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Telebriefing Transcript
CDC Modernizing Control of Communicable Diseases Regulations


November 22, 2005

DR. GERBERDING: I thank everyone for joining us today. Sitting here with me Dr. Marty Cetron, Director of our Division of Global Migration and Quarantine, and Dr. Ram Koppaka, I'm going to spell that for you, R-a-m, K-o-p-p-a-k-a. He is Associate Director for Policy and Preparedness in the Division. Dr. Cetron is going to make some introductory comments and when we'll open it up for Q-A. Marty?

DR. CETRON: Thanks very much for joining me on this call. We would like to use this opportunity to formally put forward that CDC today proposed some critical updates to existing regulations which will allow our agency and HHS to move more swiftly to control potential outbreaks of infectious disease that may result from international importation or interstate movement.

These proposed regulations are on display in the Federal Register for public comment, and they will be posted in the Federal Register on Wednesday, November 30, for a 60-day period. We look forward to the opportunity to receive public comment on these Notices of Proposed Rule-making.

These regulations are an important step in one of many steps that CDC is taking to enhance our preparedness to respond to global emerging infectious disease threats and the globalization of infectious diseases and its translocation across borders. We feel that along with other steps in enhancing our nation's preparedness, these are some critical activities that are in place and feel very pleased to see that this announcement is being made today and look forward to moving this ahead in a high-priority manner.

Let me just end the opening comments by highlighting I think three of the important areas where these regulations have been revised. One, we have expanded the definition of ill passengers that is in the previous regulations, and these are 42 C.F.R. Part 70 for interstate movement, and Part 71 for international arrivals. And we've critically added the definition of fever and influenza-like illness which is fever, cough and sore throat, to the other definitions that were included in ill passengers which require reporting from captains of conveyances. These will enable a more rapid advance notification of ill passengers upon arrival and prior to arrival.

We've also clarified the requirements for maintaining passenger manifests and holding that information of passenger name, seat location and emergency contact information for a period of 60 days after the arrival of that international conveyance for international airlines and cruise ship passengers, and the requirement to submit that information electronically to CDC upon request in a short duration of time.

We've also in the third major change to the regulations have been very explicit about the due-process provisions in attempting to clarify the aspects of due process which balance individual civil liberties against public good in terms of these regulations which were largely silent on a lot of the issues of due process in the past, so these are the three main areas that are changed from the existing regulations.

I think that summarizes the general remarks, and I'm happy to open the phone line to questions for either Dr. Koppaka or myself.

OPERATOR: Thank you. At this time, if you would like to ask a question, please press star followed by 1 on your touch-tone phone. To withdraw your request, you may press star followed by a 2. Once again, star-one if you would like to ask a question.

Thank you. Our first question comes from Paul Shin with New York Daily News.

MR. SHIN: Thanks for taking my call, Dr. Cetron. I was wondering, on the domestic interstate flights which flights would be affected by the changes in the regulations. And also in the past, how frequently were the quarantine and isolation regulations invoked?

DR. CETRON: Let me clarify both parts of your question. With regard to domestic interstate flights, it really applies to the large and medium hub cities as defined by FAA, and there's a listing of those that are available in the text. So it is not every single interstate flight or small charter or small city airport, but really a listing of those that are predominantly involved in large-scale movements.

I think the second question about how common is isolation and quarantine probably needs a little bit of clarifying remarks. Let me just distinguish what isolation and quarantine are as tools in the public health toolbox for controlling emerging infectious disease.

Isolation refers to the limitation or restriction of movement and separation of persons that are ill with a communicable disease, and this is a practice that's been in use in public health and in medical circles for a long time. It's typically something that's done at the state and local level or in hospitals and used on a daily basis for separating folks who are infectious with tuberculosis or other common contagious diseases.

Quarantine on the other hand refers to the separation and/or restricted movement of those persons exposed to communicable diseases who are not yet ill. They are typically in the incubation period of one of these illnesses and that incubation period with time. It's also possible that during the asymptomatic state of that incubation period, persons may or may not be communicable with the disease to which they were exposed, but in that asymptomatic incubating period, if one restricts the movement of such individuals, that's referred to from a public health aspect as quarantine.

These tools have been long used as part of the public health toolbox for centuries, and typically public health recommendations are made as recommendations and are requested on a voluntary basis for compliance. In the vast majority of cases, whether it is individuals or in population groups, voluntary compliance with public health recommendations is all that is needed to assure public safety.

In rare circumstances, public health authorities principally at the state and local level have the legal power through state regulations to compel or to order compulsory compliance with isolation or quarantine as a public health tool.

In the setting of these regulations which apply to the federal jurisdiction for compulsory use of isolation and quarantine, they apply in Part 71 to international arrivals, and in Part 70 to interstate movement, and these are areas where there is clear federal jurisdiction regarding isolation and quarantine as public health tools, and they've been long-standing regulations. This announcement today is really a modernization of those regulations in order to be better prepared for 21st century threats.

DR. GERBERDING: Next question, please?

OPERATOR: Thank you. Our next question comes from Maryn McKenna with the Atlanta Journal.

MS. McKENNA: Thanks for doing this. My main question is, in the past when the issue of maintaining passenger manifests and delivering them when the CDC requested has been raised, the main concern raised in response has been that passengers will feel that it is a violation of their privacy rights. Could you talk a little bit about how you managed that negotiation with the airlines and transportation companies, if you did?

DR. CETRON: That's a great question, Maryn, and thank you for that. The details of this regulation are just being made public today, so we are incurring a period of public comment on this, and so this hasn't been negotiated out there in the industry or in the public forum, and that's part of the process that we're engaging in right now.

But I think really getting at the heart of your question is how does public health assure privacy in meeting its responsibilities to carry about its actions, and I think that there are some very rigorous standards of privacy with which this information will be treated on a confidential basis. The confidentiality and privacy concerns are spelled out very clearly in the language of the proposed rule.

In addition, we have found that through surveys that have been done of the public through Robert Blendon and his team at Harvard's School of Public Health as well as other surveys that have been done, there is actually a public expectation that CDC and public health officials have the ability to contact them in the event that they sat next to or were exposed to a serious communicable disease, and very much when asked those questions, while they maintained some of their individual concerns about privacy, by and large they were outweighed by their more significant concern that they be reachable so that interventions and mitigations of the risks could be obtained. And well over 90 percent I believe in surveys of both domestic and international passengers have indicated this. While they reserved some concerns, they were far more concerned about being inaccessible.

With respect to the airlines, I think that the airlines issues around privacy have to do with having some clarity on the part of the federal government about what is expected so that that clarity could be conveyed to passengers in advance, and that for limited circumstances such as public health use and with maintaining the confidentiality of records through the security systems that are in place, the information would be released for those purposes and not any others.

And by being able to spell that out up front and ask passengers either at the time of purchase or potentially at the time of departure if they're willing to share their contact information for public health response purposes, I think it actually makes things easier than leaving it ambiguous with the airline industries about whether to voluntarily turn over such records when requested by CDC.

So I'm hoping and optimistic, but the public comment period will validate this expectation that in fact there will be a fair amount of support for our ability to do this as specified in the new regs.

DR. GERBERDING: Next question, please.

OPERATOR: Thank you. Our next question comes from Lisa Stark with ABC News.

MR. STARK: A couple of quick questions. In trying to read through some of this document, it also talks about the provisional quarantines for 3 days and things like that. I'm trying to understand if that's something new or if that's something that always existed and you're just reiterating it.

The second question is, could you be a little more specific on what would be some of the due-process provisions that you're putting in place?

DR. CETRON: Sure. Let me take the second part first. By and large, as states review, and have reviewed it in the last several years as part of emergency public health preparedness, reviewing their own state legal authority, there is concern and consideration taken for standard components of due process. Some of these include written notification, providing a rationale and justification for an effort, that an effort be scientifically and medically justified as a need to control, that these approaches be used with the least restrictive means necessary to accomplish the goals, that there be an opportunity for filing a dispute and hearing a dispute by an independent arbiter. These are some standard components of due process which assure some of that delicate balance that we think needs to be in place.

The previous regulations had largely been silent about the specifics on how we would actually operationalize and conduct these processes, and these regulations make much more explicit the components of due process that are to be in place.

So while you rightly pointed out in your first question there was this 3-day or 72-hour kind of temporary holding period which is needed to conduct an emergency response at a point of entry, once that time is fast, a definitive decision needs to be made and issued by the director regarding a quarantine order or not, and that just is a part of the step-wise pieces that would go into place, and that the temporary holding or detention for assessment would take no longer than that period of 72 hours before a formal written order would be issued.

While we may have actually acted along these lines in the past under the older regulations, this makes it quite a bit more explicit and I think puts forward those pieces of due process that I spoke of earlier.

DR. GERBERDING: Next question?

OPERATOR: Thank you. Betsy McKay with The Wall Street Journal, your line is open.

MS. McKAY: Dr. Cetron, thank you. I'd like to follow-up if I could on some of Maryn's questions a few minutes ago about passenger manifests. One is I'm wondering if you could describe in a little bit more detail what is changing here in terms of what you're asking from the airlines and what information the passengers are being asked to provide. In other words, were airline previously required to turn over manifests or was it a voluntary thing?

The other question is, as far as I understand, while airlines would be required to turn over this information if this regulation goes through, passengers necessarily would not be required to give that information to airlines. So how would that be managed, or would they be required?

DR. CETRON: Those are great questions, Betsy, and thank you for giving me the opportunity to clarify. Let me be real clear about the way things used to be done and what the challenges are, and then highlight the specific fixes that are taken in this rule.

Often, more often than not, the vast majority of times in the era of rapid jet travel, notifications of significant public health events might occur after passengers have disembarked from planes and public health would be left to reconstruct an itinerary, a manifest, a seating chart and any contact information based on what existed at the time depending on how long after the event that disease notification occurred which could be days, sometimes even longer than days, waiting for a positive laboratory report from a state lab or something like that.

What would happen is, because of the volume of international travel, some of the early electronic records of those manifests are purged very quickly, often within 24 or 48 hours or shortly thereafter, depending on the airline maintaining that database. So these records would then need to be reconstructed by hand, and that often would only have a name and maybe a seat location at best. It wouldn't include sufficient contact information for public health authorities to actually find that person and intervene within the incubation period.

We would then be going to customs declaration forms on international arrivals and try to pick those handwritten papers out of a warehouse somewhere and reconstruct them and identify the contact information from there and try it enter it into a database and then go back and try to find those people through state and local health officials. This was an extremely time-consuming process even for a single flight and almost hopelessly unsuccessful when we had to deal with large multiple fights and large volume contact tracing as occurred during SARS.

So the specific changes are requirements that passenger manifests be maintained by airlines in electronic format for 60 days after the final destination of that journey; that at the request of public health that information needs to be turned over in less than a day, by and large in 12 hours of that request; and that the information be turned over to public health authorities electronically and that specific fields be included to allow for effective contact tracing.

These are now requirements that are proposed in this Notice of Proposed Rule-making to facilitate public health's ability to intervene swiftly in a 21 century approach when often there are only hours or days to implement countermeasures, to offer postexposure vaccination or antibiotics, antivirals or to separate people who have been exposed from others who were unexposed.

In addition, you raised the question about whether individuals themselves would be required to provide this information or whether it would be voluntary, and this was discussed a lot as we put together this proposed rule. Largely this is a voluntary requirement but made as an active request either at the time of purchase of the ticket or at the time of check-in. What we're asking for us a plan for the airlines to come up with a proposal and a plan for how they would accomplish this.

We do think that when given the rationale, that is to respond to an emergent public health event like a SARS event or exposure to meningococcal meningitis or other serious significant public health conditions, that most people would in fact voluntarily comply with assurances that the information would be kept confidential and their privacy maintained and not used for other than emergent public health purposes.

So we're hopeful and optimistic that we'll have a fairly high degree of compliance with a voluntary request that's made from the airlines to the individuals for this information.

DR. GERBERDING: Next question, please.

OPERATOR: Thank you. Rick Weiss with The Washington Post, your line is now open.

MR. WEISS: Thank you. I'm wondering who is actually making the diagnosis or making the decision that someone or some group of people are suspected of being contagious or communicable? It sounds like it's the director, but I don't the director is walking down the aisle of the plane to look in everyone's eyes.

DR. CETRON: No, no. As I indicated earlier in the opening, updating regulatory authorities and jurisdiction is only a part of an enhanced preparedness plan to deal with communicable diseases that travel around the globe.

Another key part is expanding the capacity of our quarantine stations at ports of entry, and many of you may know that over the last 18 months we've added from a baseline of eight quarantine stations, 10 additional stations, and are currently are at 18 at major international points of arrival, and have phased in proposals for expanding further contingent on budget and resource allocation.

In addition to expanding the locations of these stations at ports of entry, we've also changed the skill sets significantly and have added quarantine medical officers to the ports of entry in addition to senior public health advisers. It would be their responsibility if requested by anybody, whether it's a captain of a conveyance who reports in advance, whether it's a CBP inspector who notices something at the point of disembarkation or arrival through customs, or whether it is a public health official who raises a flag either in advance or after the fact, the quarantine medical officers together with the state and local public health departments will be making these assessments and determinations.

Therein lies the component that's in the reg for this 72-hour temporizing capacity for these medical officers before a decision is made by the CDC Director.

DR. GERBERDING: Next question, please.

OPERATOR: Thank you. Larry Altman with The New York Times, your line is now open.

MR. ALTMAN: Yes. First of all, where are all these regs written out? Because I'm amiss and I don't have them and where can I look at them. Secondly, what are the listings now? You say you're adding fever influenza. What are they now and how is this expanded? I realize possibly with the written document I can find that, but I don't have it.

DR. CETRON: Firstly, we can get you a copy of the written document, but they will be posted for display in the Federal Register in the morning.

MR. ALTMAN: That does no good. We're writing a story today.

DR. CETRON: We can get you to them if we send you after this to our Website, we have them posted by section and you can look at that immediately. As well, they'll be posted in writing in the Federal Register. We've broken them down by section on our Website for your ease in making reference to them.

The other question was what is currently in the definition of an ill passenger. If you go to the Website, this will be in Section 8, actually, in the specific comments on the reg text. Line number 3199 or 3200 which may or may not be outlined that way, but page 142 has the definition of an ill person in it. And this is someone with a temperature of 38 centigrade of 104 degrees or greater, accompanied by one or more of the following, rash, swelling of the lymph nodes or glands, headache with neck stiffness, and changes in level of consciousness or cognitive function.

And then diarrhea, fever that has persisted for more than 48 hours, fever associated with severe bleeding, jaundice or severe persistent cough accompanied by bloody sputum, respiratory distress. So these are some of the changes or nuances in the definition of ill passengers.

Then the last caveat is signs and symptoms that are suggestive of communicable diseases which the director may describe in an order as the director determines necessary, and this is to deal with a constellation of emerging threats that currently are unknown, for example, in the situation of SARS.

But largely, the definition was modified to really take into account the respiratory components and the neurologic components that are compatible with the list of nine diseases that are currently specified by Presidential Executive Order as quarantinable diseases.

DR. GERBERDING: For everyone's reference, we apologize that they're not available at the Federal Register. The regulations are posted at They're available there now.

Next question, please.

OPERATOR: Thank you. Mike Stobbe with the Associated Press, your line is now open.

MR. STOBBE: Just two clarifying questions. Following Dr. Altman's question, for those symptoms, what's the significance of the addition to that definition that these are symptoms that if they're detected by a ship captain or something? How are those definitions put into use or effect?

DR. CETRON: These are requirements for a ship's captain or the captain of a conveyance, whether it's a ship or airplane. If these compatible symptoms are noticed in a passenger on a flight or on a ship, there is a requirement for that captain of the conveyance to report this information to the quarantine station of jurisdiction. The most efficient and effective responses are those that come with advanced notification prior to landing which allow for prepositioning of public health medical personnel to assess and evaluate individuals in advance at the time that the ship or plane is about to disembark so that contact information could be obtained in real time, assessments could be made in real time, and separation of ill persons from well persons could be made prior to the disembarkation and scattering and onward connecting flights of the many individuals.

So these are requirements of captains of conveyances to notify public health authorities, specifically quarantine stations, that have jurisdiction over the port of entry.

DR. GERBERDING: Next question, please.

OPERATOR: Thank you. John Rashad [ph] with Congressional Quarterly, your line is open. We'll go on to the next question, Christine Gorman from Time magazine.

MS. GORMAN: Yes, thank you. I was wondering how many reports were sent to the CDC of ill passengers in a given year, let's say, prior to this new proposed rule, and how do you think this new proposed rule will affect that number?

DR. CETRON: That's a great question, and I can't give you a specific answer to it right at the time, but we can look into it and try to get back to you.

Your point is a good one, and let me just back up by saying in general what happens is the majority of ill passenger reports really come after the fact. So what we have now is a very passive system that we occasionally can enhance with awareness and education through various networks to get greater reporting, and during SARS and during large-scale public health emergencies, the degree of reporting in advance in comparison to after-the-fact reporting was increased dramatically through what we call enhanced passive surveillance.

There are also opportunities to do active surveillance and to physically have quarantine and medical officers reviewing and assessing people at the point of arrival along with their surrogates.

In reality, the volume of these reports varies by station. It varies by the volume of arrival, it varies by the nature of the conveyance, the age distribution of the conveyance. There are some cruise ships which cater to elderly or particularly infirm or persons with chronic disabilities for which the nature of some of those reports are much higher.

I really wish to emphasize, most reporting of ill events and persons who were traveling ill and ill while they were on an international conveyance or on an interstate conveyance actually happened after the fact through traditional public health system surveillance, and the quarantine station staff and the federal public health response needs to retrospectively reconstruct the itinerary, the exposures, those at risk, the nature of the communicability at the time of travel, in all of those things so that the vast majority of our incoming reports are really after the fact and not meeting with the requirements for notification by the captain of conveyances, and we hope to stimulate a more enhanced system of passive reporting in the absence of an emergency in order to better respond and respond more swiftly.

DR. GERBERDING: We probably have time for two more questions. Next question, please.

OPERATOR: Thank you. Anita Manning with USA Today, your line is open.

MS. MANNING: Thank you very much for taking this question. I just wonder if you could walk us through an example of a person on an airplane who has a fever or is coughing. I don't understand how the pilot is going to know that. So the first line of defense would be flight attendants? Is that correct?

DR. CETRON: Yes. In reality what happens is, and this why again most of the reporting of a totally passive nature occurs much after the fact, that a lot of people against advice of public health recommendations while travel while ill, and a smaller number will develop their acute illness in the course of their journey. But a lot of folks, really motivated to get home or get where they're going will do the best to plug on and may travel while they're ill.

For an illness to really reach the awareness and notification of flight attendants and other people who are clearly more appropriately focused on other job responsibilities, it has to be quite evident and quite apparent, someone whose illness often requires medical assistance or intervention in flight or some degree of response on the part of a flight attendant, and it may be that that individual actually asks for assistance with regard to their illness while they're traveling. That may or may not result in a request that people hear occasionally while they are flying whether there's a physician on board a flight that can help in an assessment of somebody who's quite ill.

What we're looking for is in the subset of occasions where that type of illness not only brings the attention of a flight attendant, but is also likely to be of a communicable nature and meet these definitions of an ill passenger, where the illness is likely to be an infectious disease and one that may be contagious, to get that notification into the public health officials.

We have tried to enhance the ability to notify and detect by developing short cards, some type of cockpit briefing cards with a list of the major signs and symptoms to be on alert for. Also enhancing the ability through airlines and other conveyances through their medical departments to educate broadly across the staff of what kinds of things to look for.

Then of course, the concerns are much greater in times of significant global public health emergencies or threats like SARS where we ramped up into a different state of awareness, and really it's in these settings in particular that we need to be much more complete in our surveillance and assessments in catching such cases.

DR. GERBERDING: We'll take two more questions. Next question, please.

OPERATOR: Thank you. Our next question comes from Sabin Russell with The San Francisco Chronicle.

MR. RUSSELL: One other point on the Website. If you could repeat those last numbers very slowly before we hang up that would be very helpful.

The question I have, I don't know if it goes under the jurisdiction of the CDC, but I'm wondering about the legal liability questions for a false alarm where somebody either misses a flight or misses a convention or has a vacation and that these are real practical things that can happen when people are quarantined for cough that's just a cough. I'm just wondering if these regulations in any way address that kind of practical issue of what happens when someone is quarantined for no good reason.

DR. CETRON: I would hope that that never occurred, that people aren't quarantined for no good reason. As I mentioned earlier in my remarks, there are only nine specific diseases specified by Presidential Executive Order for which the legal federal authority can be used to quarantine individuals, to quarantine people. I'm happy to recite them, but I can also point you to our Website where you can find them.

There were seven until recently in 2003 when SARS was added to that list, and in April 2005 when pandemic strains of influenza were added to that list. So the threshold for diseases for which a quarantine order would be issued is really quite high, cholera, yellow fever, plague, smallpox, infectious tuberculosis, diphtheria, and then SARS and viral hemorrhagic fevers and influenza. So we're talking about things like Ebola virus and people who are really quite ill and are spontaneously hemorrhaging from multiple body sites, these are not always subtle conditions that would really raise people's awareness and attention. We're not talking about quarantining anybody for a sniffle or a cough alone. That's really not going to be the case and it has not occurred.

I do think that there are lots of things specified in these regulations which do allow for due process and balance of civil liberties against public good, and for these things not to be applied in a capricious or whimsical manner and not to be applied in a discriminatory way, but to be applied even-handedly across all persons.

I'm hoping that the safeguards as well as the requirements for the disease thresholds to be quite significant that would get us away from the kinds of situations that you are in. And I would also point out that outside of the CDC arena a whole other set of ways of handling passengers who are inadvertently for whatever reason detained from their ability to make their connections as is reasonable that have been worked out through the industry at times whether that be weather or all sorts of other things. So it's not like there isn't precedent for those kinds of adjustments to be made by reasonable people.

DR. GERBERDING: Our final question, please.

OPERATOR: Thank you. Bob Roth [ph] with--News, your line is now open.

MR. ROTH: Hello. Thank you. I was wondering if you could talk a little bit about the challenges that CDC encountered during the SARS episode, how much you had to use isolation and quarantine and what kinds of problems occurred then.

DR. CETRON: That's a great question and I think it's very germane because as many know, it really was the global SARS epidemic in 2003 that highlighted our global gaps as well as our global strengths and abilities to respond to these threats.

From the specific focus of these regulations, one of the things we realized is the absence of rapid electronic passenger manifests with detailed contact information to find individuals, completely paralyzed our ability to notify people who were on board together with suspect SARS cases during this epidemic in a timely way, that is, within the incubation period of 2 weeks of that illness, and that was really, really quite shocking.

On an individual basis, it is challenging enough for a single ill person with a significant public health disease and a planeload of folks around them for that information to be achieved and notification to occur in a timely way to get somebody postexposure prevention for meningococcal meningitis, for example, or even for measles situations and other things.

So filling the gap in inadequacies in contact tracing is a very important one to plug, and it was a leading recommendation of the after-action GAO report to the Secretary of Health, as well as the Secretaries of State and Transportation in addressing.

There were other issues around SARS which was that globally where there was a tremendous amount of community transmission and intense burden of the epidemic in several Asian countries and in Toronto, voluntary isolation and quarantine orders and in many cases compulsory orders for isolation and quarantine were used and were an important component of effectively stamping out that epidemic and sort of putting the genie back in the bottle.

In the United States where the impact of this disease was minimized, we had a policy of rapid isolation of suspect cases that met a compatible case definition for SARS as defined by the World Health Organization which was the illness profile in conjunction with an epidemiologic link with a transmission area, and we very much used rapid detection and rapid isolation along with heightened surveillance through passenger notifications.

During this period, CDC staff were present at 25 points of entry, meeting every flight arriving from an impact area directly or one stop indirectly and handing out yellow notification cards in what symptoms to look for and how to rapidly respond to the emergence of those symptoms over the incubation period of SARS. So the general policy was early detection, rapid isolation and containment, and we did not have a federal policy of using quarantine of contacts as part of our containment strategy at the federal level during the SARS epidemic in 2003.

I will say that many states, however, when faced with high-risk situations, health care workers exposed to unsuspecting laboratory confirmed SARS cases in emergency rooms where aerosol producing procedures were going on and there were lots of people at risk, did recommend that those immediately exposed health care workers not come to work and stay home voluntarily during the period of incubation and monitor themselves for symptoms and an onset of SARS symptoms and self-exclude.

So during SARS in 2003 worldwide, largely voluntary isolation and quarantine, home quarantine, was a principal strategy used to contain this epidemic, and in some areas compulsory quarantines as well as fever monitoring and other approaches were used. These are important tools that we need to keep in our toolbox and not forget that really our history of having direct medical countermeasures is quite short, in the last five decades or so in contrast with centuries of public health practice in which nonpharmaceutical countermeasures were used to contain communicable diseases.

With that I'd like to wrap up that these proposed changes are just one component of CDC and HHS's strategy to better prepare us for the globalization of communicable disease threats. They're necessary to expedite and improve our operations, they facilitate contact tracing, they provide immediate medical follow-up of infected passengers and contacts, and the streamlining of this procedure will enhance and benefit the American public by reducing deaths and illnesses and avoiding unnecessary quarantines and unnecessary delays by detecting outbreaks and responding to them early.

I think that there are many other things going on to enhance our country's preparedness to combat these threats both in the isolation and quarantine arena, in the community controls, in the international controls, as well as in the preparation of stockpiles and direct medical countermeasures that are available for the significant threats that are on our horizon.

In addition, the international health regulations were just passed by the World Health Assembly in May 2005 and in many ways provide an analogous global framework for containment of these types of threats as well.

This notice that is released today is a Notice of Proposed Rule-making to combat and to plug the gaps that we're identified in this arena. We very much look forward to public comment and comment of stakeholders and constituents that may be impacted by this proposal in a way to enhance and improve upon it before issuance of a final rule which will take place following the receipt and incorporation of public comment.

So with that, I'd like to close and thank everybody very much for getting together on short notice to communicate this message.

DR. GERBERDING: Thanks, Marty. Let me repeat the Website where the regs are posted and apologize again. We initially thought they would be available immediately at the Federal Register, and they'll pop up I believe later this week, Wednesday, tomorrow, but today they're available at, Division of Quarantine. If anyone has any questions, please don't hesitate to call the clerk's office and we'll get back in touch. Thanks everybody.

OPERATOR: Thank you. This concludes today's conference call. We thank you for your participation.

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