly exposed to the virus, the fact that we haven't seen a great deal of suspect cases is fairly reassuring.

As far as other cases of interuterine infection, we do have one well-documented case that we have followed, where the woman clearly became infected during her pregnancy and delivered a healthy infant, and it was shown that the infant had not been exposed to the virus.

QUESTION: And that that women got sick and that's why you knew she was infected.

DR. PETERSEN: Correct.


CDC MODERATOR: Can we have our next question, please.

AT&T MODERATOR: Our next question comes from Larry Altman with the New York Times. Please go ahead.

QUESTION: Actually, a couple questions here. It's not clear from the report why the doctors suspected abnormalities in the baby, because as I read it, it said the neurological--I mean the initial examination was normal, in that part. Second, what would it take to prove cause and effect? If you got the virus by PCR [ph] from the bra--well, you wouldn't be doing a brain biopsy--but is there any way that you could prove cause and effect?

Thirdly, what is the risk of DEET to mothers who would take it, and what if this mother had used DEET and then had the baby with the abnormality? How would we be assessing it?

And, lastly, what other viral infections can be transmitted in utero besides Japanese B and dengue?

DR. O'LEARY: I'll take the first question. The doctor suspected abnormalities in the child on a general physical examination after birth. The doctor was doing an examination of the child's eyes and noticed, was having a hard time doing a complete assessment of the back of the child's eyes with an ophthalmic exam, and so ordered a consult, and an ophthalmologist was called in, completed an ophthalmologic exam and documented some abnormalities in the child's retinas, which led to an expanded neurologic exam that revealed the brain abnormalities.

The second question about proving cause and effect in interuterine infection, in the cases documented with interuterine infection of Japanese encephalitis and dengue, the virus was actually cultured from either blood or blood of live-born children or aborted fetuses, and in this case we would consider confirmation of--we would consider a culture of the virus from tissues from the baby, actually the baby's central nervous system, confirmation that there was infection, and many times, what is required for further proof of actual causality, virus causing the pathology, is to look at biopsy tissue, and in this case of course it was unavailable. You can see pathology in biopsy tissue slides.

The use of DEET in pregnant women.

DR. PETERSEN: Yes. This is Lyle Petersen. The other thing is that if we started to see certain types of congenital abnormalities that were more likely to occur in women who were exposed to the virus during their pregnancy versus women who were uninfected, that would also provide evidence that there was some cause and effect of the infection with the virus to certain congenital abnormalities.

DR. O'LEARY: We know of no contradictions to the use of DEET in pregnant women. There's no evidence that using DEET during pregnancy causes problems for either the mother or the infant. I'm sorry. Your last question, sir, was...?

MALE: Other upper viral infections.

QUESTION: Or other viral, not necessarily upper viral.

DR. O'LEARY: Well, there are other viral infections such as rubella virus, herpes virus, and there are other viral infections. Off the top of my head, none are coming to me; but those are two that I know are transmitted in utero.

QUESTION: What I'm trying to get at is how unusual or how usual is adding the possibility of West Nile to the list? I mean, is it a small list? Of viruses that are known, is it a small percentage or a large percentage?

DR. O'LEARY: I do not have in my recall right now a comprehensive list of viruses that are transmitted in utero, so I can't answer that question very accurately at this point.

QUESTION: Can we get an answer afterwards?

CDC MODERATOR: Yes, Larry, just call the Press Office, and we'll try to square you away?

QUESTION: Well, can you call back?

CDC MODERATOR: Shoot me an e-mail, and we'll square you away.

DR. PETERSEN: Yeah, I mean, Larry, as you know, a number of viruses all can be transmitted, and it includes CMV, lymphocytic choriomeningitis virus, EBV. Others could be transmitted that way. What the whole long list is we could supply you later, but it is quite a long list.

CDC MODERATOR: Next question, please.

AT&T OPERATOR: Our next question comes from Rick Weiss with the Washington Post. Please go ahead.

QUESTION: Thank you. I have three questions. One is you've got evidence so far of antibodies in the child, but not good evidence yet of infection, and I'm wondering if there's any feeling on your part that antibodies themselves can cause the kind of problems that you're looking at here, and, if so, what are the implications for that with vaccination, potential vaccination if such a vaccine were to be developed for pregnant women? That is, if antibodies to West Nile might have an effect on the developing central nervous system.

Second question is, to the extent that other viruses have been shown to cause problems in fetuses or newborns, have any of those complications been similar pathologically to the evidence of brain problems that you're seeing here or is this different?

And, third, I still don't have a sense of the clinical condition of the child. I mean, is behavior and development right now? To a lay reader like myself, I read about major changes in white matter in the brain, and I think the kid is pretty messed up, but can you please describe the condition.

DR. PETERSEN: This is Dr. Petersen.

Going to your first question about the evidence of antibodies in the child, we have no evidence that the presence of any West Nile Virus antibodies would have any adverse effect on the infant. What is important is, is that IGM antibody was detected in the infant, and IGM antibody is not transmitted from mother to child, so the presence of IGM antibody in the child indicates that the child was actually infected with the virus.

Now, for your second question, whether other viruses caused similar complications or whether they're different from what we've seen here, I am not a pediatrician, actually, and so I'd be happy to answer that question off-line when we can get you a better answer. Some of the abnormalities associated with this child could be consistent with other viruses that have been ruled out, but I would like to defer that till later.

Now, as far as the clinical condition of the child, the child does have severe neurological abnormalities, and further information can be obtained from the Onondaga County Health Department.

QUESTION: I'm sorry, but that's, you know, you're giving me an assessment of the nerves, strictly speaking. Is there anything at all you can say with regard to behavior? I mean, what does it mean to have severe neurological abnormalities. You're not talking simply about an MRI image. You're talking about the way the child behaves?

DR. PETERSEN: Correct, and we do not have the details of the child's exact clinical condition at this moment. However, the Onondaga County Health Department has access to that information.

QUESTION: I just have to say, if I can try one more time, I'm not optimistic about the Onondaga County Health Department, even though it's my home county, is going to tell me a lot about this.


QUESTION: But, certainly, you could at least narrow it down to, you know, motor versus cognitive or both, something like this?

DR. PETERSEN: If I had the details, I could tell you, but we do not have the details of what you're looking for. Another source you could contact would be the New York State Health Department.

QUESTION: All right.

CDC MODERATOR: Next question, please.

AT&T OPERATOR: Our next question comes from John Lauerman with Bloomberg News.

Please go ahead.

QUESTION: Yes, thanks for doing this. To the best of your knowledge, is this the first such case in the world or just in the U.S. or is it possible that this has happened elsewhere or likely? Could you reflect on that?

DR. O'LEARY: We've done a literature search, and this is the first documentation of this type of infection that we've seen reported anywhere.

QUESTION: Thank you.

CDC MODERATOR: Next question, please.

AT&T OPERATOR: Our next question comes from Alison McCook with Reuters Health.

Please go ahead.

QUESTION: Hi. I was wondering if you had, if anyone had suspected before that West Nile Virus could have been transmitted from mother to child, and if you hadn't, why not? And now that you know it may be, does this give you any clues as to how the virus works in the body, any clues that might help come up with treatments or anything in the future?

DR. O'LEARY: I think that this is a case of hindsight is 20/20. We, in looking back through the literature, we can see that there are other related viruses that have caused abnormalities in young infants, but we were looking for, actually, we were looking for, throughout the season, we were looking for these cases after the breast-milk incidents. We have been doing surveillance for these abnormalities in pregnancy, but we hadn't a precedent to compare against, and so--

DR. PETERSEN: Yes, because congenital infection has occurred with other related Flaviviruses, we had put out the word to state health departments to report any cases such as this to us, and this is how, through that kind of informal surveillance system, this is how this case was reported.

QUESTION: I'm sorry, who was that speaking first and second?

DR. PETERSEN: Dr. Petersen.

QUESTION: You were first, Dr. Petersen?

DR. O'LEARY: No, I was first. Dr. O'Leary was first.

QUESTION: Okay, thanks.

DR. PETERSEN: I think your second question was about treatment.

QUESTION: Yeah, well, if that gives you any clues as to how the virus behaves in the body, anything.

DR. PETERSEN: Well, the one clue it does give you is that the virus can be transmitted in utero, which hadn't been documented previously.

QUESTION: Okay, that's it. Thanks.

CDC MODERATOR: Next question, please.

AT&T OPERATOR: Our next question comes from Lynne Boyle [ph], with WebMD. Please go ahead.

QUESTION: Hi, I have two questions. I wanted to make sure I understand correctly. There has been one other documented case of West Nile Virus in a pregnant woman or more than one, and there was no transmission there?

DR. O'LEARY: That's correct. We've had one documented case that has come to term, and the baby was born. We know of other--we know of, actually, a couple of other cases where pregnant women have not had their children yet.

QUESTION: My next question, can you elaborate on what is known or suspected about transmission from breast milk?

DR. O'LEARY: Do you want to take that, Lyle?

DR. PETERSEN: Yes, all we know about the breast-milk transmission is that we have had one, a fairly well-documented transmission, although not completely conclusively proven. This was a case of a woman who received a couple of transfusions immediately postpartum. One of those transfusions was subsequently shown to be infected with the West Nile Virus. The woman became ill with West Nile Virus several days later, and was actively breast feeding before and during part of her illness.

We measured IGM antibodies in the baby, which were positive, which suggested that the baby had been infected. IGM antibodies are not transmitted from mother to child, so we know, for a fact, that the fact that there were IGM antibodies in the baby, we knew that the baby had actually become infected. We were also able to show viral genetic material in the breast milk of that woman.

Now we have another case that's a very similar case of a woman who got infected from a blood transfusion immediately postpartum who did breast feed her baby, and that baby did not become infected.

QUESTION: Thank you.

CDC MODERATOR: Next question, please.

AT&T OPERATOR: Our next question comes from Jim Erickson with the Rocky Mountain News. Please go ahead.

QUESTION: Hi, it's actually three questions.

Dr. Petersen, you said you don't have details on that infant's case, but in the MMWR article, where it says "severe cerebral abnormalities, including severe bilateral white-matter loss in the temporal and occipital lobes, and cystic change in one temporal lobe consistent with focal cerebral destruction," can you just explain, in simple terms, what that is, what that means. That's my first question.

Second is are you allowed, can you tell me a DOB and sex on this infant?

And the third question is we had a case out here in Denver where a woman who tested positive for West Nile claimed she got it by having intercourse with her husband, who was also positive for West Nile. Does this case with the infant lend any credence or say anything at all about the possibility of getting West Nile through sexual intercourse?

DR. PETERSEN: As far as the neuro imaging results that we've presented here, in lay terms what it means is that, for some reason, the infant has had destruction of part of its brain, for whatever cause. One cause would be West Nile Virus infection. And whenever you have this degree of destruction of the brain cells, it would be expected that there would be some cognitive and other neurological abnormalities associated with that.

As far as the date of birth and sex of the infant, we are not releasing that information for patient confidentiality reasons.

Now to your question for what does this mean for sexual intercourse, you can't draw any conclusions between the case in Denver and the trans-uterine transmission. We know that this is a blood-borne virus, and as a blood-borne virus, we knew that there was a potential for transmission in utero. As far as sexual intercourse, the case that was presented in Colorado was extremely inconclusive that sexual intercourse was the mode of transmission of that case.

Although sexual intercourse could potentially be a mode of transmission, there's no evidence that suggests that it is at this point in time.

CDC MODERATOR: Next question, please.

AT&T OPERATOR: Our next question is a follow-up question from Larry Altman with the New York Times. Please go ahead.

QUESTION: Regarding the laboratory cases, you have in there that laboratory workers need to be trained in precautions, and you're saying there's a lot more lab work going on, suggesting there are a lot more lab workers involved now. Were the two who were involved here given specific training in precautions for this or does this suggest a lapse in training?

DR. PETERSEN: I cannot speak for the training of one of the cases. For one of the cases, the person was a very experienced microbiologist who has decades of experience in handling these types of viruses and is well trained.

CDC MODERATOR: Next question, please.

AT&T OPERATOR: Our next question is a follow-up question from John Lauerman with Bloomberg News.

QUESTION: I think my question was answered. Thanks.

AT&T OPERATOR: Then, our next question comes from Michelle Meyer with AARP Bulletin. Please go ahead.

QUESTION: Yes, thanks. I just wanted to get Dr. Petersen's and Dr. O'Leary's full names and titles. It's Dr. Lyle, L-y-l-e, Petersen, M.D.?

DR. PETERSEN: Right, and it's P-e-t-e-r-s-e-n.


DR. PETERSEN: Right, M.D., and my title is I am the Deputy Director for Science of the Division of Vector-Borne Infectious Diseases.

DR. O'LEARY: And my name is Daniel R. O'Leary, O-apostrophe-L-e-a-r-y, DVM, and I'm a medical epidemiologist with the Arboviral Diseases Branch, the Division of Vector-Borne Infectious Diseases.

QUESTION: The other thing is you mentioned some statistics about this spread this year to 37 states or, actually, 47 states. What were the statistics between January 1st and November 30th?

DR. O'LEARY: It was 44 states, ma'am.

QUESTION: And how many people?

DR. O'LEARY: How many people? There were 3,389 reported cases of human West Nile illness.

QUESTION: And how many had the encephalitis?

DR. O'LEARY: Sixty-nine percent or 354 had meningoencephalitis.

QUESTION: Of that 2,000, how many?

DR. O'LEARY: Three hundred and fifty-four.

QUESTION: Had the encephalitis, and how many died?

DR. O'LEARY: There were 201 deaths--199 of the deaths occurred in patients with meningoencephalitis, and the remaining 2 occurred in people that were reported to have had a milder form of the disease called West Nile Fever. However, both of the two decedents from West Nile Fever infection were elderly persons over 80 years old.

QUESTION: Agewise, how about the other people; what percentage were over 50, what percentage were over 70? Do you have age statistics?

DR. O'LEARY: Yes. Well, I don't have the percentage of the total in each age group, but I can tell you that the percentage of people with meningoencephalitis who died increases with age. For instance, people from between 70 and 79 years old with meningoencephalitis, 13 percent of those individuals died of their illness; people between 80 and 89, who developed meningoencephalitis, 25 percent died; and of people 90 to 99 with meningoencephalitis, 27 percent died.

QUESTION: What about under age 50 versus over age 50?

DR. O'LEARY: Under age 50, I would have to total those up for you, and I'd be happy to do so--

CDC MODERATOR: Why don't you just read her the percentages.

DR. O'LEARY: I'll start at age 0 to 9. From ages 0 to 9, there were 0-percent fatalities; ages 10 to 19, 0-percent fatalities; ages 20 to 29, 1.5 percent died; 30 to 39, 0.8 percent died; 40 to 49, 1.7 percent died; 50 to 59, 3 percent died; 60 to 69, 9 percent died; and I gave you the other percentages. Again, these are all patients with meningoencephalitis, the central nervous system form of the infection.

QUESTION: Okay. Great.

CDC MODERATOR: I think, Mary Sue, we'll take just a few more questions, please.

AT&T OPERATOR: Our next question comes from Rick Weiss with the Washington Post.

Please go ahead.

QUESTION: Thanks. Just two quick questions.

One, I wasn't sure again who was speaking with regard to the potential for sexual transmission. Was that Dr. O'Leary?

DR. PETERSEN: Dr. Petersen.

QUESTION: Dr. Petersen, okay, thanks.

Secondly, comparing the two cases now that you've tracked of infection in pregnancy, one in which there appears to have been infection in the child and one in which no infection was documented, were there differences in the degree or extent or type of infection in the mother in terms of CNS involvement or anything like that?

DR. O'LEARY: No, both, though, pregnant women were infected in the third trimester of pregnancy. Both pregnant women had evidence of West Nile infection in their central nervous system based on the presence of IGM antibodies.

So they both had West Nile meningoencephalitis.

QUESTION: Okay. I'm sorry. I should recognize you guys by now, but who's that?

DR. O'LEARY: I'm sorry. This is Dr. O'Leary.

QUESTION: Okay; thanks.


AT&T MODERATOR: And our next question comes from Dietra Henderson with the Denver Post. Please go ahead.

QUESTION: I just have one more quick question about the lab workers. In the case of the microbiologist with the extensive experience, it doesn't sound as though having been exposed to Japanese encephalitis or yellow fever incurred any protection against West Nile but it may have reduced the severity of the infection.

Have you worked in animal models that actually underscore that result? I mean, have you infected birds or mammals with one of the other flaviviruses and then gone on to reinfect them with West Nile?

DR. : Yes. There is some evidence that what we call a heterologous antibody or infection with one virus may have some partial protection against another related virus, or another related flavivirus.

There is some evidence that there is some protection, although this protection is not certainly, as was shown in this case, would not be of the degree that it would completely prevent infection.

For example, if you look at dengue viruses, there's actually four dengue viruses, and you can be infected with one of the viruses and then, you know, shortly thereafter, become infected with another one.

So there is some cross-protection but it's not complete.

CDC MODERATOR: Okay. We'll take one more question please.

AT&T MODERATOR: And then our final question comes from Lanny Peterson with the Savannah Morning News. Please go ahead.

QUESTION: Thank you for taking my question. This is a different West Nile question. It concerns the quarantined blood that was taken off shelves in the last week because of West Nile virus, and I'm wondering why the quarantine was limited.

Apparently West Nile virus in this county, which is Chatham County around Savannah, is endemic here and it's endemic in Georgia, and so I'm wondering why all products were not asked to be taken off the shelves?

DR. PETERSEN: The recommendations by the blood collection agency were state specific, they were not county specific, and recommendations were made to take plasma off the shelves during certain time periods when we know that West Nile virus was epidemic in Florida, or all the other states.

Now why there still may be plasma on the shelf in certain places and not others is largely due to issues of supply.

The blood collection agency had recommended that products that were collected from donors during the peak period of transmission are removed first, and replaced first, until all the products during the epidemic period have been removed.

QUESTION: I'm sorry. I didn't know who was speaking here.

DR. PETERSEN: Dr. Petersen. I'm sorry.

QUESTION: Okay. And the other thing is a follow-up question.

Do you know how many cases of transmission from transfusions of West Nile virus you actually have? And really also here, we have culex mosquitoes biting people right now, and infected birds dying here right now. Why is the blood here collected safe?

DR. PETERSEN: Okay. We have reported to on 13 cases of transfusion-related infection. There are approximately twenty more cases under active investigation and we fully expect to have more transfusion-related cases identified in the coming weeks. Now the salient question was why are blood products still being collected in Florida, given the fact that some transmission is occurring right now.

The reason is because it's all a matter of supply and need, and right now, as always, there is a large need for blood products in any given area, and the supplies are fairly limited.

So it would not be practical to stop blood collection in places where some transmission may be occurring. More harm would be done than good.

Right now, in Florida, although cases have been reported late in the season, the number of cases is rather small--

QUESTION: Hey, Lyle, Chatham County's in Georgia, not Florida.

DR. PETERSEN: Excuse me; sorry.

QUESTION: It's close, though.

DR. PETERSEN: Georgia applies too. Sorry. I lived in Georgia, I should know this, but--sorry about that! But I think my comments pertain to the entire southern United States where transmission could be occurring late in the season, and it would not be practical to stop blood collection in places where one or two cases may have occurred.

Just the fact that a very small number of West Nile virus cases are occurring at this time of the year indicates that really very few people are getting infected and the risk, while there would be some risk, the risk would be extremely small, and thus stopping the blood collection in those areas would probably produce more harm than good.

QUESTION: Thank you.

Do you think we should be warning, though, people about to have surgery, that maybe they don't want to have a transfusion from somebody else's blood?

CDC MODERATOR: And we'll make that our last question.

QUESTION: Thank you.

DR. PETERSEN: The bottom line is that people who need to get blood products need them, and the benefits of giving those blood products is going to be much greater than any potential risk of getting West Nile virus infection, even at the height of the epidemic.

What is being done now is an extraordinary safety precaution. The blood supply has never been massively contaminated.

The number of transfusion cases remains rather small, despite the fact that we've had a very large epidemic. But the blood collection agencies and the Food and Drug Administration and CDC want to be extra cautious and that's why these measures are being taken.

So if you need blood products, West Nile virus should be very low on your list of concerns.

CDC MODERATOR: All right. I'd like to thanks Drs. Peterson and O'Leary for taking time out of their schedules to participate as well as thank all the reporters who joined us today, and should you have any follow-up questions or need additional information, please call the main press office here at CDC at [404] 639-3286. This concludes our briefing. Thank you very much.

AT&T MODERATOR: Ladies and gentlemen that does conclude our conference for today. Thank you for your participation and for using AT&T executive service. You may now disconnect.

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