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CDC Telebriefing Transcript

CDC Update on Severe Acute Respiratory Syndrome (SARS)

May 6, 2003

DR. GERBERDING: I'm here today to provide an update of the status of the SARS epidemic, both from the domestic perspective as well as from the international perspective.

Altogether, the WHO is reporting 6,521 cases of SARS with 461 deaths in 30 countries.

In the United States, we've had no new probable cases in the last 24 hours. We have a total of 65 probable cases and 255 suspect cases.

We have no evidence of ongoing transmission beyond the initial case reports in travelers for the last, for more than 20 days.

We have a chance, I think, to step back from this global epidemic and really take stock of where in the world we are at six weeks and counting into the epidemic as we know it here in the United States.

What we can see is some good news. Certainly the fact that we've been able to contain this problem in many parts of the world is very good news, but the fact that there continues to be ongoing transmission in China, Taiwan, in Hong Kong, is sobering.

We are aware from extremely reliable sources, as well as high-ranking health officials in those three areas of the world, that very aggressive efforts are underway now to try to achieve containment there as well.

Thousands, tens of thousands of people are undergoing quarantine for exposure to potentially infected patients in China and the health ministers there are working extremely aggressively, using all of the tools that we would recommend if we were in a similar situation.

So they are stepping up to the plate and are very aggressively working to isolate infected people and quarantine exposed people to bring this problem under control, and we will work with them in all manner of ways to support their efforts, and remain optimistic that significant progress will continue to occur there.

The containment in the United States has been successful. We still do not have a complete understanding of why, so far at least, we've not had spread into the community, but I do want to specifically acknowledge the tremendous contribution that our health officials have been making at the local and state level.

On Friday, I had the opportunity also to hear from some health care personnel in Pennsylvania who were very directly involved in containment of a SARS situation there, and I know full well from that experience, how much effort has gone into SARS containment across the United States.

People have stepped up to the plate, have developed locally relevant infection control guidelines, have worked aggressively to identify and respond to patients, and I think a large part of our success so far is due to the incredible efforts that these individuals are making, and I salute them.

I also appreciate the fact that individual travelers who return to this country have been diligent about acknowledging their own symptoms and seeking medical attention, and we thank you so much for that. That also has really helped us, I think, understand where potential SARS is evolving and to take the very early steps to isolate and prevent further spread.

So we still need to maintain our vigilance. As long as there is SARS transmission ongoing anywhere in the world, it remains an issue for us in the United States.

I would also like to try to provide some framework around the various travel alerts, advisories and health alerts that are still ongoing.

As you know, a travel advisory is advice that pertains to people leaving the United States and specifically the travel advisories for SARS recommend that people not travel to various countries that are specifically named, unless they have essential reasons for being there.

We are very pleased to announce today that Singapore is no longer on the list that we have a travel advisory for, because they have been able to contain the epidemic there and they have gone more than two incubation periods, or more than 20 days without a new case in Singapore. Therefore, they meet the criteria for containment. We are lifting the travel advisory. We will of course continue to provide travel alerts to that country as well as to the other countries where SARS has been an issue.

So a travel advisory, outbound passengers, essential travel only, those advisories are still in effect for China, Hong Kong, and Taiwan.

Travel alerts also apply to outgoing passengers, and they are simply a reminder to passengers that there may be SARS in the area to which they are traveling, and that they should use commonsense measures to protect themselves, specifically avoiding places where SARS may be more likely to be transmitted, such as health care settings, and also very specifically, recommendations about washing hands or using good hand hygiene to prevent the unexpected exposure.

That leads me to a very specific issue that's raised a great deal of concern, and that is the reports that have appeared about the longevity of the coronavirus implicated in SARS.

Several laboratories from around the world have described experiments in which the virus has been recovered for various periods of time after it's been inoculated into various types of fluids or body fluids.

These experiments are very important to do, and this is a typical way of understanding what is the appropriate disinfection protocol for a virus. But it's important to remember that these are also artificial situations. When very large amounts of virus are spiked into the fluid under question and then the material is sampled at intervals thereafter to see if any viable virus remains in them, the methodology for these kinds of experiments is extremely variable.

I myself did some work like this back in my lab in San Francisco and I can tell you that the methods are all over the map. But the point is that we recognize that under certain experimental or perhaps real-life situations, the virus can survive for prolonged periods on surfaces.

That's exactly why, at the very beginning of this issue, we issued guidance that recommended people use good hand hygiene to avoid contacting contaminated objects, and we implemented airborne contact and droplet precautions to be sure that we had covered all possible modes of transmission.

So this information that's emerging in the laboratories about the survival of coronavirus is important to us, it needs to be validated, we need to understand the methods in a lot more detail. But it doesn't change our recommendations, because we already have in place the advice that would be necessary to manage this situation, and, again, just stressing the importance to everyone about proper hand hygiene or hand washing to serve as the first line of defense against any infectious disease.

Now I would also like to talk a little bit about health alerting, and some of the steps that we're taking here, in the United States, to prevent SARS from being imported into our country. These steps are being taken in collaboration with the World Health Organization and with the various countries that are currently experiencing problems with SARS.

First and foremost, individuals in countries that are "hot spots" for SARS, i.e., China, Hong Kong and Taiwan, are, by and large, quarantined, if they've been recently exposed. That's an extremely important measure from our standpoint, because if the exposed people are in quarantine, they have very little opportunity to travel or to export the infection elsewhere in the world, and those measures have been scaling up over the last week, so that as I said, thousands of people are in quarantine, and this is an extremely important public health step in the affected areas.

In addition, passengers from these areas are advised not to travel if they have illness that could be SARS, or if they have had recent contact with a SARS patient.

In addition, as WHO has advised, airports in the affected areas are screening passengers and advising them not to fly if they have symptoms of SARS.

From our end, our quarantine officers, and others at the airports where passengers are arriving, are meeting flights, they are working with the airline crew to identify anyone who might be symptomatic with SARS, and to evaluate them before they're able to leave the airport, and we're also of course continuing to pass out the health alerts. Now well over 850,000 of the alerting cards have been distributed to arriving passengers. These cards remind people that within the next 10 days, if they develop any symptoms suggestive of SARS, that they need to contact a clinician and arrange for a medical assessment.

This system is working. We are very pleased with the early detection of cases and the ability to identify individuals who are in the potential incubation period with the early onset of symptoms, so that we are not finding people late in the course of their illness, and I think this is, again, a very important component of our overall protection and detection efforts here in this country.

So I think we have a situation in the world right now where we need to remain vigilant, we need to remain aggressive about identifying and isolating case patients, and we need to continue to place a high value on the appropriate monitoring of exposed people in situation where they may be incubating SARS.

We also recognize that the public health response in our country has been measured in direct proportion to the problem that we have here.

If additional steps are necessary, we are prepared to take those steps, but right now, we believe the advice and recommendations that we have created for travelers and for other situations is appropriate to the problem and seems to be so far successful. If things changed, we're prepared to change also.

So let me stop now and take some questions. I'll take the first question from a reporter in the room and then we'll go to the telephone. I have a question from the room. Yes?

QUESTION: Thanks. I understand tomorrow, there's going to be an article in The Lancet, I guess a study out of Hong Kong by Roy Anderson, talking about a 20 percent death rate for people under 60, 40 percent for over 60, and I guess an incubation period as high as 14 days, and I guess I'm wondering if people should be alarmed by this?

How likely is it that the death rate is actually this high, I guess, outside of Hong Kong? and what about the incubation period, whether you all will reevaluate this 10 day window?

DR. GERBERDING: I'm not familiar with the paper in question. I am familiar with Dr. Anderson's work in modeling various epidemics, and so I look forward to reviewing this new paper and will regard, I'm sure, all of his findings with interest.

With respect to the death rate of SARS, we are seeing continued variability in death rate and what we need to do is to stratify the death rate by the age of the affected personnel.

That's been done to a limited extent in some countries but the bulk of the patients are from China and we don't yet have all of the information about the age of the individuals there. So the gaps in the story are still becoming filled in and until we have that information it will be really difficult to see the overall case fatality rate.

Also, it's very important when looking at the mortality rates that WHO is reporting, to appreciate that there is a bias in the sense that depending on when cases are reported, you may have to catch up to determine whether people recover or don't recover from the illness. So we can expect some movement in the mortality rates as we go forward and fill in the gaps in our reporting.

As said all along, not surprisingly, the mortality rate that we're reporting may be increasing, in part, because our case definition is getting more specific and also because people diagnosed with SARS have a fairly long period of time in the hospital before they either recover or die.

We are very gratified that the mortality rate in the United States remains zero, and of course we are concerned and empathetic with the people who have been affected by this, including those who have died.

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

OPERATOR: Thank you. Ladies and gentlemen, on the phone, once again, if you do have a question or comment, please press one on your touch-tone phone.

The first line we'll open is Elizabeth Kaliden [ph] with CBS. Please go ahead.

QUESTION: Hi, Dr. Gerberding. I'm interested to hear you talk about the things going on at the local public health level that you really think has led to the success of containing SARS in this country, but I've also been fascinated to hear as many infectious disease experts talk about luck in terms of containing this epidemic here.

Do you think that luck has been a part of this at all? Have we simply dodged a bullet here or is it all down to this grassroots public health level that we're talking about?

DR. GERBERDING: I would reframe luck as good fortune, and I think good fortune in this case is a consequence of a prepared public health system and a prepared clinical community, but also perhaps, to some extent, we have been fortunate in that a particularly infectious patient has not slipped through the cracks or had a long period of time to be exposed to others in the home or in the health care setting.

We need to appreciate and acknowledge that we are fortunate and, at the same time, that is not a permanent state, and we do need to be aware of the fact that, as we saw in Taiwan, just a single highly infectious individual who is not picked up through the public health system or the clinical system can set off a cascade of transmission with very serious consequences in the community.

We'll take another question here.

QUESTION: Thank you, Dr. Gerberding. Betsy McKay from the Wall Street Journal. Two questions, if I might.

One is that over the past week or so the number of probable cases in the U.S. has increased substantially from about 40 to 65 yesterday. I'm wondering if you can explain to us, go into the numbers a little bit, explain to us what that means. Are those suspect cases that are now being defined as probable or are there more people getting sicker? That's one.

Secondly, could you give us a little more detail on what you're seeing in Taiwan to control the situation there?

DR. GERBERDING: Thank you. Let me answer the question about Taiwan first.

We have a team in Taiwan, and the best way to frame the organizational activities there is to compare them to what we're doing here at CDC. I think, as you may appreciate, we have used the emergency operation center here as our focus of coordination, but the way this actually works is that we have a centralized coordinating body that is supported by a number of specialty teams, such as a clinician team or a laboratory team or the epidemiology team, and Taiwan is taking a very similar approach.

They have a central coordinating body, and then they have established expert teams with a number of individuals from Taiwan, as well as from CDC, and soon I'm sure the WHO people who have arrived will be increasingly involved in this as well. So they're using a multidisciplinary coordinated team approach, and I think that's been one of the ways to make sure that the right hand and the left hand know what's going on.

In addition, they re implementing a very aggressive strategy for identifying contacts of case patients and initiating quarantine when appropriate to prevent spread from potentially exposed people. That has been a step that has been necessary in Hong Kong and Singapore to gain control of the epidemic, and so they are obviously implementing that in Taiwan as the next stage of the response, when the early measures failed to prevent transmission.

With respect to your first question, which was the change in the probable case definition, we have seen an increase in cases over the last week of probable cases. The main reason for this is that Toronto is still listed as a country from which individuals with respiratory illness should be considered suspect cases of SARS until proven otherwise.

And given the very large number of travelers from Canada, particularly Toronto, that we see every week, it's not at all surprising that we would see, for at least a period of time, an increase in probable cases. In fact, I would be worried if we didn't see an increase in probable cases because it would suggest to me that our surveillance system was insensitive and not casting the wide net that we want to cast.

As we have additional laboratory testing on these individuals and other diagnostic tests to evaluate other conditions have been completed, I'm sure we'll find that many of them have alternative diagnoses. And the fact that there have been no new cases in Canada suggests that the recent cases coming in from Toronto are highly likely to have other conditions. It's just going to take us some time to sort that out.

I'm sure it's very inconvenient and potentially distressing for the people who are isolated with potential SARS, and we want to get information as quickly as possible to more accurately present them with a diagnosis, but it is one of the necessary steps to ensuring that, again, our net is cast as wide as possible.

DR. GERBERDING: We'll take a telephone question, please.

OPERATOR: Thank you. The next line we'll open is Miriam Falco at CNN. Please go ahead.

QUESTION: Hi, Dr. Gerberding. Thanks for doing this, as always.

Two questions: One is can you tell us about the progress USAMRIID is making on antiviral testing for any medication.

The other question is about Taiwan. The WHO seems to be concerned about the jump in cases in Taiwan, and obviously--

DR. GERBERDING: Excuse me, Miriam. I just can't quite hear you on your second question. I got the first one.

QUESTION: Oh, okay. Is this better?

DR. GERBERDING: Yes, thank you.

QUESTION: I apologize.

Taiwan, WHO is concerned about the increase in cases over the past few days, and CDC has a team there. What do you think is not happening there that might explain some of these cases, as compared to other countries? Is this just we're learning about this later, kind of like in China or are they lacking some resources?

DR. GERBERDING: Thank you. With respect to your second question about the situation in Taiwan, what happened there was that initially they did an excellent job of containing the first round of illness that appeared there, but unfortunately a traveler went to the country while ill and initiated a series of chains of transmission in various settings.

And so it's taken significant detective work to track down those chains of transmissions, and the number of people ultimately exposed, as the story was unfolding, was extremely large.

In addition, transmission was initiated in the health care setting, so that health care providers who were not initially protected acquired SARS and, again, served as potential vectors for transmitting to others. So it's an example of how quickly a situation can get out of hand if there is not an immediate detection and isolation capacity.

Of course, Taiwan has some marvelous medical facilities and significant capacity to manage a public health emergency, but this is a very large situation for them now, and they have requested technical assistance and other forms of assistance, and WHO and CDC are very happy to contribute what we can.

I have to apologize because I actually didn't hear your first question completely either. Can you go back?

QUESTION: This was on testing the coronavirus against the antiviral at USAMRIID.

DR. GERBERDING: The testing status of looking for an antiviral drug compound. USAMRIID is aggressively screening compounds in a rapid throughput assay, and they have looked at many, many compounds so far.

There is some enthusiasm for the possible activity of a couple of compounds, but as I understand it right now, although they can see test tube activity, the doses of the compounds required to make, inactivate the virus are much higher than we would [be] able to safely administer to patients.

So we have not identified anything that we can take out of that system and really be optimistic, that would provide something useful for patients at this point in time.

There are thousands and thousands of compounds that remain to be tested, so we're not pessimistic, but obviously there's a great deal of work to be done, and we don't have anything yet.

Let me take a question here.

QUESTION: Hi. Dr. Gerberding [unintell.] represent [inaudible] Taiwan. But don't worry. We're [inaudible]. So--


DR. GERBERDING: We're very happy to have you here.

QUESTION: So as you say you already, I mean, believe already has been a change with Taiwan. Would you please be more specific about how--I mean, what they have done in Taiwan and how many of them, and how many more days will they be there, and if they come to any conclusions about it. Thank you.

DR. GERBERDING: Thank you. We've had a team in Taiwan for some time, and in fact we've had a change of personnel, just recently, because people come and go on our teams. We have sort of a "revolving door," to some extent, to make sure that people are fresh and we bring in fresh sets of eyes to assist.

The government has asked for us to provide technical assistance in some specific areas, including infection control, consultation. Again, a fresh set of eyes can often see something that you don't see when you're in the same situation, day in and day out.

Our team is also evaluating the spread of the problem in the country and assisting the government in looking for the chains of transmission that have resulted in the ongoing spread outside of the health care environment.

So we are there to provide whatever technical assistance is requested from the government and of course we're also working on laboratory testing and trying to assist in getting accurate diagnosis of the patients and a complete clinical picture of the presentation of the ill persons in the hospital.

So it's a work in progress, and I think--I can't speak for Dr. Hughes, but I believe that our basic philosophy is that we would want to continue to provide technical assistance as long as it's useful and helpful to the government.

Let me take a question from the telephone, please.

MODERATOR: Thank you. The next line we'll open is Jennifer Warner at Web MD. Please go ahead.

QUESTION: Thank you, Dr. Gerberding. Could you update us on the status of the advice that you're giving to colleges and other types of organizations that employ or involve large numbers of foreign persons. For example, I see that the UC-Berkeley has effectively banned students from SARS areas from attending summer sessions.

What type of advice are you giving to organizations such as colleges and universities?

DR. GERBERDING: Thank you. The advice to colleges and universities is the same advice that we're giving to everyone.

That is, first of all, to recognize that we are taking many steps to prevent importation of SARS in United States and I've outlined those steps already, which include the quarantine that the host, or that the original country is implementing, the steps at the airport, the active meeting of planes here, and the delivery of health alert messages.

I had an opportunity to speak with the chancellor of UC-Berkeley this morning and I understand full well the unusual predicament that they are facing there, in that they were expecting an unusually large contingency of students arriving from countries where SARS is actively being transmitted, and the university needed some time to make sure that they had in place the appropriate measures, should they need to isolate an individual or potentially monitor exposed persons.

So because they didn't have those systems in place, up front, they made the decision for students coming in from countries where there was a travel advisory, and that as of this morning included Singapore--of course that no longer should include Singapore--that they would temporarily not have those students arrive on campus.

The chancellor has also requested that CDC work together with UC-Berkeley in the same way that we've worked with other colleges and universities to assist in any way that we can to develop strategies that certainly protect the students and the travelers to the campus, but allow the ongoing business and collegial activities that are so very core to their mission.

I'm very optimistic that these kinds of measures can be worked out, and I look forward to working with not just UC-Berkeley but the other colleges and universities who have similar concerns. Again, I think it's important to emphasize that, first of all, this was a particular situation at UC-Berkeley. They intend to have their fall classes resume as usual with their full student body, and we will be working very hard to make sure that the practical aspects of making sure they have the steps in place to protect their students, should they need one, or they need to implement them, are fully engaged.

Let me take a question here from the room.

QUESTION: Hi. Could you just be a little bit more specific about what you would advise to colleges. Should they quarantine people with symptoms all in one room or one dorm, or what? And then the other question is the CDC is one of many parties that is applying for a patent on the SARS virus.

Can you just talk a little bit about what the purpose of that kind of a patent would be.

DR. GERBERDING: Thank you. The advice to people coming in from countries where SARS is being transmitted is uniform, across the board, from a CDC perspective, and in addition to the other measures, it's an alert that says if you develop a symptom you should make contact with a health care provider so that you can be assessed, and we emphasize make contact by phone or in advance of your arrival in the health care setting, so that there is the opportunity to initiate the appropriate infection control precautions at the point of first contact.

So that is the generic message and that applies to any of us who are returning from the areas where SARS transmission may be occurring in the community.

For specific situations such as might occur on a college campus, we are encouraging the college officials to include in the orientation for students information about SARS, if they are recently arriving or have traveled on their break or whatever from a country where SARS is a problem, that they be advised with the same sorts of cautions that we have on the health alert, which tells them that they need to identify a health care provider and seek attention if they develop any symptoms.

In addition, we're recommending that they provide specifically to students information about where their health service is, or how to access appropriate health services, because sometimes students don't pay attention to that information and then, when they need it, they are confused and don't necessarily take the appropriate steps.

So that is the nature of the CDC advice at this point in time.

Your question about patents is a story that's unfolding. Our highest priority in all of this was to get information about SARS and the SARS genome and the SARS coronavirus into the public domain as quickly as we possibly can.

That's why we published the genome on the Web site. The concern that the federal government is looking at right now is that we could be locked out of this opportunity to work with this virus if it's patented by someone else, and so by initiating steps to secure patent rights, we assure that we will be able to continue to make the virus and the products from the virus available in the public domain, and that we can continue to promote the rapid technological transfer of this biomedical information into tools and products that are useful to patients.

So from our standpoint, it's a protective measure to make sure that the access to the virus remains open for everyone.

Let me take a telephone question, please.

MODERATOR: The next line we'll open is Kathleen Doheny with LA Times. Please go ahead.

QUESTION: Yes; hi. Is there any consensus at this point from CDC officials about how long it might survive on surfaces, the virus?

DR. GERBERDING: The question is how long can the virus survive on surfaces. The answer to the question is it depends. It depends on what form the virus is in. It depends on how much virus was put on the surface in the first place, and it depends on the environmental conditions, and the media in which the virus is suspended.

We know from early work with coronaviruses, that you can recover the virus from surfaces for at least 24 hours. Some of the data from the investigators suggests this possibly could be longer but we really need to understand more about the methods of these evaluations.

For me, it reminds me of similar questions that came up when we were first learning about HIV virus, and we had a very familiar series of experiments there, where people would spike various laboratory samples with virus and let it dry on a tabletop, and then go back days later to see if they could recover it, and we know that that was something that occasionally did yield virus, but we also know that tabletops were not at all important in the transmission of HIV from one person to another.

So we need to be very careful to distinguish the ability, under laboratory experiments to recover virus, from that being an important route of transmission.

Our data still indicate that face-to-face transmission is the most common mode and explains transmission in most all of the settings. We do have concerns about the potential for airborne under certain circumstances, and I know the people in Hong Kong have been concerned about fecal-oral transmission in a particular apartment complex.

So, to err on the side of caution, we continued to recommend the hand hygiene, which is what you would do to protect you if there was concern about virus remaining for periods of time on surfaces in a contagious form

Let me take another question from here in the room.


QUESTION: On Thursday, there was a symposium at Emory on SARS, and Dr. Cetron was saying that he's going to be gearing up states and public health partners to develop plans for a quarantine isolation at hospitals and residential facilities, including apartment complexes. And I'm kind of wondering if you could elaborate on that and how that would be different than what's being done now.

DR. GERBERDING: There's a very important distinction between planning and implementing. We visited Canada. I was there last week. I learned the steps that were taken in Canada and in Ontario to contain the epidemic in hospitals and in the community, and we heard this morning from some of our disease detectives about steps that were taken in other parts of the world to contain the epidemic and to initiate isolation in hospitals.

We haven't had to move outside of our regular infection control precautions so far, but if we needed to, if we had a situation where there was a leak in our containment, we need to be prepared to take additional steps, and we would much rather have the plans in place to initiate those steps now, learning lessons from everyone else who's already had to invent those processes on the fly.

And so working with our health officials and our infection control community to prepare in advance for that possibility, it's the best way to assure that if we ever needed to do that, we'd have the best possible chance of doing it successfully.

One of the specific lessons I learned in Canada was that if you're going to take a step like that, if it becomes necessary, you have to be bold, and you have to do it quickly, and you have to be aggressive in the implementation. There is not a lot of time for a lot of committee meetings or a lot of discussion and debate. You've got to get the job done.

And so we have brought back, for example, from Canada, that experience and the protocols and plans that they develop there in a hurry, and we intend to vet those with the stakeholders in the state, and local and hospital community to make sure that we're ready. And this is something that's important for SARS, but it could be important for smallpox, it could be important with the next emerging infectious disease that comes our way. So I think it's time well spent.

I don't want to say that SARS is a dress rehearsal because we certainly know that in parts of the world it's been a very, very serious epidemic in this country. It has not been trivial, but it also is the heads up that we live in the world of global emerging infectious diseases, and if we don't have to deal with them this way this time, we need to at least be prepared for the next organism on the block that might come our way.

So as I always say, practice makes perfect, and I think the opportunity to learn from the experiences of others and advance our own preparation is exactly what we're here to do, and that's part of the whole culture and philosophy of this operation.

Let me take a telephone question, please.

OPERATOR: Thank you. The next line we'll open is Elizabeth Cohen with CNN. Please go ahead.

QUESTION: Thank you, Dr. Gerberding.

In JAMA this week, Canadian authors talk about how most of the people who died had some kind of other comorbidity; for example, had diabetes. And I was wondering if we've learned anything about why some people get very sick and die from this disease, whereas, other people don't get all that sick.

DR. GERBERDING: We took stock this morning of the things that we know or think we know about SARS and the coronavirus and the things that we don't know yet, but really want to know as quickly as possible, and the question you're asking about why do some people get so ill or die and others have a mild illness or recover very readily is a question that we still don't have an answer to.

I'm an infectious disease clinician, and I know this is a common scenario with most infectious diseases. In general, people who have compromised immune systems or who have other medical problems often have worse outcomes from common diseases. We see that with influenza.

So it's not going to be surprising that there would be variability in the severity and mortality of this particular virus, but beyond that, at this point, it's too early to define the specific risk factors that predict the outcome.

We're also open to the fact that in addition to sort of the clinical characteristics and the age of the patient, that factors about their genome or factors about the dose of exposure that they had could also be playing a role, and so we have to complete many of the studies that are currently in progress before we'll have those answers.

Is there another telephone question?

OPERATOR: Thank you. The next line we'll open is Maggie Fox at Reuters. Please go ahead.

QUESTION: Hi, Dr. Gerberding. Thanks.

Back to the previous issue of being prepared and being able to take bold steps, Georgetown Professor Lawrence Gostin, who I know you know, talked about his proposed law that would strengthen state and local capabilities for responding, and he makes it quite clear that he doesn't think the framework of laws that are in place right now are any good, and in fact would lead to exactly what you said is not needed, which is dithering and people wondering whether they have the power to act.

Can you talk about that?

DR. GERBERDING: I think, because of Dr. Gostin's leadership at Georgetown and Johns Hopkins, we have worked very hard since September 11th, 2001, to make sure that we understood what the components of a model public health law should include.

Every state has been engaged in evaluating their current public health laws. Thirty-nine states have initiated specific statutes or legislative activity to improve their public health laws, and I believe 22 states have already passed improvements in their public health laws. So this is an ongoing process. Some states also have recognized that the laws that they do have are adequate.

There are gaps, but we are working aggressively to fill them, and I think, if anything, SARS and the experience that we're having in the last few weeks will motivate speeding up that process and probably encourage people to take this very seriously because they can't help but recognize that it could be necessary.

Is there another telephone question?

OPERATOR: Thank you. The next line we'll open is Rob Stein with the Washington Post. Please go ahead.

QUESTION: Hi, Dr. Gerberding. Thanks for doing this.

You talked earlier about the large number of people that come to the United States from Toronto. I was wondering if you had a breakdown for where the imported cases were coming from in the United States. Are most of them coming from Canada or most of them coming from China?

DR. GERBERDING: We do know where the travelers who are on our probable and suspect case list traveled, and we are going to be pulling that all together for our MMWR on Thursday. So we will be providing that information, in aggregate form, in that particular publication.

Is there another question here in the room?

[No response.]

DR. GERBERDING: All right. Then, I'll take the last question from the telephone, please.

OPERATOR: Thank you. The next line we'll open is Larry Altman, New York Times.

QUESTION: Yes, Dr. Gerberding, the first question that was asked concerned the Lancet report tomorrow regarding--or that's being released early--regarding the study of 1,425 cases in Hong Kong. I realize you said that you weren't familiar with the report, but I find, if I can step back, I find it a bit surprising that CDC isn't aware, given the cooperation that the WHO network has, that you wouldn't have seen this data or CDC wouldn't have seen this data in advance, and what does it speak to the cooperation of the WHO network and what has been advertised as unprecedented cooperation and so forth?

I would have thought this type of information would have been shared earlier.

DR. GERBERDING: Larry, it's important to distinguish what the CDC Director has time to read and what the CDC scientists are engaged in, the laboratory collaboration. The collaboration is still ongoing in a remarkably open way, and I think we are exchanging information. We saw this morning our disease detectives presenting information that was pulled together from the various WHO teams.

So I am remiss in not having time to read the article, but I can assure you that our collaboration is alive and well. So I do look forward to reading it, and I can assure you I will do so immediately at the end of this briefing.

So, with that, let me just appreciate again the fact that everyone is here and your ongoing interest in this issue. We will, of course, update you, and as we learn more, we will tell you more.

But I also wanted to end with one reminder; that we are coming into West Nile season, and it's very, very important that we remind people that there are individual steps that need to be taken to prevent exposure to West Nile. And one of the early steps is to remove the water and the other places where mosquitoes can breed. We're having a lot of wet weather here, particularly in the South.

And so while it's not upon us yet, the earlier we get into the mind-frame of fighting against this infectious disease, the better off we'll be when it is the full-blown summer months, and the mosquitoes are about.

So I just wanted to remind you that emerging infectious diseases are appearing right and left, and we can't ignore one because of our concentrating on another.

Thank you.

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