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07 May 2003

CDC Reports SARS Containment Methods Working

(Travel advisories lowered for Singapore, Vietnam) (7400)


The U.S. Centers for Disease Control and Prevention reported May 6
that efforts to contain severe acute respiratory syndrome (SARS) in
Singapore and Vietnam have been successful. In response, the agency is
standing down from its travel advisory regarding the two nations that
had suggested travelers avoid all but essential trips to those
countries.


CDC Director Gerberding said in a briefing that travel alerts do
remain in place for Singapore and Vietnam. That means the agency is
alerting travelers to the existence of the viral illness and
suggesting that visitors avoid health care environments where
transmission has occurred.


CDC maintains a travel advisory, its highest-level warning, for
mainland China, Taiwan and Hong Kong, but at the same time Gerberding
praised the aggressive efforts that health officials are making in
those areas to contain the disease and stop the chain of transmission.

Health officials in these regions "are very aggressively working to
isolate infected people and quarantine exposed people to bring this
problem under control," Gerberding said at a briefing at CDC
headquarters in Atlanta, Georgia. "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," she said.

Gerberding also addressed findings released by several laboratories
around the world in the last few days that the SARS virus can survive
on surfaces or in fluids for 24 hours or more. The CDC director
pointed out that the results were achieved in "experimental
situations" and may not bear much relevance to how the virus is
actually being passed from person-to-person in real world situations.

CDC has put a number of advisories in place about the protections that
health workers need to use to avoid infection, and Gerberding said
those recommendations are still appropriate even with findings about
the virus' survival abilities. "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."

Other recently released SARS research finds that the fatality rate for
the respiratory disease may be far higher than the 6-10 percent
estimated from the cases that have occurred so far. Research published
in the British medical journal "Lancet" shows a death rate as high as
55 percent in patients over 60 years of age.

Gerberding said at this state in a disease's course it is typical that
widely varying death rates would be reported. She also said that
there's still a lot that health officials don't know about what SARS
patients have undergone.

"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," the CDC director said.

Following is the transcript of the CDC briefing:

(begin transcript)

U.S. CENTERS FOR DISEASE CONTROL AND PREVENTION
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--

[Laughter.] 

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. 

Yes? 

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.

(end transcript)

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Department of State. Web site: http://usinfo.state.gov)