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CDC Telebriefing Transcript

SARS: Laboratory Investigation of Coronavirus

April 2, 2003

DR. GERBERDING: Good afternoon. Thank you for joining us for another update on SARS. We continue to get a lot of phone calls requesting specific information, so I'm going to try to address your concerns. We also do have callers on the phone, so if you're asking a question from the floor, please use the microphone so that we can make sure that everyone hears the question.

Let me first just give you a brief recap of where we are in the SARS global epidemic. WHO today is reporting 2,151 cases outside of the United States, and we are reporting 85 cases within the United States. There have been 78 deaths internationally--no deaths in the United States as of today, and most of the patients here domestically are doing well and recovering. Many of them are already home.

We have some good news today in terms of our laboratory investigation. We are not confirming that the coronavirus is the cause of SARS, but we are beginning the process, today or tomorrow, of releasing to state health departments coronavirus test results from the patient samples that we've received here. This is going to be a process, not an event, because it takes time to do these samples. These are the antibody test results, and so in order to really fully interpret the test result, one must have an acute sample and a convalescent sample from the patient to look for changes in the antibody concentration over time. Obviously, we don't have all those samples yet, especially for the recent patients. So as we get the information, you can fill in the blanks. We'll be providing that information to the states.

What we are telling people with this information is that the patient has an antibody response to the new coronavirus. This may be very strong evidence of an association with SARS, but it's not yet proof at this point in time. I think we recognize that we're being very cautious with this, but there are other viruses still under investigation, and so until we meet all of our scientific indicators for causality, we're going to err on the side of caution and be open to other hypotheses as we go forward.

We are also aware that the Department of State has issued some new travel advisories. In part this relates to the information that we are now getting out of mainland China. China has agreed to be a full partner in the SARS investigation. Permission has been granted for the WHO team to investigate patients in Guangdong, and they are preparing to travel there imminently.

We know that we are receiving reports of cases from several provinces in China, but most of the cases are recognized in the Guangdong Province, where we have strong suspicion of ongoing spread within the community there, and that the epidemic is not actually over there. There are new cases being reported at least as of March 31st. So the travel advisory is advising travelers to avoid non-essential travel to the Guangdong Province of China and to Hong Kong.

In addition, as you know from the CDC perspective, we have been advising against non-essential travel to those areas of the world that have ongoing epidemics, and for us right now, that includes Vietnam, Hong Kong, Mainland China, and Singapore. So we're taking a somewhat broader view of how to advise travelers and assess their individual risk, since we feel there are still areas of uncertainty. Until we have more information from all of the provinces in China, we're continuing to follow this path.

The travel-alerting mechanism continues. We've issued more than 250,000 travel alerts. Many of you are aware, yesterday, that the alert process is working exactly as we would like it to. People are aware when they have illnesses that are suggestive of SARS, the fact that we were able to intercept and evaluate passengers on an airline that had symptoms of SARS suggested that information really is getting out to people and the system is working exactly the way it's supposed to.

As a follow-up to that, we know that the passengers, who were thoroughly evaluated by the local health officials, were found not to have SARS. They were released--or the plane was released. The other passengers are under no special observation beyond that that they would be under because they were returning from--potentially returning from a country where SARS was being transmitted. But it illustrated to us that we are able to identify situations where there is a concern and take the appropriate public health action.

I also want to emphasize that right now we are not planning any quarantine for any categories of individuals. And that gives me an opportunity to spend a little bit of time clearing up some confusion about the differences between isolation and quarantine. We're getting a lot of calls, and it's clear that communication is not accurate on a lot of these fronts. So let me just indulge you a little bit with some straightforward explanations about what these words really mean. They can be very frightening and confusing to people and we really want to make sure folks understand what we're talking about.

First of all, isolation is a public-health tool that applies to people who are sick or who have infectious diseases that could be transmitted to others. We isolate people every single day in hospitals because we're concerned that they have a disease or an infection that could be communicable to other patients or to health care personnel. So it's an extremely common mechanism. It applies to sick people.

And it can be either voluntary or required, depending on the circumstances. Almost all isolation in this country and elsewhere is voluntary. It's just simple standard operating procedure in health care settings, or even in home settings, to prevent spread of disease to others but also to make sure that patients can get the proper care that they need and are given the full and humane treatment.

"Quarantine" is a word that applies only to well people who may have been exposed to an infectious disease and could be at risk for incubating it or passing it on to someone else. Like isolation, quarantine can either be voluntary or it can be required. Almost all quarantine in the United States in the last several decades has been completely voluntary. And it can last through various periods of time. Sometimes we quarantine people for just a few minutes while we are looking at them to determine whether they have SARS or whether they have tuberculosis. And this is especially common in travelers who are coming into the country and there's a concern about exposure.

It is also true that quarantine can be applied for longer periods of time; for example, for a period of time to get people prophylactic treatment so that they don't develop a disease or spread it to someone else. And rarely do we ever need to implement quarantine for longer periods of time, and when we do so, again, it's almost always a voluntary process.

So it's very important to move away from the understanding of quarantine that we had a century ago, which was really something that was required and often very unfair and very difficult for the people who were involved in it. That is not the kind of quarantine that we're talking about in the 21st century. We're talking about public health tools that simply serve to protect people or to protect themselves or others from a communicable disease.

We are aware that some countries right now have implemented voluntary quarantine for SARS contacts, and Hong Kong is in the process of implementing holiday camps as a form of quarantine for people who may have been exposed to SARS and could transmit it to others. One way to think about quarantine is like a snow day. It's simply a break from a situation where you might expose someone else or put someone else at risk for something that you are incubating.

I guess the last thing I would really like to say is that we appreciate that the people who are returning travelers from affected areas have a great deal of concern about their safety, and our empathy is with them, as it is for the people who develop symptoms or are undergoing evaluation for SARS. We're doing everything we can here at CDC to get to the bottom of this mysterious illness, because we know the more information we can provide and the sooner we can get diagnostic information or clarity to these people, we will all feel a lot better. So we are working hard and we will continue to do the best we can to put information out as we acquire it.

Let me take some questions. I'll start with a question from the telephone.

MODERATOR: And once again, ladies and gentlemen on the phones, to ask a question just press the one on your touchtone phone, and first we go to the line of Jeremy Mayer [ph] with Chicago Tribune. Please go ahead.

QUESTION: Thanks very much. Dr. Gerberding, I wonder if you might be able to just comment on the different ways the illness is unfolding in Hong Kong and Toronto, other places in Canada, and the U.S.

Does it seem like perhaps the population density in Hong Kong, and places like that, might have something to do with the continuing spread there, and is it different, as a result, in Toronto and the U.S.?

DR. GERBERDING: The question is really how do we account for the differences in transmission in, say, Hong Kong versus the United States. We don't know the true reason why these patterns of transmission or the epidemic looks different in different locations right now. We're still sorting that out and we've got teams investigating the situation in Asia. We also are exchanging information with Health Canada on a daily basis.

One part of the explanation is that when the epidemic first started, we of course didn't recognize that there was an infectious disease going on, so the kinds of isolation practices that I mentioned, and the infection control practices to prevent spread were just simply not implemented, so there was time for the epidemic to begin to spread, and to other people before we really knew that they had it.

In the United States we were lucky in that travelers returning here did not have symptoms of disease as soon as they did in some other countries, and if they did, they were not in situations where they spread the infection to others.

So I think some of this just has to do with timing and coincidence. We also recognize that there are aspects of transmissions that we just simply don't understand. We don't know why the people who stayed in the hotel in Hong Kong, why so many of those people acquired infection.

It may be that certain individuals are more efficient at transmitting virus than others, and that is a matter of chance, or other factors that we haven't figured out yet.

So our epidemiologists I think will eventually be able to answer your question, but right now the focus is simply on using the public health tools that we have at our disposal to protect people who are uninfected and to make sure that the people who are infected get the best possible care.

I'll take a question from the reporters here.

QUESTION: Thank you. Would it be correct to say, then, that the results of this antibody test, that a person wouldn't--you wouldn't know the results until the person's on their way to recovery?

DR. GERBERDING: We can test a sample any time we get it but in order to interpret the meaning of the sample, it requires us to understand what's happened over time.

For example, if a person is sending us a sample very early in their illness, there isn't time for the antibody to appear, and so the sample may be negative when in fact the person really has SARS. It's just that not enough time has gone by for their antibody to be produced and to be detected in the test.

So when we see a positive test at the end of illness and a negative test at the beginning of the illness, that's really strong evidence of coronavirus infection. It still doesn't mean it's the cause of SARS, but it's pretty strong evidence that that's what we have.

QUESTION: So would one single sample tell you--let's say you got them when they were starting to develop antibodies, would that--

DR. GERBERDING: If we have samples that are negative late in the course of illness, it's pretty good evidence that that person does not have coronavirus infection. But we have a lot of work to do before we can draw firm conclusions on any of these tests. You know, it takes thousands and thousands of samples in people who do or do not have the disease, before we can give accurate estimates of how valid the test is in any given person.

So this is information that is a useful tool and what we are seeing so far is that the people that have the most, the strongest epidemiologic link to SARS, are turning out to have positive tests. So that's a good clue, but, again, it's just not proof.

I'll take a question from the phone, please.

MODERATOR: Thank you very much, Doctor. We go to the line of Seth Borenstein with Knight Ridder Newspapers. Please go ahead.

QUESTION: Yes. Thank you, again, for doing this, Dr. Gerberding. In terms of the last few days, there seems to be a little bit more worry in the public, and U.S. public, especially after the San Jose plane issue.

Can you, for people in the United States as opposed to elsewhere, put this in perspective with everything ranging from the 1918 Spanish flu pandemic to West Nile and SARS. You know, put what is out there now and the possibilities in some kind of useful thing for everyday Americans.

DR. GERBERDING: I think the theme that ties all of these illnesses together, that you mentioned, is emerging infection. We live in a global village and we must be prepared to deal with emerging infections on a regular basis, and that's really the pattern that we're seeing increasingly as our global village becomes more dense with people, and has more travel, I might add.

So what I can say right now about SARS is that it's too soon to tell where this is all going to go. We see evidence of very high and efficient transmission in certain situations and we see other examples where there is not a lot of secondary transmission. That's very reassuring.

I think we're encouraged that people who have the infection usually do well, but unfortunately, some people do have the severe pneumonia and a few people die.

So it's just far too early to predict. But this does appear to be a contagious respiratory infection and you know how difficult it is to control the common cold. Even influenza, where we have a vaccine, is an illness that still causes infection in a large number of people.

So I think the global community has to take this very seriously and do everything we can to curtail spread now and stay on top of it.

I'll take a question from the reporters here.

QUESTION: Yesterday we had heard that there was a 1-year-old that was adopted from Asia who showed symptoms of SARS, and I guess my concern is we know how quickly things spread among children in day care centers. Is this a major concern for you all, and I don't know if you can confirm that or not, that we heard yesterday.

DR. GERBERDING: We are evaluating adults and children who have come to the United States from China, who have symptoms suggestive of SARS, including some children that are--that have just recently been adopted.

It's far too early to say whether these children actually have SARS. Earlier in the month, there was a report of such a situation. It turned out the children, the child had a completely different respiratory infection. So we want to cast a wide net and we're very alert to this. We're taking some steps now, to be sure that we're getting information to parents of adopted children. There's already information on our Web site which provides some general guidance, but in addition, we're preparing some very specific recommendations to parents, that might be useful to them when they're in the country, waiting to adopt their child--advice about what to look for and where to go for help if they have any concern.

So we know how important adoption is and how wonderful it is for these parents to finally get their adoption completed, and we want to do everything we can to support that happening, in the healthiest way for the kids and the family. So we're working on that.

I'll take a question from the phone, please.

MODERATOR: Certainly, and Doctor, this next question comes from Joanne Silberner with the National Public Radio. Please go ahead.

QUESTION: Are you satisfied with the rate of progress?

DR. GERBERDING: Am I satisfied with the rate of progress? I think, in some respects, we've had absolutely unprecedented speed in this investigation. The scientific achievements that happened within the first week of virus laboratories receiving specimens are just truly unprecedented. The fact that we very quickly were able to sequence, that we have a strong candidate for the cause of this situation, that we have developed a test that we're now putting out to health departments as hopefully a potential tool for improving the specificity of our diagnosis--these things have happened in absolutely unprecedented time.

I also would add that our communications capacity is absolutely unprecedented. The fact that we have eleven laboratories around the world communicating through a secure Internet, and that daily, we're able to put up interim guidance or the breaking news, or the global infection rates from all of the different countries. This is extraordinary and it's happening very fast.

The question is: Is it happening fast enough to keep pace with this respiratory virus? We have a lot of challenges here to really identify and contain this epidemic. So I think it's good news/bad news, and we just have to be really vigilant and keep at it.

I'll take a question over here.

QUESTION: What sort of information do you hope that the WHO team will be able to find out in Guangdong?

DR. GERBERDING: The WHO team is likely to be addressing several things and they're all important, so they have their work cut out for them.

I think the most emergent question is to what extent is transmission still continuing there and what are the patterns of transmission and who is affected, and what can be done to curtail or intervene. We're particularly interested in evaluating the infection control practices in hospitals because that's an area where we probably can assist, or at least we have I think successful guidance in how to prevent spread in those settings.

But there are lots of other things that I think we would all want to establish, that what's going on there is in fact identical to what we're seeing elsewhere, and that the cause of it or the agent, the virus is present there, or not present there as well.

So there's epidemiologic information, there's prevention information and there's scientific virologic information, and these are all really important.

I'll take a phone question, please.

MODERATOR: Let's go to the Canadian Broadcasting Company's Maureen Taylor for our next question. Please go ahead.

QUESTION: Yes. Hi, Dr. Gerberding. Thank you for taking the call. What do you know and what are your theories about why Hong Kong officials are now trapping mice in that apartment complex?

DR. GERBERDING: I can tell you that the officials and the health agents in Hong Kong are doing everything they can to try to understand why so many people in that apartment complex were infected, and the typical things one would look for in that situation would include, first of all, is there a particularly infectious patient and where did that person have contact with the other infected people?

Another way of looking at it would be to evaluate the ventilation system. Since we can't completely rule out airborne spread, it's important to understand what the air patterns were in a facility like that.

We know that coronaviruses can last on surfaces for several hours, so they'll be looking at potential environmental sources that the people who live there might have had in common, and because coronaviruses can be found in animal species, it's important to rule out some other explanation that doesn't seem to be the propagator of this particular epidemic, but we have to have an open mind and look in all of the nooks and crannies of the epidemiologic cupboard, to see that we have checked every hypothesis out.

So I know that they're doing an exhaustive and a thorough assessment to make sure they don't overlook something.

QUESTION: And just one other quick question. Why, on the WHO Web site, does it say that local [inaudible] risk factors among the patients who died?

DR. GERBERDING: We haven't identified any characteristics of the patients who've died, that would provide clues to why they had a particularly severe illness. Part of the reason for that is that we don't yet have all of the information [inaudible] where most of the people have [inaudible] Hong Kong investigation is moving along quickly, but there's not enough information there to really say.

So that is a very important question and we will want the answer to it but we don't have it yet.

MODERATOR: Very good; thank you. Next we go to the line of Robert Bazell with NBC News. Please go ahead.

QUESTION: I'll pass for today but thank you very much for having the briefing.

MODERATOR: Thank you, Mr. Bazell. Doctor, would you like to go to another phone question?

DR. GERBERDING: Yes, let's take another phone question.

MODERATOR: Very good. We go to Denise Grady now, with the New York Times. Please go ahead.

QUESTION: Thank you. I'd like to ask two questions, please. One is you mentioned a few times that although you have strong evidence and are working with this test, it's not proof yet. So I'd like to ask what will or what would constitute proof. And my second question is, could you explain as specifically as possible how it is that death occurs when people die from this disease? Thank you.

DR. GERBERDING: Thank you. The proof of causality could come in various forms. I think one of the things that we need is to know not only the numerator--meaning the number of people with the SARS syndrome who have a positive test--but we also need the denominator--the number of the people with SARS syndrome who has a negative test. If this is truly the cause of SARS, we would expect that most people with the condition would end up having a positive test. And we haven't done enough tests yet to really have confidence that we can exclude that.

So that's one piece of information that just relates to the test. Another possibility, although I don't think it's very likely, another possibility is that coronavirus is causing some sort of upper respiratory tract infection and people are developing antibodies to it and it is not related to this pneumonia or this severe condition that we're talking about.

When we see the virus in lung tissue in the part of the body that is diseased, that provides very strong evidence. And we have seen coronavirus in some lung tissues, but we would like to know for sure that it's in all of the tissues or that we find some indication that it's been there.

The thing that's tripping us up in that is that we haven't gotten lung tissue--like, for example, from a biopsy--from someone early in the course of the illness, and most of the tissues we're dealing with are from autopsy specimens, so they're very late in people who are profoundly ill and have a lot of lung damage. And so it's very common in those situations, even with influenza, not to be able to find the virus that late in the course. So we just have to be meticulous and work with all the collaborating laboratories to look there.

In terms of how do people die when they do succumb to SARS, in general what happens is they develop pneumonia and lung congestion. Some of them have developed a condition called adult respiratory distress syndrome, or ARDS, acute respiratory distress syndrome, which is really a non-specific term that simply means the lungs are congested and you can't get enough oxygen and you can't properly ventilate. Most of those patients have to be on mechanical ventilation, and sometimes they will recover but often they don't, because that really represents very severe lung damage and it's difficult to recover from it.

Can we go to the phone, please?

MODERATOR: Our next question comes from Christine Webber with Westwood I. Please go ahead.

QUESTION: Yes, I am trying to find out, to date how many states have confirmed cases of SARS and which states those may be.

DR. GERBERDING: I can tell you that we are confirming SARS in 28--or not confirming SARS, we are looking at suspected SARS cases in 27 states today. The states with the highest number of cases are California and New York. We can ask our press office to get back to you with other details on that.

I'll take a question from the reporters here.

QUESTION: Thank you, Dr. Gerberding. Number one, how many of the now--you said 78 cases in the U.S.?

DR. GERBERDING: Let me just clarify. There's 85 cases in the U.S. in 27 states.

QUESTION: How many of those got it through contact -- travelers?

DR. GERBERDING: Of the 85 cases that we're reporting, five acquired it through contact in households or similar situations, and two are health care workers. So the vast majority of the people that we are assessing have been travelers or came into the United States from the affected areas. We're seeing very little spread in health care settings--hopefully because the infection control precautions are in place and are working--and very little contact in the home. And again, maybe the guidance that we put out to help resist spread in the home is having an impact. But we're still very, very vigilant in monitoring the contacts of the cases that we are most suspicious about.

QUESTION: And just to follow up, folks are--and it was mentioned earlier, too, you had the plane incident, you've got an entire school in Connecticut that has shut down because the superintendent thinks that because a class was in Hong Kong a month ago there's a threat being posed. Folks obviously--maybe the message isn't getting out clear and maybe we're not doing our job, but what do you tell those people who are reacting in that way, that might be going way overboard? What is your message to them?

And then, if I can ask one other quick question, is there any particular mask you should be wearing if you're doing the protective--preventing the contact?

DR. GERBERDING: Thank you. First of all, keep in mind that we are still learning as we go. We are taking a very humble posture here at CDC. We recognize we don't know everything about this and we have been very careful not to second-guess anybody's decision on the front line of this.

Having said that, we also are doing, I think, a pretty heroic job of monitoring the situation in the United States and are looking very carefully for evidence of spread from suspected cases, and certainly evidence of spread within the community. So we have not seen that and we're several weeks into this now. So we don't have, from an epidemiologic perspective, evidence that children in school are at risk. But, you know, people who are in the front lines often are seeing different things or are responding to different pressures, and we're very respectful of that.

With respect to masks, this is a very important point of confusion. Again, a lot of questions have come in about this. There are basically, for purposes of this discussion, two main kinds of masks that are important in preventing transmission of SARS. In health care settings, because we have suggested that people be put on airborne precautions as well as droplet or contact precautions, that requires use of something called an N-95 respirator, which is a mask that is certified by NIOSH and has to be proven to fit properly on the person wearing it, which is usually a health care worker.

So health care workers typically wear these N-95 masks for prevention of exposure to airborne diseases like tuberculosis. And if the mask doesn't fit tight, it doesn't do a very good job of keeping them from respiring those very small aerosolized particles.

So for prevention of spread in health care settings, the health care workers or visitors who are having direct contact with SARS patients are advised to wear N-95 masks. In addition, the person would be in a special isolation room that has air circulation so that the air is cleaned and filtered.

In homes, we're not talking about masks in this way. When we said if the SARS patient is in the home they should put on a mask, that kind of mask for the patient just needs to be a surgical mask, because its purpose is to prevent droplets from splattering out of their mouth and nose. And you don't need a particularly great mask for that. You know, some people would say a cloth or even a T-shirt could be useful in an emergency. But that kind of mask just gets rid of the big particles of fluid material that typically come out when you cough or sneeze.

So we're recommending that if a SARS patient is able to wear a mask like that in the home when they're around other people, that would keep those particles from getting into air and then, you know, drying out and becoming aerosolized to the size where they could be airborne later. If the patient can't wear that material, then we're advising the contacts wear those surgical masks as well, just to keep those big droplets from coming in contact with their mucous membranes.

But we are not recommending masks for other people. Right now, this is a recommendation for those who are in contact with SARS patients and not for people who are on the streets or who are in other situations where there may be exposure to other people.

I'll take a phone question, please.

MODERATOR: Let's go to Newsday's Laurie Garrett for our next question. Please go ahead.

QUESTION: Hi. Thanks again for having the briefing. Two quick questions. First the antibody test that you're talking about, is this an Eliza or Western Blot test? Is it double-performed? How is it cross-validated?

And the second is sort of harkening to Jeremy Manier's first opening question of this entire briefing. Up at least until yesterday, folks there at the CDC were saying that, for reasons no one really understood, none of the cases seen in the United States so far have actually been acute. And most presentation, two health care workers has been a pretty benign, sort of, form of the illness. Why in the world would that be so? What possible epidemiological explanation could there be for why--I mean, this isn't about the quality of the health care, this is before they ever even get there--why we have yet to see anything equivalent to the cases that have surfaced in Toronto, Hong Kong, Southern China, Vietnam, and Singapore?

DR. GERBERDING: Laurie, your question is breaking up a little bit so I'm just going to repeat it. I'm going to actually ask Dr. Hughes to provide a little bit more information about the indirect SARS antibody tests that we're talking about right now.

But with respect to your second question, why are the case patients in the United States having relatively mild illness, this is a conscious decision on our part to include anybody with fever and a respiratory symptom who had traveled to an affected area. The cases that WHO is including from countries on its list--at least most of the cases that are formally appearing on the WHO list--are only people who have the severe form of SARS, with the pneumonia. And so we are casting a broader net in this country because we want to be vigilant about identifying anyone who could possibly be infectious, and isolating them if they're sick, and advising their contacts how they can protect themselves.

So not surprisingly, we do not have as many patients with pneumonia. In fact, I think we have altogether--I'll have to get back to you on the exact number, but less than 50 percent of our case patients have had pneumonia. And one of our case patients has required ventilation. But most of that is the artifact of the way in which we are conducting our evaluation and our epidemiologic assessment. Actually, about 20 of the case patients have been diagnosed with pneumonia.

Dr. Hughes will take the other question.

DR. JAMES HUGHES: In terms of the serologic testing, realize that 10 days ago we didn't have any antibody test to detect evidence of infection with this previously unrecognized corona virus. As a result of a lot of hard work that's been done here over the past 10 days, we now have two that look promising. One is an indirect fluorescent antibody test, and the other is an Eliza.

More work needs to be done to validate these tests. I would remind you that these are tests that are not approved for routine use for patient diagnosis yet--not surprisingly, since they've just been developed. So we have to interpret results using these tests with caution.

Having said that, they look promising in that they appear to perform well in suspect cases, particularly a subset of those that are relatively more severe. We have looked for evidence of this antibody in roughly 400 sera collected recently from people in this country without any suggestive evidence of SARS, and they're negative in all of those people.

DR. GERBERDING: I'll take a question from a reporter.

QUESTION: Hi. Two associated questions. First, could you give us an update on the virologic work that's being done, and at what point you think you'll have a sequence of the virus.

DR. GERBERDING: We visited the virus sequencing laboratory yesterday with Secretary Thompson, and we looked at the sequences that were available from the component of the [inaudible] that has already been sequenced and compared to other known corona viruses. And the laboratory team told us at that time that they had several teams working on the sequencing and it was going well. They wouldn't promise to have it this week, but it looks like they'll be see something end of next week or the beginning of the week after that.

You sequence, and then you need to double-check and recheck to make sure that the sequence is faithful, basically. And we have more than one isolate that we're working with, so we are wanting to sequence all of the isolates that we have right now.

QUESTION: Thanks. So returning to your question about the tissue samples that you've had that have come from patients who have died, could you say what sort of samples you're looking for that you haven't yet received, and in particular are you going to be looking for any tissue or sera samples from Guangdong?

DR. GERBERDING: We would, of course, like to share tissue samples or serum samples from all of the affected patients, and that's part of what's been so good about the collaboration among the laboratories, is that there has been a great deal of exchange of information. But we do not yet have any samples from Guangdong and I'm not sure anybody has those samples in the collaborating network at this point in time. So that would be very helpful information, at least to understand what was going on there.

We certainly recognize that it's difficult to get tissue from people early in the illness--and thankfully so, because that means that they're not so sick that they either die and have an autopsy or need invasive procedures for diagnosis. But sometimes when people present with an unexplained pneumonia, it is important to get a biopsy of the lung either through the chest wall or, more often these days, by using a bronchoscope and going down to see what's in the airways and sampling the lower airways.

So in patients that might have that procedure as part of other medical care, the material from that specimen can be very useful for us. It may just be a wash, where they put some water down there, some saline, and then bring it back up and we can culture virus from that. And we do have a virus isolate from that kind of a sample from one patient. And sometimes when they do that bronchoscopic procedure, they also do take a sample of tissue for evaluation and culture and so forth.

So if by any chance patients have those procedures done, we're not suggesting that it's something to do for our purposes, but if it's done for other medical care and they're available, we would definitely be interested in sharing with them.

Let me take a phone question.

MODERATOR: Thank you, Doctor. And we're presenting the Journal of Emergency Medical Services. We go to the line of Marian Garza [sp]. Please go ahead.

QUESTION: Yes, thank you. As you probably know, there are 180 paramedics in Toronto that have been quarantined in their homes. Three have hospitalized with these symptoms of SARS. I wonder, have any paramedics in this country been quarantined, and do you have any recommendations for ambulance personnel who may be transporting people, unknowingly, in their ambulances--which are, of course, closed and don't have a lot of air circulation--to protect themselves?

DR. GERBERDING: In the United States we are not quarantining anybody with this condition at this point in time. So no, there are no paramedics or anybody else being quarantined.

We are not aware of paramedics being among the group that have acquired infection from contact in the country--at least, I'm not aware of that. And I appreciate that there's always concern about ambulance-transported patients. That's why we recommend standard precautions and that health care workers are advised to use masks or to put masks on patients if they're coughing and have an unexplained respiratory illness. So there are some generic things that can be done to offer protection.

We also are advising contacts of SARS cases that, should they develop any symptom of a viral illness, that they make contact with the health care delivery system so that we can get an alert that they're going to be coming in for care and we can take the appropriate measures to protect them from the moment that they have initial contact, whether that's in the emergency room, the clinic, or an ambulance.

So I appreciate your concern, and I think it's one of the components of the health care delivery system that we need to attend to.

Right here.

QUESTION: Thank you. Dr. Gerberding, can you talk about the size of the personnel of the CDC that are devoted to this case, in terms of how it compares to what was working on the West Nile virus outbreak last year? Are they working around the clock, are they working 12-hour shifts, 15-hour shifts? How has that changed from just normal, say, three or four weeks ago?

DR. GERBERDING: Thank you. We have adopted one word to describe the operation, and that is "parsimony." We are working very hard to be right-sized and make sure that the staff and the people who are involved in this particular investigation and response are exactly what we need to do this job well, but also to do it for a sustainable period of time, because we think we're going to be in this business for at least several weeks, if not longer. And we're doing this in the context of a country who's at Orange Alert, and we're doing it in the context of knowing we have to protect our response-team capacity and our readiness forces to be able to take other actions or initiate other investigations simultaneously.

I'm guessing that probably 200 people are involved in, sort of, the overall operations, implementation, and support; in addition, all folks in the laboratories who are working long hours and, hopefully, their job will get easier as we learn more and make more progress on the scientific front.

So I'm going to end now. Again, thank you very much for being here. We have made a commitment to keep you update with SARS as we go forward, and as we learn more, we'll tell you more.

Thank you.

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