CDC Telebriefing Transcript

Dr. David Johnson, Deputy Director and Chief Medical Executive
Michigan Department of Community Health

Dr. Matthew Boulton, State Epidemiologist
Michigan Department of Community Health

Dr. Steve Solomon, Acting Director
Division of Health Care Quality Promotion, CDC

July 3, 2002

CDC MODERATOR: Hi. Thank you, John, and thank you all for joining us on the weekly teleconference all. Today we'll be discussing two articles that appear in this week's MMWR. The first article concerns the drug resistant staph aureus that's been identified in Michigan and the second article we'll be discussing is the article on heat-related death.

First of all I'd like to introduce from the Michigan Department of Community Health, Drs. David Johnson and Matthew Boulton, who will have some introductory remarks to talk about the investigation there in Michigan. They'll be followed by Dr. Steve Solomon, here at CDC, who will sort of put this into perspective for us, and then we'll take some Qs. So at this point I'd like to turn it over to Dr. Johnson.

DR. JOHNSON: Thank you. Approximately two weeks ago clinical laboratories here in Michigan contacted our department about their identification of Vancomycin-Resistant Staphylococcus aureus organisms. Here after we'll refer to these as VRSA, V-R-S-A. Specimens of these resistant organisms were promptly shared with our laboratory here, and we very quickly got the Centers for Disease Control and Prevention involved as well.

So this is an investigation that is in progress and is proceeding on two fronts, both in the laboratory and in the field. In the laboratory investigation, both at our laboratory here in Lansing, Michigan and at CDC, have confirmed VRSA but only in one particular patient. The field investigation is focused on the known and potential contacts of that patient. Swab samples have been completed for several hundred of these contacts, and to this point that testing shows no evidence of VRSA transmission.

Tom?

CDC MODERATOR: Okay, thanks, Dr. Johnson.

I'd like to turn it over to Dr. Solomon, Dr. Steve Solomon here at CDC, a medical epidemiologist here at CDC that will sort of put this into perspective for us.

DR. SOLOMON: Thanks, Tom.

This is in fact the first case of Vancomycin-Resistant Staphylococcus aureus. It represents an evolution in drug resistance in this particular microorganism, which has been going on, as the MMWR points out, for 50 years. This is a naturally-occurring, another step in the resistance of this microorganism. And microbial resistance generally continues to be a very important problem affecting patient safety for patients receiving care in the health care system.

As Dr. Johnson was indicating, the--we are reassured by the fact that while we're continuing to evaluate this problem, there has been no evidence of spread so far to anyone. The microorganism remains identified only in the single patient. The other reassuring thing is that this bacteria, although it is resistant to Vancomycin, is susceptible to a number of other antibiotics which can be used to treat any infection.

The immediate impact of this to the general public is not significant because it has not spread and because it is susceptible to other antibiotics. However, this case does serve to reinforce for those of us in health care the absolute necessity of adhering to strict infection control precautions as has been done in this case, and to continue to use antibiotics wisely and judiciously. CDC, NIH and the FDA, with partners both inside and outside of government, have developed a number of initiatives to combat antimicrobial resistance. One is a public health action plan to combat antimicrobial resistance, a comprehensive approach that addresses the surveillance, prevention, control of antimicrobial resistance, includes research and product development and the development of better diagnostics and new antimicrobials.

In addition CDC has initiated a campaign aimed specifically at clinicians to assist them in their efforts to prevent antimicrobial resistance in health care settings.

CDC MODERATOR: John, with that, we'd like to take questions from reporters, please.

AT&T MODERATOR: All right. Ladies and gentlemen, if you wish to ask a question, please depress the "1" on your touchtone phone. You will hear a tone -- at any time by depressing the pound key. Once again, if you do have a question, press "1" on your touchtone phone. One moment, please, for the first question.

Our first question comes from the line of Tony Bascione (ph) from Drug Topics Magazine. Please go ahead.

QUESTION: Yeah. My question is, can you identify or reveal the setting that this patient is in; are they in an intensive care unit? Is it at a community health, a university-based hospital? Can you elaborate on that?

CDC MODERATOR: Dr. Johnson or Boulton, please.

DR. JOHNSON: This is Dr. Johnson. The individual is being treated as an outpatient, is not currently hospitalized. The individual is 40-years-old, has complicated diabetes and peripheral vascular disease, and does undergo on a regular basis hemodialysis. So the patient is cared for on an outpatient basis and in a dialysis center.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: It comes from the line of Megan Brooks from Reuters Health. Please go ahead.

QUESTION: I just want to know what the--how you spell your names, and your titles again, if you wouldn't mind?

CDC MODERATOR: Yeah. I can give those to you. Dr. Johnson, Dr. David Johnson is Deputy Director and Chief Medical Executive for the Michigan Department of Community Health. Dr. Matthew Boulton, spelled B-o-u-l-t-o-n, is the State Epidemiologist for the Michigan Department of Community Health.

QUESTION: And Steve Solomon?

CDC MODERATOR: Dr. Steve Solomon, S-o-l-o-m-o-n, is the Acting Director of the Division of Health Care Quality Promotion at CDC.

QUESTION: Thank you.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: It comes from the line of Rachel Calderon from WILX. Please go ahead.

QUESTION: My question is you talk about other kinds of treatments. What are those treatments besides this one which apparently isn't working?

CDC MODERATOR: Dr. Solomon?

DR. SOLOMON: There are a number of antibiotics that this microorganism is susceptible to. One is trimethoprim-sulfamethoxazole; another is lanasolid (ph), and the other--there are other drugs which are currently being tested in the laboratory, but those are the drugs among which--to which this microorganism is susceptible.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Comes from the line of Carrie Dooley from Bloomberg News.

QUESTION: Hi. It's in the same vein. Can you spell the name of the first drug, not the--not lanasolid but that first one.

CDC MODERATOR: You know what, Carrie. I'll give you my phone number, and if you call me, I can actually fax to you those. They're pretty
complicated. My phone number is 404-639-1735, and you can call me and I'll fax those to you.

QUESTION: Okay.

CDC MODERATOR: A follow-up?

QUESTION: Sure. That was--on the patient, I mean, how is the patient doing?

CDC MODERATOR: Drs. Johnson or Boulton.

DR. BOULTON: The patient is currently, as Dr. Johnson indicated--this is Dr. Boulton--the patient is being treated as an outpatient and is doing fine. The patient has had multiple courses of antibiotics, but her clinical course has proceeded very well.

CDC MODERATOR: Next question please.

AT&T MODERATOR: Comes from the line of Brooke Lotts, from WXYZ, Channel 7, Detroit. Go ahead.

QUESTION: Two things. I just wanted to know what this means to the health community in Michigan and in general, and is the patient male or female?

CDC MODERATOR: Drs. Johnson or Boulton.

DR. JOHNSON: To your latter question first--this is Dr. Johnson. We regard confidentiality in outbreak investigations, and in any public health investigations as of paramount importance, and we do everything that we can to protect that confidentiality. In this situation we're not going to reveal the gender of the patient or the address or even the specific community in which this individual lives.

And your first question was about the implications for health care in Michigan. I think the implications Dr. Solomon referred to before, this is another step in the evolution of this common microorganism, Staph aureus, to develop further resistance, really highlights the need for all of us in Michigan, as is true elsewhere in the country, to be very vigilant about how we use antibiotics and what kind of infection-control procedures we have, particularly in health care settings.

CDC MODERATOR: Okay. Next question, please.

AT&T MODERATOR: Once again, if there are any questions, press "1" at this time. And sir at this time--one person did queue up. We have a question from Brooke Lotts from WXYZ. Please go ahead.

QUESTION: It's me again. I just wanted to know, how come the CDC was called in to assist on this if it's just--I mean if it's just a common thing or a common microorganism, is this dangerous? How serious is this? Why is the CDC involved and coming out to Michigan to do this?

CDC MODERATOR: I think Dr. Solomon could probably touch on that.

DR. SOLOMON: CDC has a long-standing interest in antimicrobial resistance, and as I indicated, we have a number of national initiatives to deal with antimicrobial resistance. This is in fact the first case of Staph aureus which is resistant to this particular common antibiotic, and so scientifically, it's of tremendous interest to use. As I indicated, the impact on the general public right now is not significant, but it's very important for us to understand what happened in this situation, so we can use that knowledge to continue our efforts to combat antimicrobial resistance nationwide.

QUESTION: Okay.

DR. BOULTON: Tom, this is Dr. Boulton. Could I add something?

CDC MODERATOR: Sure, please.

DR. BOULTON: It's also important to understand that we work collaboratively with the CDC on a very regular basis, almost on a weekly basis, so it's not at all unusual for the Centers for Disease Control to dispatch a team to come assist us with various public health problems that occur in the state.

CDC MODERATOR: Any more questions?

AT&T MODERATOR: There's one from Carrie Dooley from Bloomberg News. Please go ahead.

QUESTION: I just wanted to say, I know that you said that you weren't going to reveal the patient's gender, but in an earlier question I thought you said that she had something. So is it a 40-year-old woman?

DR. JOHNSON: We choose not to confirm that one way or the other. This is Dr. Johnson. Once again we're trying to respect the patient's confidentiality, and to the extent that we give out additional information about the patient, even without revealing name or address, we jeopardize the process of maintaining confidentiality.

QUESTION: Okay. And just one more question. I wasn't able to track which speaker was saying that the impact to the general public right now is not significant.

CDC MODERATOR: That was Dr. Steve Solomon, S-o-l-o-m-o-n.

QUESTION: Thank you so much.

AT&T MODERATOR: We have a question from Brian Bechtel (ph) from Infectious Diseases. Please go ahead.

QUESTION: Yes. I read in the MMWR that the first [inaudible] susceptible to Vanco was discovered in '96. So the CDC must have known that completely susceptible was just around the corner. And I was wondering if any steps could have been taken or were taken to prepare for this?

CDC MODERATOR: Dr. Solomon.

DR. SOLOMON: We in fact have a number of nationwide surveillance programs, one in particular looking for the emergence of antimicrobial resistance in any microorganism including Staph aureus. The campaigns that we have been involved in to improve and enhance infection control precautions and especially to monitor and improve the use of antimicrobial drugs, have been ongoing. Those are our primary efforts directed at preventing the development of antimicrobial resistance in a variety of microorganisms, including Staph aureus. Those have gone on. They continue to go on. We've gotten excellent cooperation from the state and local health departments, from the health care industry, and from professional societies. Those efforts are going to continue.

AT&T MODERATOR: And we have a question from Tony Bascione from Drug Topics Magazine. Go ahead.

QUESTION: Yeah. Tony Bascione from Drug Topics. Just to clarify, did you say it was the first case in Michigan or the first case nationwide?

CDC MODERATOR: Steve?

DR. SOLOMON: This is the first case in the United States of the Staph aureus that has this level of resistance to that one particular drug.

QUESTION: And also, the outpatient dialysis center, where this patient is frequenting, is it affiliated or associated with a hospital, or is it in a hospital setting, and if so, are they taking any steps to evaluate their infection control procedure?

CDC MODERATOR: Dr. Johnson or Boulton, please.

DR. BOULTON: This is Dr. Boulton. This is a outpatient dialysis center that is associated with a hospital system. And I should say that this is an investigation that's still in process, and we are exploring multiple clinical settings where this individual may have had contact with other individuals, and also, nonclinical settings as well.

DR. JOHNSON: This is Dr. Johnson. Just in quick follow up, yes, that particular dialysis center has been very cooperative in reviewing their infection control procedures, and making sure that they've been enhanced now that this VRSA organism has been identified.

CDC MODERATOR: We've got time for one more question on the staph article please.

AT&T MODERATOR: Okay. That comes from the line of Brooke Lotts from WXYZ. Please go ahead.

QUESTION: Two things real quick. Could you spell the name of the lab where the bacteria was found and also what would you want us to tell our viewers in ways to alleviate antibiotic resistance?

CDC MODERATOR: Dr. Johnson and Boulton for the first question, and maybe Steve can touch on the second.

DR. : Once again, we're not going to get specific about the clinical laboratory where this was first identified, but there are a couple of clinical laboratories in Michigan that have been involved with this investigation and continue to assist with this investigation.

Then, Tom, you wanted Steve to respond to the second question?

CDC MODERATOR: Yes. Steve can touch on the second question.

DR. SOLOMON: I think the thing to tell listeners and readers is that the health care system is safe. This should not discourage or concern anyone about visiting the doctor or seeking health care. It is important, as CDC and other health care public health agencies have pointed out, that individuals, when they go to the doctor, should be aware of the fact that antibiotics are not required to treat all infections, especially viral infections, and that we're encouraging doctors to use antibiotics wisely and appropriately, and it's helpful for the public to understand that that's what their doctors are trying to do.

CDC MODERATOR: Okay. Thank you very much. John, I think we'd like to proceed to the second part of our telebriefing at this point.

I'd like to introduce Dr. Michael McGeehan from our National Center for Environmental Health here at CDC, who's going to talk today about the MMWR article on heat-related deaths. So I'd like to turn the call over to Dr. McGeehan at this point right now for some introductory comments, and then we'll take some Q's for Dr. McGeehan.

DR. McGEEHAN: Thank you, Tom. I think our message with heat is a relatively simple and direct one. CDC considers that heat-related death and heat-related illness is an important public health problem. In this country on any year, any given year, we lose about 200 people or more to heat, and in years when we have large heat waves like we had in Chicago in 1995, we can have 6 to 700 deaths in as little as 10 days. So heat-related death and heat-related illness are important. We consider every one of those deaths each year and in each heat wave as preventable. We know what the risk factors are. We know who dies from heat waves, and we know things that can keep them alive.

So it's an important public health message for CDC to get out so that people understand that heat in fact can be a big risk to their well being and even to their life.

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

AT&T MODERATOR: Once again, ladies and gentlemen, if you have any questions, press "1."

And we have a question from Allison McCook from Reuters Health. Please go ahead.

QUESTION: Hi. I was wondering why are children and the elderly most at risk of a heat-related death?

DR. McGEEHAN: Well, because their bodies are less resilient to handle the heat, because of their circulatory systems, because of the children, because they are still developing and they have a high surface to weight ratio, so heat can affect them a great deal more.

And in the elderly, their vascular system can't handle the pressures that living in a hot environment can put on them, so there's a couple of reasons for the elderly, not only because of things that have happened to their body and that their body is less adaptive at that age, but also because elderly, in the urban areas, the elderly who die tend to be poor, tend to live alone, and tend to not have access to air conditioning. So when you combine all of those factors that is what usually leads to an increased risk of death from heat.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: Our next question comes from the line of Edward Ettelson (ph) from Health Scout. Please go ahead.

QUESTION: How does the current heat wave that's enveloping the East Coast rank among the sort of thing that has happened in recent years?

DR. McGEEHAN: Well, we don't actually rank heat waves. We haven't received reports from the states as to whether or not they're seeing an increase in heat-related death or illness. Normally the things that we worry most about with heat waves are the two factors, and that is the intensity of the heat wave and the duration of the heat wave. If it gets up to the heat indexes of the upper 90s and/or into the low 100s and it lasts for a number of days, we usually see an increase in both death and illness. Short term heat waves, heat waves that only last a couple of days, we usually don't see that same amount of increase.

But this one that is on the East Coast right now, my understanding is that it is supposed to break either tonight or tomorrow with a front coming in, and that should be a great relief as far as the public health impact of it.

CDC MODERATOR: Question please?

AT&T MODERATOR: And at this time there are no other questions in queue.

CDC MODERATOR: I'll give it a few seconds.

AT&T MODERATOR: Okay, a few did pop up. We have a question again from Allison McCook from Reuters Health. Go ahead.

QUESTION: What are some of the warning signs of heat excess that people can try and pay attention to in themselves to try and know to cue themselves to drink more water or get into air conditioning?

DR. McGEEHAN: Well, that's a great question. For one, the thing that we want to stress most often is if people are exercising or out in the middle of the day during a heat wave or just when it's warm, that they should drink more water than they think even is reasonable. We don't have an exact number of cups of water a day that they should drink, but they should drink large quantities of water or sports drinks.

However, if they are sweating profusely, if they are feeling very warm and uncomfortable, and then they notice that their body temperature seems elevated, and at one point they may get to the point where they stop sweating. That is a point where it is a danger point and they need to immediately seek a cooler environment or the shade, and that is a point where they could get into dangerous territory of heat stroke very quickly. If their skin becomes red hot and dry and a little bit clammy, they should immediately go as quickly as possible and get cool drinks and get indoors and get into an air conditioned environment.

If they get to the point where they're having dizziness and nausea and maybe confusion, that is a point when they should begin to seek medical care.

QUESTION: So they'll sweat a lot and then they'll stop sweating, and that's when it becomes dangerous?

DR. McGEEHAN: Sure. When they stop sweating and their skin becomes red, hot and dry, that is when it's beginning to be dangerous.

QUESTION: Why is that happening to them?

DR. McGEEHAN: Well, basically the body is beginning to shut down. The system of controlling the temperature of the body by evaporation on the skin with the sweat is no longer working, and the body begins to shut down.

But basically what we want to get the message out is before that even begins to happen, just if you're out in an environment, first of all, limit your activities during the hottest part of the day. Take in a lot of cool water. Limit your activities during the day. Seek out shade. Wear the right kind of clothing, and try and avoid getting to the point where you're becoming ill.

QUESTION: Okay, thanks.

DR. McGEEHAN: You're welcome.

AT&T MODERATOR: And we have a follow up from Edward Eddelson from Health Scout. Go ahead.

QUESTION: I have two questions, one of is a variation on the previous one. You were talking about the individual who might be in trouble. How about the companion on an individual who might be in trouble? What are the signs that, you know, you're walking or exercising with somebody. What is it you should be alert for?

DR. McGEEHAN: Well, they're the same signs that I just mentioned, that if the person--if you notice that they have stopped sweating. If you notice that their skin looks particularly red and is dry and hot, they should try and get them into a different environment. They should try to get liquids into them. Keep them from--cease their activity. Get them into shade or air conditioning.

The other thing is that if they start acting confused or making statements that don't make a lot of sense, that is another indication that they could be in trouble, but when you're getting to that point, you need to seek medical care. When they start having confusion and dizziness you need to seek medical care. Prior to that, I think just if you notice a change in their perspiration and that they have maybe the red, hot, dry skin and no sweating that we talked about earlier, they should get them into a different environment right away and get liquids into them.

QUESTION: And another question. There's an accompanying thing in the same MMWR about children being left in cars, which is--is this the sort of weather in which a child should simply not--a young child should not be left in a car?

DR. McGEEHAN: Oh, it's easier than that. A young child should never be left in a car, no matter what the temperature is outside. Even beyond the heat problems, there are too many dangers with leaving a child in a car alone, whether it's a closed car or not. But as far as the heat problem goes, any time that there is sun out, that car can become very hot very shortly. I mean it doesn't have to be during a heat wave. The temperature will rise above 100 in a car--on an 80-degree sunny day it will rise above 100 within 5 minutes. So you don't want to ever leave a child alone in a car under any set of circumstances.

QUESTION: Okay.

AT&T MODERATOR: And at this time there are no other questions in queue.

CDC MODERATOR: Thank you. This concludes our weekly telebriefing, and I want to thank everybody who participated in the call, and please look for announcements concerning future telebriefings. Thank you, John.

AT&T MODERATOR: Thank you. Ladies and gentlemen this does conclude our conference for today. Thank you for your participation, and thank you for using AT&T Executive Teleconference.

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