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CDC Telebriefing Transcript

Update on Severe Acute Respiratory Syndrome (SARS)

May 22, 2003

DR. GERBERDING: Good afternoon. I'm here today for two reasons. One is to provide an overview and an update on some of the information in today's MMWR, and second, to report on a situation involving a CDC employee who's coming home after being diagnosed with suspected SARS in Taiwan.

The WHO is reporting 7,890 cases of SARS, plus the cases in the United States which currently are 65 probably cases in the United States. The good news is that Hong Kong does appear to be increasingly successful in its containment. For several days now they have reported single-digit numbers of increased cases and have not had a case in a health care worker in the last four days. So that represents, I think, a significant process in containing spread in the hospital and in the community and we continue to be cautiously optimistic that containment will ultimately be achieved there.

The more disturbing news is the situation in Taiwan. As described in today's MMWR, there is ongoing transmission primarily in health care facilities in several parts of Taiwan, but in addition there is transmission in community contacts as well.

The report in the MMWR describes a situation where an index patient present in the hospital, actually a health care employee, was ill for several days with fever and other illness, actually a cellulitis that was eventually treated by a surgeon, and in the course of his employment and his hospitalization, he had contact with several thousand employees and patients in that facility. So there was an opportunity for ongoing transmission of SARS.

That initiated a cascade of transmission which is ongoing in those facilities, and has resulted in many diagnosed cases. We fully expect the case counts to go up because of reporting delays, recognition delays, and the overall complexity of trying to track such a rapid and complex outbreak in real time.

The Taiwanese are taking all of the appropriate steps to achieve containment, including quarantine of the hospitals that are most affected, quarantining of potentially exposed people, isolation of case patients while they are in the infectious stage, and implementing a whole variety of infection control precautions in health care facilities.

But it's a huge challenge and one that is going to take continued effort on the part of the entire health system in Taiwan, and they are continuing to request and utilize technical assistance from WHO, CDC, and many other agencies who are in country, on the ground, doing what they can to provide assistance.

It's a very serious and sobering situation and I think we remain hopeful that ultimately, they too will be able to achieve containment as they did in the early stages of the epidemic, but this is an extremely challenging situation right now.

Now let me discuss a situation that's hitting a little bit closer to home.

We have, since the beginning of the SARS outbreak, deployed more than 30 people, internationally, to Asia, to provide technical assistance and a variety of other kinds of support to the investigations that are ongoing there.

We currently have a team of individuals in Taiwan and on Monday morning, in Taiwan, one of our physician/scientists developed a fever. It was a very low-grade fever, had no respiratory illness or nothing to suggest SARS at that point in time, but he was specifically in Taiwan to evaluate the adequacy of infection control measures in health care settings.

As we do with all of our employees, before he left for Asia he was trained, he underwent fit testing for a respirator, and while in the health care facilities there, he was dressed in all of the appropriate infection control equipment that we recommend, and was observed to be highly compliant as was the rest of the team with that measure.

Nevertheless, he did develop a fever and so he spent a day in his hotel room under the supervision of another physician on the team who was checking in on him periodically.

The next afternoon, he felt well, his fever was gone, he really had no evidence of any kind of infectious disease, and was trying to busy himself in the hotel, and the next morning he frequented the breakfast room, the business center, and some other areas in the hotel.

Unfortunately, on Thursday afternoon, he was found to have again a fever, and developed a cough which immediately signaled a potential for SARS, and so he was admitted to the hospital, to an isolation area where he continues to be present.

Fortunately, his chest x-ray is not showing evidence of pneumonia at this point in time, he's doing very well, but we are very worried about him, obviously, and as his employer, we have made the decision that it is in his best interest to come home.

So we have arranged for air ambulance to transport him back to an Atlanta hospital and that is being accomplished over the next few hours and we expect that he'll be home some time this weekend.
He was in the company not only of the physician who was checking in on him but also two other members of the CDC team. The physician and the two other members of the CDC team are in a precautionary quarantine right now in Taiwan because they have been exposed to him in the period of potential infection. They are being housed separately. They will accompany him on the air ambulance home, even though they're perfectly fine right now, we are taking the steps of bringing them home. Fortunately their tour of duty was coming to a close and we have the other team standing by to head back to Taiwan. So we will be able to continue our operations there.

But this is a sobering situation for all of us, and as we've been saying from the very beginning, SARS is a problem for everyone, not just people in Asia.

I think it's also important to stress that some additional steps have been taken in Taiwan as a consequence of this individual's residence in the hotel while he was potentially infectious. As I mentioned, he did not develop a fever--I mean he did not develop a cough until yesterday, so it's unlikely that he was contagious, and in fact the clinicians involved are not particularly confident that he even has SARS, but as we do here, a wide net was cast, and so the hotel has been temporarily closed and cleaned, and the personnel in the hotel who had direct face-to-face contact with this individual have also been put into precautionary quarantine to be sure that they were not exposed to him during a period of contagion.

So the bottom line is one of the CDC scientists has developed symptoms that are an indication for isolation.

Three of our scientists are in quarantine and all four of these people are on their way home, and we'll be real glad when they get here.


QUESTION: Diana Davis from WSB in Atlanta. Doctor, if this man does indeed turn out to have SARS, and you say that he followed all these precautions, as we believe, we're sure he did, how troubling is it to you that even despite all those precautions, he may have contracted SARS, and what does it say to you about the spread of this illness?

DR. GERBERDING: I would say that as we've seen in other health care facilities, even when we know people are following the precautions as they've been prescribed, you have to be 100 percent compliant in order to be absolutely certain that there isn't an inadvertent airborne exposure, and that's exactly the same puzzle that we had in Canada.

However, we also know that these individuals are in a community where there is ongoing SARS transmission in other settings. So while we are worried about the health care as a source, we can't exclude the possibility that exposure occurred somewhere else in the community. Of course, we also can't exclude the possibility that he's ill with some other, you know, some other unrelated infectious disease, but it will definitely be a place where we will be looking hard and long at the adequacy of the measures to be absolutely certain that we haven't overlooked anything.

And this morning I requested that we inventory our team and personnel available for deployment to Taiwan to make sure that we have our absolute best experts in infection control being able to weigh in on this, and I know WHO also is adding to their team some individuals with extreme credibility and experience in on-the-ground infection control. So we'll be looking at that with a fresh set of eyes as we go forward.

QUESTION: [Inaudible].

DR. GERBERDING: He is not requiring any intubation or any extra oxygenation. He has a fever. I understand that his fever has been controlled fairly easily on other antipyretics, and he's just under close observation, and I'm sure he's real anxious to get home too.


QUESTION: Can you give us a little insight into his work history with the CDC and how long was he in Taiwan, and are you taking any other precautions with the personnel that are still there as far as protecting them from SARS?

DR. GERBERDING: He had just been in Taiwan for a few days, and let me just add that we really do feel a strong sense of responsibility for his health and safety, but we also feel a strong sense of responsibility for his confidentiality, and we would request that all of you respect that as well.

He is, as I said, a physician-scientist who has expertise in infection control, and he had arrived in Taiwan a few days before he visited the health care facilities and this scenario unfolded.

I'll take a phone question, please.

OPERATOR: And as a reminder, if you have a question from the phones, please press the 1 at this time. Our first question comes from the line of Miriam Falco with CNN. Please go ahead.

QUESTION: Good afternoon, Dr. Gerberding. I have a couple of questions. Specifically with this incident of the CDC worker becoming ill, do you think that there needs to be a change in the guidelines and how to protect yourself, not just for CDC employees but just in general?

And I have what might sound like a very silly question. But there's a Lancet article coming out this evening about SARS from outer space, a theory that the origin of this--I know. I just want to ask it so that you can say whatever you have to say, and so we can go from there. These scientists have put this theory out before that infectious diseases might be dropping off of meteors, but do you have any comment on that? Have you seen the study, and do you know what I'm talking about?

DR. GERBERDING: Well, let me answer your second question first. I'm so glad you asked it because I think we could use a moment of levity. We have no scientific evidence that SARS or any other infectious disease has dropped off a meteor at this point in time, but we have an open mind, and should we discover any evidence supportive of that, we would let you know.

And of course in all seriousness, I think what we're seeing here is a situation that is most explainable by natural evolution of coronaviruses either from an animal or a poultry source, or possibly a coronavirus that's evolved in a human. And we don't know the source of the coronavirus, but we have many hypotheses that are far more plausible than meteorites.

With respect to your first question, which is a very serious one in terms of the adequacy of our infection control precautions in the field, we have, as I mentioned, a protocol here for ensuring that people who are dispatched in situations that could pose an infection threat are not only trained in the basics, but are actually specially fitted to be sure that their respirators are tight and that they know how to use them, and that they have the proper safety equipment. They generally are transported with an adequate supply of the safety equipment that they would need.

These measures are adequate for protection and are the kinds of measures that we use when we go and deal with ebola or any other kind of disease that poses a high degree of communicable threat.

I think the concerns are that the physical environment of a health care facility and the air handling in a health care facility can be very variable, and we have learned that there are examples where you think you have the proper airborne precautions in place, but the mechanics of the ventilation in the room fail, or the degree of air exchanges expected are not adequate to provide that level of ventilation. And in a time of crisis and when these health care facilities in Taiwan are undergoing rapid expansion and the whole system is under extreme stress, it's entirely plausible that there could be breeches in infection control.

So what we need to do is step back and say, are our current measures adequate to address that kind of contingency, is there anything else that we realistically could add to the safety profile to be sure for us, but also for the people who are living and working in these conditions, is there any other sensible thing that could be done to provide that level of protection?

I think that is part of the reason why we were very pleased with the invitation to collaborate in the Canadian hospital in Toronto because our hope was that we would learn things there that would help inform our own infection control precautions, and so far we haven't identified anything that needs to be changed, but we are definitely looking, and we will continue to look hard at that.

Let me take another telephone question.

OPERATOR: And our next question comes from the line of Seth Borenstein with Knight-Ridder. Please go ahead.

QUESTION: Yes. Thank you, Dr. Gerberding. In terms of your CDC worker, is it--would you say it's more probable that he got in the--which are you leaning toward, more in the hospital or in the hotel, in his buzzing around on that one day?

And second, has he been--have you--has he been tested for either the antibodies or the other test that you've developed there?

DR. GERBERDING: Let me say that I just don't want to speculate on this. This is an evolving situation for us, and we are collecting information and trying to go backtrack over his activities for the past several days, but we're not really talking directly to him right now, because we want to respect the fact that he's ill.

I think we couldn't say what was the most likely source of his infection if this is SARS. Certainly, we know that transmission in health care settings has accounted for the vast majority of cases in Taiwan, and that's the leading hypothesis, but there are people who have been exposed in the community.

Also our team is interacting with a great number of health care workers who are there and have been there for some time trying to solve the problem there, and any one of them could potentially be a person who's been exposed or potentially infectious. So the chain of transmission is extremely complex in Taiwan, and it may be that we'll never exactly know when or where his exposure occurred, if again, if this even proves to be SARS.

Let me take a question from here in the room.

QUESTION: Maryn McKenna, Atlanta Journal Constitution. Just to clarify, was the CDC employee involved in direct contact with recognized SARS patients?

DR. GERBERDING: The employee was not taking care of patients. My understanding is that he was there assessing the infection control protocols, so he was not a care deliverer, but he was part of an assessment team providing technical consultation to the infection control staff there on the ground.

I'll take a telephone question, please.

OPERATOR: And our next question comes from the line of C.C. Connelly with the Washington Post. Please go ahead.

QUESTION: Thank you. I actually have two questions, Dr. Gerberding. I'm wondering first if you can tell us a little more in terms of how you're getting the CDC team home from Taiwan? I'm guessing that they're not going to be flying commercially. You mentioned something about an air ambulance. But if you could tell us how exactly that works.

And also I wanted you to perhaps discuss a little bit more of the situation in Taiwan. In reading the MMWR, I'm flabbergasted, frankly, at how this spread. And I wonder if to you there have been some suggestions and some claims that there have been cover-ups of this by hospitals and doctors in Taiwan? Do you think that the MMWR article lends some credence to those charges?

DR. GERBERDING: With respect to the air transfer of the ill CDC employee, we are using a means of transportation that we refer to as an air ambulance. And what this basically means, that under contract with the U.S. Government there is an entity that is in the business of moving ill people out of countries where their care needs demand a return to a different facility, or a return home, and so it's simply a matter of working with the State Department, contacting these individuals and arranging for a plane to be flown to Taiwan, and to pick up the patient.

Now the air ambulance is equipped with a flight crew that is capable of providing advanced medical services if something should go wrong on the flight, or his clinical condition deteriorates. They are fully equipped to provide additional respiratory care, even mechanical ventilation, if that would become necessary.

There's also room on the plane for the other three CDC employees and the crew and flight attendants on this flight are also skilled and trained in the use of appropriate infection control measures to protect themselves en route. So the transport is in progress, in terms of getting the plane there and making the arrangements to load and go with the team, and as I said, it'll be coming home some time before the end of the weekend, certainly.

I can't comment at this point in time about the reliability of information in Taiwan, but I think our team has had a strong sense that the information is coming forward in the way that we would expect it to, that they are receiving reports. When I mentioned a potential lag or that we would expect the numbers to go up, part of that is that there are two layers to the reporting process in Taiwan.

One is that cases are reported and public health action is taken, and the second is that there is sort of an advisory group that reviews all of the reported cases to make sure that they actually meet the definition of SARS, and when they are evaluated by experts and are found to meet the WHO case definitions, then they are reported to WHO.

As you can imagine with the number of cases that are currently in the queue, that reporting process is taking a bit longer, but I think the important thing is that they are responding to the suspected cases on the ground with the appropriate public health interventions and our team is, been very highly respected. I think they've been enthusiastic that the WHO and CDC expertise has been welcomed, and there really is a team effort.

So I'm not concerned at this point in time about a cover-up on the part of the government. There is another element to cover-up, however, that I do think it's important that we all be aware of, and that is individuals sometimes are frightened or fearful of seeking attention because of concerns about consequences.

In this country, I think we have demonstrated that we treat people with SARS humanely and fairly, and are doing our very best to minimize any unnecessary consequences, but there are people in other parts of the world that don't benefit from that perspective or that knowledge and there is always the concern that someone would be reluctant to come forward and seek care, even though they were ill.

Let me take a question from here in the room.

QUESTION: Thank you, Dr. Gerberding. Betsy McKay from The Wall Street Journal. Two questions. One, could you just tell us what care these employees, the sick one as well as the three who are accompanying him, what the care they will have when they get back to Atlanta. Secondly, there have been some comments made in the past few days about fears of a recurrence or resurgence of SARS next fall, in the next flu season.

I was just wondering if you could update us on your thinking alone those lines. Thanks.

DR. GERBERDING: The patient will be hospitalized for medical evaluation and will be in an isolation area. He will, like all of our probable or suspect SARS patients in the hospital, he will be on airborne droplets and contact precautions to avoid extending any infectious disease that he may have to someone else.

There is no specific treatment for SARS, so obviously the main measures will be to make sure that his oxygen status is good and that his hydration status is optimized, and the usual kinds of supportive measures, and we of course still continue to remain hopeful that this will prove to be a false alarm and that we'll find some other diagnosis.

With the people who are in quarantine right now in Taiwan, they too will be evaluated to make sure that they're not febrile or developing any symptoms, but assuming that they still remain asymptomatic, we would have them in an active monitoring system that would be orchestrated through the health department here in Georgia, the same way that we would for anyone who had been potentially exposed to SARS.

So the health officials in Georgia are already in the loop and will be making those decisions because that really is their jurisdiction.

I think you asked a question about what is in the future for SARS. Do we anticipate a resurgence? What do we expect coming down the road?

The bottom line is we don't know. This is a respiratory illness. Most respiratory illnesses are worse in the winter months and improve or disappear over the summer months; but it is anybody's guess what's going to happen in the fall.

We need to be prepared for the possibility that we'll see a resurgence or even expansion of SARS next fall, and so we are prepared, and the Department of Health and Human Services under Secretary Thompson's direction, we are currently in the process of developing a contingency plan for the potential for a resurgence or an expansion.

I think that's a prudent measure, I pray we don't need it, but we want to be ready and we'll be ready if we have to go there.

Let me take a phone question, please.

MODERATOR: And our next question comes from the line of John Lauerman, Bloomberg News. Please go ahead.

QUESTION: Hi; thanks for taking my call. I'd like to get a little more detail on the patient. What, right now, separates him from having a SARS diagnosis, and what would have to change for him to be diagnosed with SARS?

Is there a possibility--or when will we know whether or not he has SARS or not?

DR. GERBERDING: Right now, the patient meets the suspect case definition of SARS in that he's been in a SARS area or had exposure to people who've had SARS, and he has a fever, and he has respiratory symptoms. He has a cough.

And so those are the criteria for a suspect case of SARS. He does not have pneumonia, so he does not meet the probable case definition of SARS, and therefore he is not going to be included on our list of probable case reports unless his condition evolves consistent with WHO case criteria.

He will be of course medically evaluated here. He's under the care of a team of infectious disease physicians in Taiwan also.

The reason that there is some optimism that this is not SARS is because he did have sort of an unusual presentation. He had a very low-grade fever and then had a day or two where he felt completely well, without any fever, and now his fever has recurred, accompanied by a pretty mild cough. That could still be consistent with SARS, but it could also be that he has had any number of other respiratory illnesses that are all too common and particularly among travelers and other parts of the world.

So we just to have more information. When he gets here, assuming that his clinicians who are responsible for his care agree, we would want to make available the same kinds of testing that we make available to other SARS patients, and that would include PCR testing, as well as antibody testing during the convalescence of his illness.

And, you know, we will be careful about sustaining his confidentiality as we go forward with this, but we understand that everyone is interested, and this is a special case, so we'll give you all the information that we can as it evolves.

DR. GERBERDING: Let me take a question over here.

QUESTION: Janice McDonald, Fox News.

Could you address the decision to bring him back here, as opposed to treat him there, and talk about what precautions are being taken in the transport to make sure it doesn't spread, if it is indeed SARS.

DR. GERBERDING: Yes. As you will note, if you read today's MMWR, the health care delivery system in Taiwan is under enormous stress. Hospitals are closed, hospitals are quarantined. There are additional pressures as they anticipate the expansion of the epidemic there.

This is not a time for us to add to their burdens by having an additional person in the health care system there, and we felt that it was in the best interests of our employee to have him come home and receive care here in Atlanta, where he could be with his family and with the other people who care about him.

So the decision was based, in part, on the fact that the health care system in Taiwan is under duress and also a desire to make sure that he was home in the place where he chose to receive care until such time that we know that he's either going to get better or, in the worst-case scenario, should he get worse, then he will be in a place where we're confident he'll receive the best possible care.

En route, the infection control managers will be based on the same premises that we use in the health care setting. So basically precautions will be taken to prevent airborne spread on the plane, to prevent droplet spread on the plane, and to prevent contact transmission on the plane. So the individuals on the plane will wear properly fitting masks.

He will probably wear a mask because he's not compromised from the respiratory standpoint, so he should be able to tolerate wearing a mask, and that will eliminate the possibility of droplets or splatter entering that environment.

People will have face protection on so that all of their mucous membranes are protected from splash or splatter, and they will of course wear gloves and gown. So it's just simply like a little hospital room flying through the air.

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

OPERATOR: The next question is from the line of Larry Altman, New York Times. Please go ahead.

QUESTION: Yes, Dr. Gerberding, in the line of the questions just asked, with a tight-fighting mask, this is going to be an extremely long flight, so how is somebody going to be able to have the same mask on in terms of the other individuals or the patient and how will that be taken care of?

And, secondly, related to that, how is the decision justified, beyond the reasons that you've given, when I believe, and correct me if I'm mistaken, the recommendations have been not to transfer a patient once in a hospital if infected.

And, lastly, how long was he in Taiwan?

DR. GERBERDING: The issue about wearing the mask for such a long period of time is going to be a challenging one. This particular aircraft is one that does not have long flying times, so it goes up, it comes down, it refuels, it goes up, it comes down, it refuels.

And so I don't want to characterize it as a puddle jumper because that would be an exaggeration, but this is not a nonstop flight, let me just put it that way. So there will be opportunities for the crew to rest, for example, and for--he can remain on the plane, but the others on the plane can change out, and relax, and you know make sure that they are still in quarantine, but at the same time get a breather.

And this is one of those situations where the personnel on board the plane have a great deal of experience working on this kind of situation, and so we can trust that they will have figured this out.

The justification for transferring a patient out of a country to receive care in another country is a bit different than moving a patient from one hospital to another in-country. This is not a commercial aircraft. We are not posing a risk to other passengers or other individuals. We are basically putting a patient into a health care environment and moving him in an expeditious manner to another health care environment.

We are, of course, aware that this means that we will be admitting him to another hospital in the United States, but the hospital has already prepared to receive SARS patients, and they are confident that they have the appropriate precautions in place to protect their staff and their personnel, and we have confidence in their capability as well.

I forgot your last question, Larry.

QUESTION: If you have the length of time that he was working in Taiwan.

DR. GERBERDING: Yes, I don't actually know when he arrived in Taiwan. We can get back to you with that information if you just give our press office a call.

Can I take a question from here in the room?

QUESTION: Just to clarify again, you said that in addition to the patient, three other members of the CDC team are returning with him.


QUESTION: Does that leave you with anyone from the CDC on the ground in Taiwan?

DR. GERBERDING: Yes. We still have CDC personnel in Taiwan. We also have personnel in Southern Taiwan, where there's an ongoing evaluation of additional clusters there, and I'm not sure when the next team is due to leave, but I think it's imminently.

As I said, we had already planned a passing of the baton, and we're just moving that up a bit faster to make sure that we still are there and can maintain the continuity of our operation.

I'll take another telephone question.

OPERATOR: And it's from the line of Joanne Silberner with NPR. Please go ahead.

QUESTION: Hi. I want to thank you for taking these questions. I wanted to clarify the blood testing. You mentioned that he'll have a PCR and the antibody test when he gets back. Has anyone done a PCR on him yet? And, if so, when would those results be available?

DR. GERBERDING: I'm not aware of what testing is being done in Taiwan, and we are not aware of what tests they are doing in Taiwan in terms of their quality concerns or how they would compare to the tests that we're doing here. So if we got information about test results from his experience there, of course, we would take it seriously, but I think, regardless, we would want to have him go through the same kind of assessment that the other SARS patients in the United States experience, if he's willing.

I'll take a question over here. I know you've been waiting.

QUESTION: Well, actually, we just got here. So I'm sorry I'm going to ask you to repeat a little bit of the information.

Can you tell me what kind of work this employee was doing and how he might have been exposed.

DR. GERBERDING: The employee is a medical epidemiologist, so he was there in Taiwan as part of the team of people from CDC providing technical support to the Healthy Ministry there, and he was specifically involved in assessing infection control measures in the hospitals and advising on any opportunities for improvement.

I'll take a telephone question.

OPERATOR: And it's from the line of Anita Manning, USA Today. Please go ahead.

QUESTION: Oh, hi. Thank you very much. Dr. Gerberding, you mentioned that people who came in contact with the CDC employee who were in the hotel are now in quarantine. Do you have any idea how many of those people are in quarantine?

DR. GERBERDING: Off the top of my head, I don't know, but again we can find out the estimates from the folks on the ground and provide you with that perspective. It's not a huge number of people, but it's more than a couple.

I think I can take one more telephone question.

OPERATOR: And that will be from the line of Robert Bazell, NBC. Please go ahead.

QUESTION: Hi. What will happen to the people who are traveling back with the epidemiologist on the plane? Are they going to come right back to work at CDC or are they going to be encouraged to take a few days off to see if they feel okay? And it's a serious question because what, in this kind of, where you have a mildly suspect case, what should the other people who have been around that suspect case be doing?

DR. GERBERDING: Well, as we would advise any individual who was a household contact or who's had exposure to a SARS patient, we want to, first of all, assess their overall health status. I'm sure this has been very stressful for them, and they'll probably be very tired when they get home. So a good night's sleep in a comfortable bed would probably be extremely welcome.

But we would also advise them to assess their temperature on a regular basis, and the health officials in Georgia will make additional recommendations, depending on their assessment of the situation.

More than likely they will have a generous opportunity to take a little bit of time off, and then knowing the CDC teams, I'm sure they'll be back at work as soon as the health officials deem that it's appropriate.

Thank you very much for your interest in this. As we learn more about this situation or as the situation with our employee unfolds, we will be sure to update you.

Thank you.

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