CDC Telebriefing Transcript
Update on SARS and Smallpox Vaccine Program
March 27, 2003
MS. TELFER: Good afternoon and thank you for waiting. I'm Janet Telfer,
Acting Director of Media Relations for the Centers for Disease Control and
Prevention, and we welcome you to what is becoming a continuing series of
news briefings on breaking news and updates related to severe acute
respiratory syndrome, or SARS, and smallpox. Today, we're bringing you two
topics. First will be severe acute respiratory syndrome. Then we'll break
at 12:30, switch speakers, and bring you an update on smallpox.
I want to advise people who are dialing in on the phone that if you're
experiencing trouble dialing in, our operators are able to accept a fairly
large number of calls at one time, but they can't accept all of the calls
at one time, and what we're finding is that people are all dialing in at
the top of the hour, and that's indeed what has been causing the delay that
some people have been experiencing. So if you can start dialing in a little
bit before the hour, that would be helpful. That way we can get everybody
through and have you live on the phone for the beginning of the conference.
We appreciate everybody's perseverance with us. We know that we have been
bringing information to you very suddenly, and sometimes with last-minute
notice, and we appreciate your staying with us and of any receptiveness to
this kind of an environment.
Our first briefing, as we said, is an update on severe acute respiratory
syndrome, and I'd like to introduce Dr. Jim Hughes, who is the Director of
the National Center for Infectious Diseases.
DR. HUGHES: Thank you very much, Janet. Good afternoon, everyone. Thank
you for coming and thank you to the others for dialing in. CDC continues to
work with the World Health Organization and other national organizations to
investigate an ongoing emerging microbial threat, referred to as SARS. This
is a major challenge, but is also an excellent illustration of the kinds of
threats that microbes can pose and the rapidity with which they can move
around the world.
The number of cases of suspected SARS continues to grow, both in the U.S.
and worldwide. In the United States today we're reporting 51 suspected
cases of SARS. That would be an increase of six cases from yesterday, from
21 states. And increase of one from yesterday. So far, happily, there have
been no deaths attributable to SARS in patients in the United States.
Of these 51 cases, 44 are associated with travel to areas where we know
transmission is occurring. Five cases are occurring in people who have had
contact with people who are ill with SARS, and there are two health care
workers who are I'll as a result of caring for one patient with a suspected
case.
Internationally, WHO is reporting 1283 suspect or probable cases,
exclusive of those from the United States. Now, I've not yet seen today,
because of the timing of the conference, the case counts for WHO today. So
I would urge you to consult with their website this afternoon for an update
on that information. Those cases come from 12 countries and a total of 14
geographic areas that have not changed from yesterday.
There are a total of, the case fatality ratio for cases internationally
is 4 percent.
We're encouraged that many of these patients with SARS are improving over
time. In spite of that, we know that this is a very severe illness. We know
it is causing great concern for patients, for family members, and for
health care workers. So, it is quite understandable that people are
concerned about this, and I'd like to assure you that we and the World
Health Organization and national authorities are doing everything possible
to move this investigation forward, just as rapidly as possible.
CDC is participating on teams assisting in the investigation in Hong
Kong, in Hanoi in Vietnam, and Taiwan, and in Thailand. We're also
conducting very active surveillance and prevention activities in this
country, working with numerous partners at the state and local levels of
clinicians and public health officials.
We've set up a special investigative team here in Atlanta to focus on
international aspects of this investigation, which is quite complicated.
And I would refer all of you to the morbidity and mortality weekly report
article that's released today and will be available on the web.
For those of you in the room, there's a figure that appears in that MMWR.
And what this figure shows is the linkage of many of the cases of SARS,
certainly not all, but many of the cases of SARS, to a specific hotel in
Hong Kong. When you have a chance to look more closely at that figure,
you'll be able to see how patients infected with whatever it is that is
causing SARS through their travels moved this infection to other countries.
Again, a very vivid illustration of the complexity of the situation, but
also the nature of global microbial threat.
Much laboratory work continues here at CDC and in a WHO-supported network
of laboratories working worldwide, to continue to try to sort out the cause
of this illness. The evidence in favor of this illness being caused by a
previously unrecognized virus in the group of viruses known as corona
viruses continues to mount. I'm not prepared that we're ready to say it's
definitive evidence yet. Much work remains to be done. But the
preponderance of the evidence as it evolves here and in other laboratories
around the world is consistent with a previously unrecognized corona virus
playing an important role.
We have taken action to meet aircraft returning to the United States,
bringing passengers to the United States from other parts of the world
where SARS is occurring. We're providing disembarking passengers with
information in terms of the nature of the illness and what to do if the
individuals develop such an illness. This is part of our overall national
surveillance effort on the one hand, and reflects our interest in
early-case identification, so that proper infection control measures can be
implemented.
With that in the way of a quick overview, let me stop and open this to
questions, and we'll try and alternate between people in the room and
people on the phone.
Let me take the first question here in the room.
QUESTION: Thank you, Dr. Hughes. Betsy McKay [ph] from the Wall Street
Journal. I have a couple of questions. One, I'm just wondering at this
point, with about 50 deaths around the world, and 13 or 14 hundred people
I'll, could you put this outbreak in context for some other outbreak? You
know, how large is it compared with other outbreaks? What particularly
raises the alarm felt here versus, say, a simple flu outbreak?
Secondly, I understand there is a movement to rename this disease from
SARS to CPD, I believe? And or CVP. And I wonder if you could just comment
on whether you all have adopted that name, as well. Thanks.
DR. HUGHES: Okay. Thank you. Several questions there.
First, the size of the outbreak. This outbreak is obviously no where near
as large as the global epidemic of HIV infection, for example.
Nevertheless, it is certainly significant. A number of people have been
infected, the case counts continue to increase. This is an infection that
certainly is contagious, though it does appear that proper, prudent
infection-control products and practices can dramatically reduce the risk
of transmission. So, although it's not huge, it's getting bigger and it has
the potential to get bigger still if it is not aggressively addressed.
I would take some issue with your comment that influenza outbreaks were
simple. Influenza outbreaks are actually quite complicated. And I'll use
this to remind everybody that you've heard us and others talk about the
stress posed by the next pandemic or worldwide epidemic of influenza. And
this is a good example of many of the issues that we would face when
the--we will face when the next influenza pandemic begins.
In terms of what this will ultimately be called--ultimately, if we can
agree on the virus causing this syndrome, assuming it is a virus, that
virus will have a name and the clinical syndrome will have a name. I think
we're still learning as we go. Evidence is accumulating. I think--my
personal reaction is that any name right now that includes pneumonia is
too--that limits the syndrome to pneumonia is too restrictive because at
least many of the suspect cases in the U.S. so far don't have evidence of
pneumonia. So I would say stay tuned on virus identification, virus name,
and syndrome name.
CDC MODERATOR: Given the number of callers on the phone, we're going to
take our next two questions from the telephone.
MODERATOR: We do have a question from the line of Seth Borenstein with
Knight Ridder. Mr. Borenstein, your line is open if you have a first
question.
QUESTION: Yes, thank you so much for taking this. In terms of the growth
of the outbreak, there was a lot of hope a week or so ago that it was
starting to peter out. And even if you take out the Guangdong numbers, it
doesn't seem to be the case. Can you address the issue of whether you think
this--whether with the infection control that's out there, do you feel like
you're getting a handle on stopping its growth?
And then the other question I have, obviously 50 is a small number in the
U.S., but is it unusual that we haven't seen any deaths or extremely
critical ill patients, given the mortality rate?
DR. HUGHES: Well, first of all, we're extremely gratified that we've not
seen any deaths from this syndrome in this country. Now, remember, we're
working with a surveillance case definition. And that case definition in
fact is evolving as we learn more about the illness. What the case
definition currently lacks is a laboratory component so that we can confirm
cases of SARS. When we have that and we're able to test all these suspected
cases, my feeling is that some will be confirmed and some will be
eliminated. So I know it's frustrating to follow case counts, but you're
going to have to bear with us on this.
In terms of changing numbers internationally, there's the potential for
swings there in part because of the recent report from China with reference
to Guangdong Province, and the number of total international cases
increased dramatically yesterday with the reporting of those cases from
Guangdong. I would also just remind you that there's a WHO-led
international team that we at CDC have two individuals participating in,
working with Chinese colleagues in Beijing right now, looking at much of
the data that they have developed over the past few months. So I would just
say stay tuned, watch the WHO website, watch our website, and you may well
see some changes in these numbers in the near future.
MODERATOR: We have a question from the line of Jeremy Manier with the
Chicago Tribune.
QUESTION: I apologize. Could I pass and save my question for smallpox.
MODERATOR: Thank you. We have a question from Laurie Garrett with
Newsday.
QUESTION: Is anybody talking about or trying to initiate any kind of a
case control study anywhere that might begin to answer some questions about
transmission and, you know, explain how transmission might have occurred in
the hotel, for example.
And the second is, Jim, we've talked about it before; I want to ask you
again about these two clusters and then scattered reports across the
country of sudden onset pediatric respiratory deaths in American children
that occurred in January and February and whether or not CDC is actively
investigating any possible link to SARS.
DR. HUGHES: Thank you, Laurie. Let me address the questions in the
sequence you asked them. First of all, your question about case control
studies is an excellent one. As with any evolving, emerging infectious
disease, there are many research questions that are raised immediately.
Some are critically important in the short terms; others are critically
important in the longer term. But right now, much of the focus is on better
definition of the precise mode of transmission of this agent and the risk
factors for transmission. So yes, we are working, in the United States
particularly, to look at health care workers and household contacts to see
if we can better define risk factors for transmission in those settings.
Similarly, in the international setting, case control studies and other
studies are being organized and are getting under way.
In terms of the clusters of unexplained deaths associated with acute
respiratory infections--and there were at least two that we were involved
in, going back six, eight weeks ago in the U.S.--severe unexplained
infectious disease-like illness occurs not infrequently in the United
States and around the world. Many people haven't in the past realized that
even with aggressive diagnostic workups for people that die with syndromes
that look like they may be infectious, you're often lucky if you find cause
in maybe half of the cases. So there are other unknown causes of infectious
diseases out there.
When clusters occur, we assist state and local authorities in
investigating them when we're asked to do so. We recently did that in two
different states. We were able to identify the cause in many of these cases
as being influenza, and in one case Group A streptococcal disease.
Now, for those who didn't have an explained etiology, we do have
specimens remaining, and as time goes on we will be looking back to see if
there was any evidence of this disease occurring in the U.S. prior to early
February.
MODERATOR: We have a question from Jennifer Coleman [ph] with KYM-TV. Ms.
Coleman, your line is open. Do you have a SARS question?
QUESTION: Yes. I think you touched on this a little bit. I know that
right now there's only 51 suspected cases in the U.S., but how are the
cases in the U.S.--I mean, I guess I'm just wondering if it's better
medical care or if--you know, why there's no deaths at this point reported.
DR. HUGHES: Well, we're concerned that there are as many as 51 cases in
the U.S. We're extremely pleased that there have not been any deaths. I
suspect in part that reflects early recognition and good clinical
management and we continue to urge good, prudent infection-control
practices as well. We haven't had very many of these suspect cases having
real severe disease, fortunately. Of the 51, 14 have had pneumonia and only
one has required ventilatory support with a respirator.
So we're seeing among our suspect cases milder illness overall than
people in Asia are encountering. So we're fortunate in that, but I think
we're also fortunate that we're well-positioned to provide good clinical
care to the patients who need it.
MODERATOR: We have a question from Robert Bazell from NBC News. MR.
Bazell, your line is open. Do you have a SARS question?
QUESTION: Thank you. Dr. Hughes, since the emergence of HIV and other
than influenza, have you had an emerging infection that you can recall
that's caused you so much concern?
DR. HUGHES: Well, there was that one that you recall, Bob, as well as I
do, back in 1993, Hantavirus Pulmonary Syndrome. That was a severe,
unexplained, acute respiratory disease that was recognized in previously
healthy young people on the Navajo Indian Reservation in the Southwest.
That was astonishing, to say the least, in a similar way that this current
outbreak is astonishing in terms of its complexity and challenges.
These microbes have continually illustrated that they will continue to
challenge us. You'll never see better examples than that Hantavirus
situation and the current situation to drive home the important points made
by the recently issued medicine report on global microbial threat, which
points out the critical need to continue to rebuild global response, global
surveillance and national and local infectious disease surveillance and
response capacity, and to address the many research questions, the training
needs, and the communication issues that these challenges pose.
CDC MODERATOR: Next question, please.
MODERATOR: We do have a question from the line of Maggie Fox at Reuters.
Miss Fox, do you have a SARS question?
QUESTION: Oh yes. Thanks, Dr. Hughes. The authorities in Hong Kong seem
to be a lot more confident than you are that corona virus is to blame. Can
you address that and the possibility that the corona virus and the
paramyxovirus may be acting in concert?
And also how unusual is it to find samples of both these viruses in
tissue?
DR. HUGHES: Okay.
Let me say that I thought I had said earlier that the weight of the
evidence, as far as we're concerned, continues to build in support of the
corona virus having a causative role in this syndrome. We're not ready to
be totally definitive about that? There is more work to do. You have to be
cautious. It doesn't do anyone any good to jump to conclusions prematurely
when you're investigating a problem as complicated as this.
Labs in many countries now have found evidence of corona virus infection
in these patients. That's in contrast to just a few days ago, you may
recall when metapneumovirus was clearly the leading candidate. I would say
corona virus likelihood is going up; metapneumovirus likelihood is probably
going down. We're not willing to take it off the table yet. We keep an open
mind in these things. And the possibility of their being some co-infection,
at least in some patients, and have that play a role in the overall
presentation of this illness has to be kept in mind.
CDC MODERATOR: Next question, please.
MODERATOR: We do have a question from the line of Larry Altman with New
York Times. Mr. Altman, do you have a SARS question?
QUESTION: Yes. It was along the lines of Maggie's question. But could you
put this in a little more perspective in terms of the evolution of paramyxo
and then the subset of metapneumovirus, and then the emergence of corona
virus. Can you just outline the steps as how this has evolved over time?
CDC MODERATOR: Jim?
DR. HUGHES: Yes, thank you, Larry.
Actually because Dr. Larry Anderson is here and is an expert in both
these groups of agents, let me seize the moment and ask Larry to come up
and make some comments.
DR. ANDERSON: Thank you.
It's actually been a very interesting progression of laboratory and
clinical and epidemiologic findings. I think some of the early suggestions
came from electron microscopic studies, when they noted paramyxovirus-like
particles in respiratory secretions. Around that time they also identified
evidence of the human metapneumovirus in respiratory secretion specimens in
Hong Kong. This virus has also been identified in specimens from some other
countries as well.
We pursued that, but continued to look for other agents. A group in Hong
Kong and Germany identified some other particles and secretions that were
suggestive of probably not a paramyxovirus by size. And we and other groups
isolated or found evidence of cytopathic effect in tissue culture material.
Our electron microscopist identified corona virus-like particles in this
tissue culture material. We then used molecular techniques to look at the
genetics of this virus and confirmed that in fact it was a corona virus.
And then developed tools to look at additional specimens, and then provided
the tools for other laboratories to look at this finding as well.
So that's been the progression. And I think as in any investigation, you
develop hypotheses and then test the hypothesis to see if it fits with the
clinical and epidemiologic characteristics of the disease, and we're kind
of trying to finish up the linking to disease at this point.
DR. HUGHES: So let me just follow on and point out again to remind
everybody, this remains a work in progress, and there will continue to be
new data and new observations that are important that will be made.
CDC MODERATOR: Next question, please?
MODERATOR: We do have a question from the line of Bob Stein with The
Washington Post. Mr. Stein, do you have a SARS question?
QUESTION: Yes. Thank you very much.
I'm trying to get a little bit more information about the 51 suspected
cases. First of all, I was wondering, are they all being held, or kept
isolated? And if so, is it homes, or in a hospital? And of the five cases
that appear to have been the result of close contact, were they all family
members, or were they some other kind of contact?
DR. HUGHES: Okay, to get to the second question first. Three of them were
family members, and two of them were health care workers. The infection
control precautions that are recommended for these patients are in addition
to standard precautions recommended for everyone. We call for contact
droplet and airborne precautions. And that's being prudent, because the
bulk of the evidence suggests that this infection spreads through close
contact between patients and others who are unaffected.
We have to keep an open mind here in terms of exactly how this
transmission occurs. Whether it's by physical contact or by large droplets
that spread over short distances, or possibly through contamination of
articles in the inanimate environment that might be handled. And then
finally we have to keep open the possibly that this is transmitted at least
in some cases by the airborne route. There's no evidence of that today but
we are keeping a very open mind in that regard, I assure you.
So patients that are ill with this syndrome are kept on these isolation
precautions throughout the course of their hospitalization. And because we
just issued, last night, some additional infection control guidance, and
because Dr. John Jernigan from our Division of Health Care Quality
Promotion is here with us today, let me ask John to come up and just
briefly comment on that one specific aspect of your question. John?
DR. JERNIGAN: Sure, Jim. We issued some guidance last night to hospitals
in the United States on some more detail on how to handle infection control
procedures in the hospital, and specifically how to handle health care
workers who may have been exposed to patients while they were taking care
of them. And we have no reason to believe that people can transmit this
disease when they don't have symptoms. So what we've recommended the
hospital, since they close track of health care workers who are caring for
SARS patients, and do surveillance and touch base with the very frequently
to make sure that they don't develop signs of illness. And if in fact they
do develop signs of illness, we are recommending that they probably should
not be taking care of patients in the hospital.
We are not excluding, not recommending exclusion from duty if people do
not have respiratory symptoms. Again, the weight of the evidence that we
have so far suggests that the infection cannot be transmitted from
asymptomatic people. We are monitoring that situation closely and we are in
close collaboration with our international folks who have had a lot of
experience. And the bulk of the evidence suggests that as well.
To date, all the patients with SARS in the United States have been either
in persons with history of foreign travels, or transmission with close
contacts. And so we're pretty comfortable with those recommendations that
we put out last night for health care institutions.
CDC MODERATOR: Given that we have two important topics to cover today,
this will be out last question on SARS.
MODERATOR: We do have a question from the line of Qeta McPherson [ph]
with Star Ledger. Please go ahead.
QUESTION: Thank you.
My question concerns the investigation itself. I was wondering, Dr.
Hughes, for my readers who are not scientists, what tools do you have at
your disposal this time that you didn't have when the AIDS was breaking
out, and maybe even more recently? And does this reflect an investment
that's more towards bioterror precautions?
DR. HUGHES: Thank you. I thought you were going to ask, perhaps, what
tools do we have today that we didn't have back in 1993 when we encountered
the Hantavirus situation. But you went way back 23 years ago to the
recognition of HIV infection. And you might recall that it took three or
four years to identify the cause of that syndrome. So keep that in
perspective.
We have much more sophisticated tools today at the national level and at
the state level and in clinical laboratory settings to diagnose infections
disease as compared to, certainly, the situation 23 years ago. We've made
dramatic progress. The Institute of Medicine report that I mentioned points
that out, but it also emphasizes the fact that we need a much broader array
of diagnostic tests. In many cases of pneumonia, a positive agent is only
found in roughly 50 percent. And many of these tests that do exist take a
long time to conduct.
One of the major problems that we're facing nationally and globally now,
if you move SARS, is the problem of antimicrobial resistance. I mention it
because it's a big problem for clinicians and public health officials. But
it also is one that illustrates why it's so important to continue research
to develop rapid, sensitive, specific diagnostic tests that can be used
both in clinical and public health settings.
So yes, we have better tools today. We don't have all the tools that we
need to sort these things out as rapidly as we need to. And we don't have
all the highly trained people with the range of skills needed to address
these issues that we need as well. So keep that in mind.
Let me stop there. Thank you all very much for your continuing interest,
and again, I ask you to stay tuned.
CDC MODERATOR: Thank you very much, Dr. Hughes. We're now going to give
you just a moment to switch files from the SARS to the smallpox. While
you're doing that, let me thank you again for joining us today. I know we
had several people on line who were unable to ask their SARS questions.
Please, call the Media Relations Office upon conclusion of this broadcast,
and we will assure that you're connected with somebody to have your
question answered if it was not answered in the telephone briefing that we
just concluded.
We are going to also repeat for those people who were frustrated by not
being able to get on the line immediately the caution that, while our
operators do have plenty of capacity, they don't have capacity enough to
handle 50 calls at once, and that's how many came in at 11:59 today. So we
appreciate your promptness. If you can bear with a little bit more music,
please try to dial in a little bit earlier and we will get you through as
rapidly as possible.
Now it's my pleasure to introduce the head of our National Immunization
Program, Dr. Walter Orenstein, do give you an update on smallpox.
DR. ORENSTEIN: Thank you very much, January, and good afternoon.
First of all, I'd like to say that we are deeply saddened by the reports
of deaths of two of our health care colleagues after smallpox vaccination.
Our thoughts are with their families. They were valued members of our
health care community, and their families can rest assured that we at CDC
will be working closely with our colleagues in the states and other outside
scientific experts to try and determine the possible reasons for their
deaths.
Smallpox vaccine safety remains a top priority for CDC and we are
committed to the safety of individuals involved in this program. We will
continue to carefully monitor the safety and will update our partners, the
public, and vaccine recipients whenever we have a concern about potential
health issues that can affect their lives.
Between January 24th and March 21st, smallpox vaccine was administered to
25,645 individuals. These are health care workers and public health workers
in 53 jurisdictions around the country. This is part of our effort to
prepare the United States for a smallpox attack, should it ever occur.
Seven cases of cardiac adverse events have been reported among civilian
vaccinees since the beginning of the program. Of the seven cases reported
to CDC, two are cases of inflammation of the heart, the membranes around
the heart--so-called myopericarditis--and five are the result of coronary
artery disease. This includes two cases of angina and three cases of heart
attacks, two of whom have died. In addition, there are 10 cases of
myopericarditis, or inflammation, reported among military vaccinees.
While available evidence suggests that vaccines may be playing a causal
role in inflammation of the heart or around the heart, it is not clear
whether the other cardiac events are causally related or coincidental and
would have occurred anyway. We are actively investigating whether there is
any association between smallpox vaccination and these other cases. If our
investigation shows the precautionary measures we have adopted--which I
will mention in a moment--should become permanent, or if there are other
reasons for change, we will take immediate action.
CDC has taken the following actions.
We have recommended that persons with histories of heart disease be
temporarily excluded from vaccinations until more extensive evaluation and
review have taken place. We have been in contact with the states and
informed them of what we are doing.
We have developed interim screening criteria and an addendum to our
vaccine information statements and fact sheets, which we are sending to the
states.
We have sent staff to states where deaths have occurred to collect more
detailed information, and we will continue to work with states to refine
our information and make further recommendations.
Our Advisory Committee on Immunization Practices, supplemented by members
of the Armed Forces Epidemiological Board as well as cardiology experts and
other experts will meet on Friday, and we hope to accomplish the following:
One, to determine which group should be deferred for vaccinations. What
are the best ways to screen for conditions in the setting of a vaccination
clinic, and what further studies are needed to determine if there is a
causal relationship. Our preliminary discussions with some of our experts
have reinforced that we should continue the program with the exclusion
criteria that I mentioned.
I'd be happy to take any questions. Thank you.
CDC MODERATOR: We'll start with a question from the floor. Seeing no
hands, let's move right to the phone because we know there are several
people in queues. So again, if people on the floor have a question, please
indicate and we'll be sure you have the opportunity to ask.
MODERATOR: We have a question from Jeremy Manier with Chicago Tribune.
QUESTION: Thanks very much. What efforts are being made to reach people
who have already been vaccinated who might have preexisting heart
conditions, and what effect might this have on the larger effort? I know
the vaccine effort has not gone as quickly or as--and as widespread as had
been hoped. Might this slow down the effort somewhat?
DR. ORENSTEIN: Let me take the first question first. In terms of
notifying people, we are doing a number of things. One, we're holding media
briefings, we're getting the--trying to get the word out in a variety of
fashions. We're getting the word out to our partner organizations, our
physician organizations. We've put out a Health Alert Network. And we're
getting information out to the states so that they can use to inform people
who have already been vaccinated that should they develop any symptoms of
heart disease, such as shortness of breath, chest pain, or symptoms like
that, that they immediately consult their physician.
In terms of what this will do to the program, we are working to try to
maintain the program. The vast majority of people would not be included in
the risk factors that we are currently recommending be used to exclude
people from the program. We are developing materials for that. And we
certainly feel the need to continue our efforts to try to improve our
preparedness against smallpox. How well we do will depend on how health
care workers themselves, as well as the states, evaluate the information
that we're presenting.
MODERATOR: We have a question from John Barman [ph] with Bloomberg News.
QUESTION: Thanks for taking my question. I know you're often loathe to
give this kind of information, but what can you tell us about the second
health care worker? Can you tell us at least the state of the health care
worker?
DR. ORENSTEIN: At the moment, we cannot tell you the state because we are
concerned about identifiers. However, we do know a number of the states
have made press releases, and I would not be surprised if that happens in
this case.
What I can tell you is that the individual was a 57-year-old female who
developed her heart attack approximately 17 days after vaccination,
collapsed, was resuscitated, but not for a period of about 20 minutes or
so, and has subsequently died. We know that this individual, who was a
female, had a previous cardiac catheterization. At the moment we're not
clear what the rationale for it is. We know she had a previous history of
hypertension, and we know that she had, during the cardiac catheterization,
other evidence of perhaps underlying arteriosclerotic heart disease, which
is based on having what's called a transient ischemic attack during the
episode.
I need to emphasize, again, what--the points I've made. While the
evidence is somewhat suggestive that vaccine is playing a role in the mild
pericarditis, the inflammation side of this, particularly based on the
military data, the data that we have on the civilian side, from the heart
attacks and from the cases of angina, the numbers we have, at least to
date, are within what we might have expected by chance alone.
So that this very well could be coincidental illnesses and we will be
trying to determine whether there is a causal role, but we are trying to,
again, be precautionary, by excluding those at the very highest risk of
having underlying heart disease from vaccination at this point.
QUESTION: A question from The Wall Street Journal. Can you tell us
anything more about these ten cases in the military, their ages or risk
factors--
DR. ORENSTEIN: I think, one, it would be best to talk to the military
about those cases. What I can tell you is that all of them are primary
vaccinees, meaning they've never been vaccinated before. So that gives you
a picture that they're generally a younger population than in the civilian
side. On the civilian side, what we can say is that roughly two-thirds of
our civilian vaccinees are over 45 years of age, which is very, very
different than the military population.
In the military population, they have not seen any cases in about a
100,000 revaccinees. So it's been only in their first vaccination group
that this is occurring, which makes sense from a biologic perspective,
because it's the first vaccinations in which you expect the maximal viral
replication and where you might expect to see some kind of increased
inflammation.
In the civilian side, again, we really don't have solid data on causation
and based on the numbers of deaths at least, this is within what we might
expect in a similar population of this age.
CDC MODERATOR: Our next question is from the phone.
MODERATOR: We do have a question from the line of Laura Meckler with
Associated Press. Please go ahead.
QUESTION: Thank you.
I have two questions related to the inflammation cases. First, do any of
the people on the civilian or the military side, are they still having
problems or have they all recovered? Could you just tell us something about
their condition.
And secondly, the screening provisions that you've put into place, as I
understand it, would not do anything to prevent these cases because the
sort of history of heart disease, as I understand, is not related to
inflammation of the heart. So what can be--if I'm right about that--what
can be done about trying to prevent these inflammation cases?
DR. ORENSTEIN: Okay. First of all, we know that all cases in the military
have completely recovered. They were not that sick and they are going, as
far as I know, are going about their regular duties.
In terms of the physician [?] population, I have preliminary information
but I'm concerned I don't have adequate information to say whether they're
recovered or not. My belief is that they have also recovered fully. In
terms of screening for risk factors for myocarditis and pericarditis,
that's part of what we will be talking about when we discuss with
cardiologists, and others, whether there are risk factors that we can use
to exclude people. We do not at the moment have such risk factors.
On the other hand, there are clear risk factors for coronary artery
disease and that's why we have made the recommendations that we did, to try
and pick out the risk, highest risk factors for coronary artery disease.
CDC MODERATOR: Next question, please.
MODERATOR: We do have a question from the line of Maryn McKenna with the
Atlanta Journal-Constitution. Please go ahead.
QUESTION: Hi. Thanks for doing this.
My question relates to the ruling out potential vaccinees if they have a
known history of heart disease.
Dr. Orenstein, given that the two deaths were both in women, that women
have, that the health care population is more than 50 percent female, and
that women tend to be underdiagnosed with heart disease compared to men, do
you have any concerns that a known history of heart disease won't be
sufficient to screen out people who might potentially be at risk of
ischemic responses to vaccination?
DR. ORENSTEIN: Thank you. It's a very good question, Maryn. Clearly, if
we look at all known risk factors for coronary artery disease, we would
potentially get to very, very large numbers of the population, and we
would, in essence, be very--very difficult to enhance our preparedness.
What we've tried to do is pick out people with the very highest of risk
factors, in the absence, at this point, of any known causal relationship.
The issue of women is a very important one. Women are not only
disproportionately represented in the cases. They're disproportionately
represented in the vaccinees. About two-thirds of the vaccinees are women,
and women make up a larger proportion of the health care worker task force,
and this may in part explain why we're tending to see more of these cases
in women, and one of the things that we will be consulting with
cardiologists over the next days to weeks is to see whether there are other
risk factors and other issues we ought to be doing for evaluation.
CDC MODERATOR: Next question, please.
MODERATOR: We do have a question from the line of Marilyn Marchone [ph]
with Milwaukee Journal. Do you have a question on smallpox?
QUESTION: Yes, I do. Dr. Orenstein, I understand you're mostly talking
about adverse events but some of us just finished a conference call with
the Institute of Medicine and there's a great deal of confusion about
whether Phase II is starting with other emergency responders.
Has CDC made any determination about beginning Phase II smallpox shots,
and if so, are states free now to begin?
DR. ORENSTEIN: We are planning to issue guidance by mid April on further
vaccination against smallpox. Certainly states, at this point, are free to
increase their vaccination target populations as they feel important, but
we will be issuing guidance by mid April on this.
CDC MODERATOR: Next question, please.
MODERATOR: We do have a question from the line of Rachel LeClerk [ph]
with the Associated Press. Do you have a question on smallpox?
QUESTION: Yes. This is getting back to the second death being reported
here, this woman from St. Petersburg. Any sort of timeframe on determining
the connection between her prior heart problems and the vaccination?
DR. ORENSTEIN: It's hard to give an actual timeframe. Clearly, we have
epidemic intelligence service officers in both locations where the deaths
occurred, to try and collect more information and ideally specimens that
will allow us to look for virus, if it happens to be in the heart tissue,
to look for signs of more diffuse inflammation, if inflammation is an
inciting event for someone with underlying heart disease for a heart
attack, and that will take some time.
I really can't tell you at this point. We do have involved a variety of
people in this, including cardiac pathologists. We have our virologists
here, at CDC, and others, to try and look at this.
CDC MODERATOR: Next question, please.
MODERATOR: We do have a question from the line of Kerry Fursnyder [ph]
with Arizona Republic. Do you have a question on smallpox?
QUESTION: Yes. [inaudible] vaccinations were stopped in 1972, were there
ever any reported problems among children or adults receiving the vaccine
in terms of cardiac issues?
DR. ORENSTEIN: The greatest experience with regard to cardiac issues came
from Europe, where there were reports of myocarditis and pericarditis in
the past, but not with the strain of vaccine that we use in the United
States, the New York City Board of Health strain.
There are always case reports of different things, but certainly heart
problems were not an accepted, or scientifically accepted adverse event of
smallpox vaccine with vaccine use in the United States.
In terms of the issue of coronary event and smallpox vaccine, that too
was not an accepted adverse event. Certainly, there may be occasional
reports of this but not enough to support a role for vaccine causing any of
these events.
CDC MODERATOR: Next question, please.
MODERATOR: We do have a question from the line of Helen Chickering with
NBC News. Do you have a question on smallpox?
QUESTION: No; thank you.
MODERATOR: We do have a question from Ceci Connelly with the Washington
Post. Do you have a question on smallpox?
QUESTION: Yes; thank you. Doctor, earlier, we were on a conference call
with the chairman of the IOM advisory committee and its report coming out
today, and they continue to express concern about having enough of what
they describe as a pause, to evaluate, say, how your Phase I is going.
Their initiate desire was before you moved into Phase II. It seems that now
we're, in some respects, already in Phase II while still operating in Phase
I.
I'm wondering if you can respond to some of the IOM concerns about the
lines of the Phase II potential population is very different from your
Phase I target population and so in terms of public health, is it really
wise to begin vaccinating police, firefighters, EMTs, without giving
guidance in terms of information packets, consent forms, what kind of
education and training you might need?
It seems that so much work went into the preparation for Phase I and now
we don't really see any, and we're in the middle of Phase II.
DR. ORENSTEIN: I think those are good points. In terms of the information
packet, our intent would be to use the same kinds of information packets
that we are currently using, which gives people quite a bit of detail, as
you know, on a variety of issues with regard to smallpox and smallpox
vaccine safety.
We are also in the process of developing revised forms, which we're
working with our states on.
We plan on distributing guidance with regard to program expansions in mid
April and so that guidance will be used, I presume by the states, in
developing the ways they will move into Phase II.
Some states and areas have already selected as part of their initial
response teams a number of the staff that might be suggested for
vaccination in Phase II, such as security workers who might need to keep
order for clinics and other kinds of events.
And so again, we are concerned, we are evaluating as we go. An example of
that clearly is what we're doing with the cardiac disease in this program
and trying to get information out as quickly as possible to people.
So we are not recommending a pause, but because of the concerns of the
need to get prepared, particularly with the other events going on in the
world at the moment.
CDC MODERATOR: Next question, please.
MODERATOR: We do have a question from the line of Richard Knox with
National Public Radio. Do you have a smallpox question?
QUESTION: Yes. I do.
Thank you for having this. It's really following on Ceci's question.
Because of the greater definite evidence for some kind of inflammatory
process with the vaccine, is there some reason to do a pause now before
moving to a broader first responder population, while that can really be
worked out, because, after all, you may have a lotta people in that
population who would worry about their risk for that.
Also, I wonder whether, in your deliberations about the guidance for that
and for Phase I, you are considering whether to recommend explicitly that
people be vaccinated for this pre-vaccination effort, only if they've had
prior vaccination to minimize that.
DR. ORENSTEIN: First o fall, what we have done with regard to myocarditis
and pericarditis, is we will be discussing over the next several days, with
a variety of experts, what should be done with regard to those cases.
In the meantime, we do feel that clinics that are scheduled should go on
with the new information which we have recently distributed to the states.
Your second question was on--can you review the second question again, or
your second part of it.
CDC MODERATOR: Let's go on to the next caller.
MODERATOR: We do have a question from Debosiya Ricks [?] with
[inaudible]. Do you have a smallpox question?
QUESTION: Yes. I do. It's Delphia [?] Ricks. My question is in the
meetings that you'll have over the next several days, are these open to the
public and will you be releasing any information whatsoever regarding any
of the results that come of it?
DR. ORENSTEIN: I think I remember the second question, if I could answer
that first. The issue of should we focus vaccine solely on persons with
revaccination, based on the information from the military, which suggested
that the myocarditis and pericarditis was only in first-time vaccinees, we
have actually put out recommendations in the past, that where feasible,
health programs should focus their vaccination program on revaccinees, and
so you can tell from the age group of the serious cases of heart disease,
that is, the heart attacks and the angina cases, they're all in an age
group where they most likely had had prior vaccinations.
So at the moment, I don't think we're prepared to try and limit it only
to revaccinees, until we understand a little bit more about what's going
on, simply because we're moving into a more at-risk age group, and in fact
the data from the military suggests that the cases of myocarditis and
pericarditis were all very mild and all followed by full recovery.
In terms of the meetings, we do have a meeting on Friday, which is our
major meeting with our Advisory Committee on Immunization Practices,
supplemented by the Armed Forces Epidemiological Board. That will be an
opening meeting and we will be putting information up on how media and
others can get access to it.
CDC MODERATOR: Out of deference to Dr. Orenstein's schedule as well as
your own, this will be our last question.
MODERATOR: We do have a question from the line of Marcus Franklin with
St. Petersburg Times. Mr. Franklin, do you have a smallpox question?
QUESTION: Yes; thank you.
Doctor, is there any timetable here with regard to when you'll be making
the determination as to whether the death of Virginia Jorgensen [ph] here,
in St. Petersburg, is in fact related to the vaccination?
DR. ORENSTEIN: We have no timetable. We clearly are working as quickly as
we can. It will depend on the quality of information we have and, perhaps
more importantly, the information we get on other cases, because to make
decisions on a single case can be very, very difficult.
What needs to be seen is patterns or unusual patterns, help in trying to
differentiate that this is different than other kinds of events, and so
it's not just simply an investigation of the death of the 57 [?]-year-old
female but it's also the overall investigation that takes place and the
collection of information on cases that haven't died but who have
significant cardiac events, again, all of it put together to see if we have
a pattern. Thank you.
CDC MODERATOR: Thank you, Dr. Orenstein. because of the importance of
this issue, as Dr. Orenstein mentioned, the Advisory Committee on
Immunization Practices, or ACIP, is meeting tomorrow and we are trying to
set up an open listen-in line for reporters, so please watch for a media
advisory on that. This concludes our briefing today. Thank you for staying
with us.
Listen to the telebriefing
This page last updated March 27, 2003
URL: http://www.cdc.gov/media/transcripts/t030327.htm
United States
Department of Health and Human Services
Centers for Disease Control and Prevention
Office of Communication
Division of Media Relations
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