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CDC Telebriefing Transcript
MMWR: Infection Caused by Baby Formula and New Data: Mortality & Economic Losses Due to Smoking with Dr. Matthew Kuehnert and Dr. Terry Pechacek

April 11, 2002

CDC MODERATOR: Thank you. Today's telebriefing will actually feature two speakers. Our first speaker will be Dr. Terry Pechacek. He'll talk about the tobacco prevention article institution his week's MMWR. He'll then be followed by Dr. Matthew Kuehnert, who will talk about infections associated with the use of nonsterile powdered infant formula.

Dr. Pechacek will open with comments, followed by Q&A. He will then be followed by Dr. Kuehnert, who will also give brief remarks followed by question and answer.

And so now we are ready to begin. Dr. Pechacek?

DR. PECHACEK: Yes, I would like to keep my comments to about five minutes, I believe, right?


DR. PECHACEK: And then we'll have some questions and answers.

First of all, the Centers for Disease Control provides periodic updates on the health and economic burden to the nation due to smoking, and this week's release in the MMWR is the first new estimates since 1996 on these values.

The excess medical costs associated with smoking have increased dramatically since our last report, and this is despite the recent progress in reducing both youth and adult smoking rates. This is largely due to the escalating costs of health care in general and to the lingering burden of past smoking behavior from past decades that has continued to show itself in the health care consequences in both current and former smokers.

We now estimate that each year smoking kills nearly half a million Americans and cost the nation over $157 billion. That translates into about 1,200 Americans dying prematurely each day in this country prematurely due to smoking. The cost factor translates into an estimate that each pack of cigarettes sold in this nation is costing over $7 in excess medical costs and lost productivity. It averages out to about $3,400 of excess costs per smoker per year.

When we look at this cost, $7.18 per pack is the exact estimate on the approximately 22 billion packs sold each year, about half of that is excess medical costs and a little more than half is lost productivity. That is dying prematurely, and it's lost wages and lost contribution to the economy. This is far less than the average tax on cigarettes, which combined federal and state averages just over about 80 cents a pack. So you can see there's a big difference between what we estimate is the cost to society and what the society is getting back in terms of tax.

This $157 billion breaks out to about $75.5 billion in excess direct medical costs, which is up from about $43 billion in 1993. CDC has not put out previously a cost estimate on lost productivity, and the estimate that is for 1998 is for $81.9 billion in lost productivity. Now this is lost productivity and lost future earnings, but does not include smoking-related illness or morbidity, absenteeism, excess smoking breaks or the impact of second-hand smoke morbidity or disease-related costs. So, while these numbers are huge, they really don't capture all of the costs.

Now one of the other things that is new about this year's release of cost and economic impact is that we have the estimation for neonatal costs or the impact of smoking during pregnancy, which is estimated to be $366 million in 1996 or averaging out to be about $700 per pregnant smoker.

We make these numbers available because while we are making all of these efforts to control tobacco control, we want to help policy makers understand what is the continuing burden of past smoking behavior and why it is so important to reduce smoking rates.

One of the things that also was released today was our Tobacco Control State Highlights for 2002. Last year we had released the first report of this type that provided more detailed state-specific estimates on health effects and economic costs. This report provides a breakdown on all 50 states and the District of Columbia of these types of numbers on health care costs, as well as smoking-related disease and death.

These vary widely. For example, in smoking-related death, vary from over 400 per 100,000 in Nevada down to about 160 in Utah. So there are big variations. It is noted[?] that the costs of smoking vary greatly, and these are not necessarily related to the states with high smoking prevalence. Because the smoking-related costs varies a great deal on the cost of health care in the states, states such as New York or certain New England states have very high rates of smoking-related costs. So that the smoking-related Medicare costs per recipient varies from about $1,400 in New York down to about $300 in Tennessee. So these are a lot of new numbers that show why it is so important for us to continue the efforts at the federal and state level to reduce rates of tobacco control.

CDC MODERATOR: Thank you, Dr. Pechacek.

We are now ready for any questions.

AT&T OPERATOR: Ladies and gentlemen, if you do have any questions, please press the one on your touch tone phone at this time. You will hear a tone indicating you've been placed in queue. You may remove yourself from queue by pressing the pound key. If you're using a speaker phone, please pick up your handset before pressing the numbers.

Our first question will come from the line of Adam Marcus with Health [inaudible]. Go ahead, please.

QUESTION: Hi, Dr. Pechacek. Thanks very much for hosting the briefing.

I would like to know whether the analysis included any of the studies that have shown that premature mortality may save lives in terms of less expenses on social services like nursing home care, long-term health care and that sort of thing?

DR. PECHACEK: The CDC report does not go into all of those related types of costs, and what we are looking at is the direct medical care costs and the productivity costs and not estimating retirement and Social Security types of social service costs after age 65. So, no, we do not estimate anything on those.


Can we have our next question, Alan?

AT&T OPERATOR: Yes. That will be from the line of Erin McClean from Associated Press.

QUESTION: Yes. Hi. Thanks for the briefing.

I was speaking earlier today with a spokesman for one of the major tobacco companies, and he had a couple of criticisms of the study, and I wonder if you could respond to them.

The first, he said, is that smokers are already extremely highly taxed. They already more than their fair share to society, and the second is that these numbers are sort of presented in a vacuum. We don't know how this compares to the costs, the medical costs and productivity costs for any other disease, and so there is not really a benchmark to compare them to.

Can you answer those two criticisms?

DR. PECHACEK: Well, first of all, the issue of is the current tax rate on cigarettes sufficient to cover these direct medical costs and lost productivity? And our estimate is that the cost per pack is $7.18 per pack on excess medical costs and lost productivity, whereas, the current average tax of state and federal is just over 80 cents. Of course, it varies between states, between 2.5 cents in Virginia up to now $1.50 in New York State. But even in New York State, the total state tax, plus federal tax, is well below the $7 now.

There have been some what health economists call "ghoulish analysis" of saying that if individuals died before they start drawing Social Security or retirement, that that saves society. That type of analysis is not included in this, but even when those types of analysis are generally included, these excess medical costs have been estimated to be over $12,000 per smoker in excess through all of these social savings.

So we don't agree, and we do believe that society is bearing a burden for the individual behavioral choices of the smokers. That is why we have a lot of programs to help smokers quit as soon as possible.

With respect to the comparison with other health behaviors, we at CDC are working to try to provide economic estimates of the burden of other diseases. One of the unfortunate things about tobacco is that because it has been such a huge economic cost, that a lot more attention has been placed on it, and that is in quantifying the types of relationships, in providing the parameters that are needed to make these types of estimates, we are working on other health behaviors.

In general, smoking comes out somewhat higher than other health behaviors, but certainly inactivity, and diet, and other health choices are very costly to society, and CDC is encouraging a broad base healthy lifestyle as the most effective way to reduced all lifestyle-related chronic disease.

CDC MODERATOR: Okay. Thank you.

Alan, we are ready for our next question.

AT&T OPERATOR: Thank you.

If there are further questions, press one on your touch tone phone at this time.

Next, we will go to the line of Jim Shamp [ph] with the Herald Sun. Go ahead, please.

QUESTION: Yes. I'm sorry, I started a little bit late on the conference, thinking it started at 1:15.

But I was interested, we had a story in our paper on Tuesday of this week in which a company called Universal Leaf Tobacco Company here in North Carolina just received a $400,000 grant from the Golden Leaf Foundation, which is created by the general assembly in '99 to disburse half of the $4.6 billion of the tobacco industry settlement in North Carolina. Interestingly, some of that tobacco settlement money here in North Carolina is going to the construction of a tobacco plant, and I wondered if you were aware of that, if you had any comments on that irony?

DR. PECHACEK: Well, first of all, CDC's basic position, as stated in our Tobacco Control Highlights, where we were reporting the levels of investments by state from the settlement excise tax, general revenue and all sorts of [inaudible] is that these are state decisions. While we provide guidelines and recommendations and we do encourage that the funds be used in ways that have the potential of reducing long-term health care costs, such as reducing tobacco or other health-related behaviors, these fundamentally are state decisions.

What we feel like is important is that we provide the numbers by which people, both the policy makers or the general public, can see what the relative long-term costs and benefits are of making different types of decisions, but we leave those decisions to the individual states.

CDC MODERATOR: Thank you very much.

That will end the session with Dr. Pechacek. Right now we are going to go on to Dr. Kuehnert, but before we do, let me spell his last name for you. It is P, as in Paul, e-c-h-a-c-e-k.

And now Dr. Kuehnert?

DR. KUEHNERT: Thank you very much.

Am I being heard okay?


DR. KUEHNERT: Great. I appreciate the opportunity today to talk about the report in the MMWR summarizing an investigation of a fatal infection due to Enterobacter sakazakii in a hospitalized infant that was born prematurely. The result of this investigation indicates that the infection was associated with the presence of this bacteria in commercial powdered formula fed to the infant.

Infections from Enterobacter sakazakii, abbreviated E. sakazakii, in premature infants are rare, but can be very serious, especially if meningitis occurs. Meningitis is an infection of the spinal fluid and membranes surrounding the brain. It is unknown how many infections from E. sakazakii have occurred in the United States that can be traced to the use of contaminated powdered infant formula in a neonatal health care setting.

To prevent future E. sakazakii infections associated with infant formula, the CDC, in collaboration with the FDA and the American Dietetic Association, have developed interim recommendations for health care professionals for the preparation of powdered infant formula in the neonatal intensive care unit setting. These recommendations can be found in today's MMWR article. In addition, FDA has put out a more detailed recommendation in a letter to health care providers.

CDC wants to encourage health care providers to report bloodstream infections or meningitis associated with E. sakazakii in infants under 12 months of age to state health departments and CDC, and adverse events associated with infant formula should also be reported to the Food and Drug Administration.

CDC, in collaboration with FDA, is working to prevent further E. sakazakii infections associated with powdered formula. This is an important patient safety and food safety issue.

Thank you, and I am happy to answer any questions.

CDC MODERATOR: Okay. Alan, we are ready for our first question.

AT&T OPERATOR: And, again, if there are questions at this time, please press the one on your touch tone phone now.

Our first question will come from the line of A.J. Hostetler with Richmond Times Dispatch. Go ahead.

QUESTION: Hi, Dr. Kuehnert. Thanks for taking the time to talk with us today.

I noticed in the report the CDC suggests or urges hospitals to choose alternatives over powdered formula, and I was hoping you could explain a little bit more. Is the CDC saying hospitals should not use powdered formula, and what can you say about what families at home should be using in a nonhospital setting?

DR. KUEHNERT: The answer to the first part of the question, what we are doing is encouraging providers to select formula products based on nutritional need and that alternatives to powdered forms should be chosen when possible. We realize that there are some situations where there is no alternative to powdered formula because there are special formulations that might be needed where the only formulation available is in powdered form. But where there are other alternatives, we are encouraging providers to use those other alternatives.

Concerning, and I've just also wanted to describe just a little bit about powdered formula, just to clarify, in general, powdered formula is not sterile, and this means that it commonly contains all types of bacteria, as many foods do. Although food is not sterile, proper handling and preparation greatly reduces the risk of food-borne disease from harmful bacteria, but there are certain people, such as newborns or persons with impaired immune systems, that can become ill from certain food-borne bacteria. For instance, in this report, the E. sakazakii infections in hospitalized newborns.

We believe that the risk is very low for healthy infants who consume powdered formulas. We believe that the highest risk is for newborn infants in hospital settings who consume powdered formulas. So that is our focus. That was the infections that we investigated in this report, and that is what we are focusing on.

CDC MODERATOR: Thank you. We are ready for our next question, Alan.

AT&T OPERATOR: That will be from the line of Jim Shamp with the Herald Sun. Go ahead.

QUESTION: Yes. Thank you, again.

I wondered if there might be any plan to request such techniques as irradiation of the powdered formulas as a standard for purifying these formulas.

DR. KUEHNERT: I think the issues concerning manufacture and sterilization or a sampling of formulas, all of these are possible actions that could be taken, are really more the activity of the Food and Drug Administration. So I would defer to representatives from the FDA concerning those questions.

CDC MODERATOR: Thank you. We are ready for our next question, Alan.

AT&T OPERATOR: Thank you. Once again, ladies and gentlemen, if you do have questions, please take this opportunity to press the one on your touch tone phone at this time.

We have a follow-up question from the line of A.J. Hostetler with Richmond Times Dispatch. Go ahead, please.

QUESTION: Thank you.

Dr. Kuehnert, again, I was hoping you could answer my question about what families at home should be using or not using or if there are special cases where they shouldn't be using powdered formula, and also if you could address the sterility of the I guess liquid formula, the ready-to-use formula. That, I understand, is sterile.

DR. KUEHNERT: Yes. I will answer the second first.

The liquid ready-to-feed formulas are marketed as commercially sterile. So there should be no bacteria in them.

Concerning your first question, as I said, this report is focusing on neonates, newborns, in other words, who are hospitalized, and we believe that the highest risk is for newborn infants in hospital settings, and this is what occurred in these infections. This is a setting in which these infections occurred, and that is what we are focusing on.

As I said, the highest risk is in, we believe, in babies who are born prematurely and parents of premature or immunocompromised infants should ask their doctors which formulas are best for their infants.

QUESTION: Thank you.

CDC MODERATOR: We are ready for our next question, Alan.

AT&T OPERATOR: We have no further questions in queue at this time.

CDC MODERATOR: Okay. We want to thank everybody for joining us for that telebriefing. The transcript will be on-line this afternoon. Thank you.

Listen to the telebriefing

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