Update on the Severe Acute Respiratory Syndrome or SARS

[Guest guest]

http://www.cdc.gov/od/oc/media/transcripts/t030329.htm

CDC Telebriefing Transcript

SARS Update

 

March 29, 2003

 

MODERATOR: Thank you for standing by. Welcome to the SARS update conference

call.

 

DR. GERBERDING: Thanks for joining us for another update on the Severe Acute

Respiratory Syndrome or SARS. What I'm going to do today is just give you a

brief recap of where we are in the epidemic and then I will talk about some new

guidance that CDC will be issuing today to help prevent the spread of this

infection here in the United States.

 

I'd like to first begin, though, with just a reflection on some sad news that

CDC received this morning. Dr. Urbani, who is the WHO physician investigating

the outbreak in Hanoi, died of SARS that he acquired during his investigation.

He was a very close colleague of ours and someone that we had worked closely

with in both Hanoi and Thailand through the past several years, and we are very

sad and our condolences certainly go to his family and his colleagues as well as

our colleagues in the area who've been working with him over the past few weeks

on this investigation.

 

The global epidemic continues to expand. Today, WHO is reporting 1,491 cases and

54 deaths, plus the 62 cases that we are reporting here in the United States.

 

As you know, the U.S. cases are constantly undergoing revision and updating as

additional information about the patients is determined, so that number may

change over time.

 

We continue to regard the new coronavirus as the leading hypothesis for the

etiology of this condition. The evidence is mounting from a number of

international laboratories, that this is indeed the case; but we are also

exploring other potential viruses as are our collaborators, and we will keep you

posted as we go forward on that part of the scientific investigation. A number

of things are in progress, including sequencing of the whole virus genome, and

we'll have more information on that, potentially next week or the week

thereafter.

 

We are at a situation in time where we recognize that the disease is still

primarily limited to travelers, to health care personnel who have taken care of

SARS patients, and to close contact with SARS patients.

 

The affected travelers are those who have been in Hong Kong, in Hanoi, in

Singapore, and in mainland China, for the most part.

 

We believe, based on what the investigations have shown us so far, that the

major mode of transmission still is through droplet spread when an infected

person coughs or sneezes and droplets are spread to a nearby contact. But we are

concerned about the possibility of airborne transmission across broader areas

and also the possibility that objects that become contaminated in the

environment could serve as modes of spread.

 

Coronaviruses can survive in the environment for up to two or three hours ,and

so it's possible that a contaminated object could serve as a vehicle for

transfer to someone else.

 

In health care settings, we have already initiated guidance to protect against

droplets, airborne and contact spread of this virus, and today we're issuing an

update on how to protect people in homes of SARS patients.

 

We know that the individual with SARS can be very infectious during the

symptomatic phase of the illness. We don't know how long the period of contagion

lasts once they recover from the illness and we don't know whether or not they

can spread the virus before they have the full-blown form syndrome.

 

But most of the information that the epidemiologists have been able to put

together suggests that the period of contagion may begin with the onset of the

very earliest symptoms of a viral infection, so our guidance is based on this

assumption.

 

If we learn more or we learn something different as we go forward and intensify

our investigations, we will of course update or change our guidance.

 

SARS patients are either being cared for in the home, or who have been released

from the hospital or health care settings, and are residing in the home, should

limit their activities to the home. They should not go to work. They should not

go to school. They should not frequent public places until at least ten days

after they are fully asymptomatic.

 

In addition, if they're coughing or sneezing, they should use common sense

precautions such as covering their mouth with a tissue, and ,if possible, and

medically appropriate, they should wear a surgical mask to reduce the

possibility of droplet transmission from them to others in the household.

 

In addition, and very importantly, they should use good hand hygiene, and that

means washing your hands with soap and water, or using an alcohol-based hand rub

frequently, and particularly after any contact with body fluids.

 

For the people who are living in the household with the SARS patients, and who

are otherwise well, there is no reason to limit activities at this point in

time. The experience in the United States has not demonstrated spread of SARS

from household contacts into the community and so we are not advising any

restrictions on the activity of contacts at this point in time.

 

However, it's very important that contacts with SARS patients be alert to the

earliest symptom of a respiratory illness. That may be fatigue, headache or

fever, and the beginnings of the usual upper respiratory tract infection, and if

they have any symptoms suggestive of an impending illness, they should contact a

medical provider, alert them that they are a SARS contact, so that the health

care system can advise them where to come and get evaluation, and prepare the

delivery system to implement the appropriate infection control precautions so

that others are not exposed in the health care setting.

 

Contacts with SARS patients should also of course use hand hygiene and use the

appropriate surgical mask to prevent contact with droplets, if the SARS patient

in the home is unable to wear a mask.

 

We also are updating our guidance to travelers. I think that the travelers at

risk for SARS are those who have been in mainland China, in Hong Kong, in Hanoi

and in Singapore.

 

However, we recognize that there are passengers who moved through these areas

for brief periods of times and are arriving here in this country indirectly,

after being in those countries, so right now we are meeting both direct incoming

flights from the affected areas as well as passengers who are arriving from

different regions and have passed through those areas en route.

 

The alerting is being expanded to include arriving passengers from China, from

mainland China, and from Singapore at this point in time.

 

In addition, the alert extends the period of passenger monitoring to ten days.

Previously it had been seven days but we are aware of some patients that may

have a longer incubation period, and to be on the safe side, we want to make

sure that they seek medical attention if they develop any symptoms within ten

days of departure from one of the SARS regions of the world.

 

These travel alerts do not include passengers coming in from Canada. The

epidemiology of the SARS in Canada is very different and there is not a risk

from incoming travelers at this point in time.

 

WHO is not issuing any travel restrictions. We are not issuing any travel

restrictions either, but WHO has also implemented procedures for screening

passengers before they leave the country of SARS origin. They're asking

countries to evaluate departing passengers for respiratory illnesses or other

signs that could represent SARS. In part, this is because there are some early

reports that passengers traveling with a SARS patients on board could be at risk

for acquiring this infection, and we don't want to have any cases acquired

during flight or during transfer on a ship or other vehicle.

 

So the travel alerting process that's already been in place, and actually we've

issued more than 150,000 alerts, is being expanded and will be involving 23

ports of entry into the United States.

 

So let me just stop here and take questions and I'll take a caller on the phone

first. Can we have the first call.

 

I don't have a caller on the phone. I'll take someone from the audience.

 

MODERATOR: Ladies and gentlemen, if you wish to ask a question, please press one

at this time.

 

Okay. Our first question comes from the line of Miriam Falco with CNN. Please go

ahead.

 

QUESTION: Hi. Can you hear me?

 

DR. GERBERDING: Yes. We can hear you now.

 

QUESTION: Excellent. I don't know what that was. First of all, thanks, again,

for having this.

 

The Canadian health authorities have issued quite a restrictive quarantine, now

expanding to a second hospital.

 

Why are you not issuing any quarantine? Is it because you can't or because the

situation is not so dire?

 

DR. GERBERDING: Well, first of all, we have been in constant communication with

Canadian health authorities and they are not actually issuing a quarantine. They

are issuing a voluntary self-isolation policy which is slightly different than a

regulated quarantine.

 

The main reason we are not taking this step right now, in this country, is

because the epidemiology of our problem is very different than the outbreak that

Canada is experiencing in Toronto.

 

Although I reported 62 cases under investigation here, two of those cases are in

health care workers and there have been no further signs of spread in that

particular cluster. Five cases have been in household contact and the rest of

the cases have all been in travelers coming in from SARS areas.

 

So we are not experiencing any sign of community transmission at this point in

time, but we are alert to it, we are monitoring potential contacts very

carefully, and if we see evidence that our infection control measures are not

containing spread within communities, then we will have to reconsider whether

additional steps are necessary.

 

I'll take another question from the floor here.

 

QUESTION: I notice that you list mainland China but now Taiwan. How significant

is the risk in Taiwan?

 

DR. GERBERDING: Taiwan is a country that is reporting cases and they are

included in the travel advisory for incoming passengers.

 

A question from the telephone.

 

MODERATOR: Our next question comes from the line of Larry Altman with New York

Times. Please go ahead.

 

QUESTION: Yes. Dr. Gerberding, given the fact that Hong Kong health officials

now are reporting suspect cases from an apartment complex, large numbers,

apparently spread by one or two infected individuals in that area, how do the

United States guidelines take the possibility of airborne transmission into

effect?

 

You touched on this just a moment ago but given the new news, could you

elaborate on that.

 

DR. GERBERDING: Yes. The information that we're getting from Hong Kong does

suggest that in at least one apartment complex there has been spread. We can't

identify yet, to what extent the individuals in that apartment have had face to

face contact with each other, to what extent they might have contacted

contaminated environments in that facility or to what extent airborne

transmission could play a role.

 

It's obviously something that we're concerned about and we're working hard to

get that sort of information.

 

There are other clues that face-to-face contact is not always the only means of

transmission. Right now, in this country, our infection control precautions in

health care settings in homes appear to have limited spread of the disease, but

as I said, we are monitoring very carefully and if we see evidence of airborne

transmission or failure of our current guidelines to contain this, we will be

willing and need to take additional steps.

 

A question from the audience.

 

QUESTION: Following up on the question about modes of transmission, you

mentioned, when you began to speak, that there's some indication that

coronaviruses may survive on surfaces for a while, so could you discuss any

implications that might have, particularly for airplanes or vessels, anything

like that, in terms of this infection.

 

DR. GERBERDING: Yeah. I'll ask Dr. Citron [ph], who's our expert in

international travel, itches [?], and infection control, to see what he can tell

us about this infection in planes and boats.

 

DR. CITRON: Thank you, Dr. Gerberding.

 

We have issued preliminary guidance on appropriate means for disinfection of

commercial aircraft as well as very specific and more focused guidance for

disinfection of an aircraft that might be used in a medical evacuation of a

high-risk or critically-ill patient, and those are available on the Web.

 

Although there's a possibility [inaudible] spread, this is a virus that's

routinely susceptible to commercially available, normal types of disinfectants

that are used in hospitals, and that's basically what you'll see in that

guidance. So there's not need for taking extraordinary measures or using

extremely caustic or dangerous types of materials, but the routine types of

disinfectants are available and the specifics are on the Web site announcement

[?].

 

QUESTION: Just a follow up. To follow up. What about disinfection in the home?

Do you have guidelines for that? Is it just a question of chlorine or--

 

DR. CITRON: I think it's the same kind of principles that are going to apply,

you know, standard household disinfectant agents to clean surfaces and bathroom

areas, and things that may have come in a lot of contact with a

potentially-infected patient, ought to be adequate.

 

DR. GERBERDING: You know, any time we have a new disease there are always a lot

of questions about disinfection in the home, and I think one of the themes

that's been most helpful in the past as we've dealt with AIDS or other

infectious diseases--to use common sense. Prudent housekeeping policies are

appropriate for home hygiene under any circumstance and those certainly are

appropriate when there's a new infectious disease as well. So the common sense

measures that we take for sustaining cleanliness in the home and food safety,

and so forth, are appropriate under these circumstances as well.

 

May I have a phone question, please.

 

MODERATOR: We have a question from the line of Anita Manning with USA Today.

Please go ahead.

 

QUESTION: Hi. Thanks very much, Dr. Gerberding. Actually, one of my questions

has already been answered, but I did wonder if you could talk a little bit more

about what travelers are experiencing in terms of what the CDC is informing them

of. What are you doing?

 

DR. GERBERDING: What we are doing when passengers arrive at the 23 ports of

entry involved in this alerting process in the United States is delivering to

the passengers at the time that they're disembarking a health alert card, a

small card that we now have translated into six languages, that advises them to

be alert of any evidence of fever or respiratory symptoms for the ten days after

they've left one of the SARS countries. The card specifically mentions the

countries of concern.

 

In addition, there's a second section of the card that is information to

clinicians, so if SARS patient does seek clinical attention, the clinician

understands, they bring the card in and it gives them the specific advice,

provides them information on how to get more up-to-date information on SARS, and

also how to contact CDC and the importance of reporting any known or suspect

cases.

 

So it's a mechanism to remind people at the point of departure, that they've

been in an area where they could possibly have come in contact with someone with

SARS and that they need to be alert to the earliest possible symptoms, so that

they can get care and protect others.

 

Can I have another phone question.

 

MODERATOR: We have a question from the line of Betsy McKay with Wall Street

Journal. Please go ahead.

 

QUESTION: Hi, Dr. Gerberding. Thank you very much for holding this briefing.

 

I was just wondering if you could update us on treatments that are being used in

the U.S. for SARS patients. I understand that you have not issued specific

treatment guidance but I'm just wondering if there are any changes in treatment

that are being used around the country over the last few days and if there are

any particular anti-viral medicines, or therapies that are being used that may

seem promising? Thank you.

 

DR. GERBERDING: CDC is working with FDA and NIHD and USAMRIID and others to try

to identify drugs that might have activity against this coronavirus, but as of

today we have no leading candidates on the shelf, that we could recommend for

clinical treatment.

 

The patients in the United States are being treated according to the guidance

that we've issued to clinicians as well as standard management for pneumonia,

and that does include treatment empirically for other causes of pneumonia,

because at the initial presentation this disease could easily be confused with

other common things for which we do have specific therapy.

 

So clinicians are advised to have a broad differential, to initiate antibiotics,

if that seems appropriate under the clinical circumstances, and as they learn

more, and more diagnostic testing is done, to stop those unnecessary treatments

if, indeed, the condition does seem to be most consistent with SARS.

 

We have no evidence, unfortunately, right now, that any specific anti-viral

therapy, or steroid treatment, or other agents that are targeting this virus,

are of any benefit to patients. We hope we'll learn more as we go but that is

the status of clinical care today.

 

How about a question here.

 

QUESTION: Hi. Jim Carr with Reuters. Just a follow-up on the earlier comment you

made about Taiwan, because as I understand it, the cards that you were talking

about do not include Taiwan among the listed nations.

 

Does that mean that Taiwan is less dangerous?

 

DR. GERBERDING: Let me ask Dr. Citron to take this question. There's a couple

points of confusion here.

 

DR. CITRON: Thank you. I think there is the potential for confusing the two

strategies. The passenger alert cards, the yellow cards that disembarking

passengers get, is our surveillance tool, to be alert to the earliest possible

cases, and consequently it's broader. It lists those three countries, China,

Vietnam and Singapore at this point, and we want to be able to detect the first

case from any of those areas.

 

The guidance that goes up to outbound travelers, the travel advisory which

recommends deferring nonessential or elective travel, that is focused on helping

somebody judge whether they should go to an area of risk and it's based on a

risk assessment from the data that we have available or a risk assessment

because of the absence of information.

 

So our current understanding of the risk, of the cases in Taiwan, as well as

Canada and Toronto, is significantly different and significantly more confined,

and consequently there isn't evidence, at this point, to suggest people defer

that travel to Taiwan as opposed to Guangdong Province, for example, where

there's a community epidemic going on.

 

So the outbound is guidance to help you assess risk about where you're going.

The inbound is a surveillance tool, so we can find all cases early, and act on

them quickly, get them to health care and be isolated. I hope that clears that

up.

 

DR. GERBERDING: So it's on the list.

 

Can I have a telephone question.

 

MODERATOR: We have a question from the line of Robert Bazell with NBC News.

Please go ahead.

 

QUESTION: Hello, Dr. Gerberding.

 

Given what's happened in Hong Kong, and southern China, and given what's

happened in Toronto, how concerned are you about the possibility of a community

outbreak in the United States?

 

DR. GERBERDING: We are very vigilant about the possibility of spread. We

recognize that there are at least some patients with SARS that are extremely

efficient transmitters. We don't know to what extent all patients are

particularly infectious but there are clearly some who appear to be very highly

infectious, and, for example, in Hanoi where there was one patient who was a

source for health care worker transmission and approximately 56 percent of the

health care who had direct contact with the patient appeared to have acquired

SARS.

 

So given that high degree of contagion and what we know about spread of cold

viruses, I think we are very alert to the possibility that this could spread

outside of the confined populations that I've mentioned, travelers to the

affected areas, close household contacts, and health care workers. But we are

not seeing that now and we are looking for it very closely.

 

So if we begin to appreciate that, we will have to expand our recommendations to

be more inclusive of special protective measures for contacts.

 

I'll take another phone question.

 

MODERATOR: We have a question from the line of Hija Charapadeya [ph] from CBC

Radio Canada. Please go ahead.

 

QUESTION: It's actually Pia. Dr. Gerberding, I'm wondering how would you

characterize the situation in Canada, specifically in Toronto, now that we

upwards of about 70 probably and suspected cases?

 

And as a follow-up, you said the epidemiology of SARS in Canada is very

different. What do you mean by that?

 

DR. GERBERDING: In Canada, unfortunately, when the initial patients arrived with

SARS, we did not yet appreciate the illness and we did not know that infection

control measures were appropriate, so the earliest patients were not placed on

the special isolation precautions that we're talking about now, generically.

 

I think that allowed the epidemic to get started there and to spread to more

people before there was a chance to really intervene with appropriate infection

control.

 

We are incredibly impressed with what Canada is doing and what the local health

officials are doing in Toronto. I think they're airing on the side of caution.

They're taking eery step that we could imagine would be appropriate given the

circumstances that they're facing.

 

We also have a liaison from Canada here in our emergency operations center and

are preparing to send one of our CDC staff to Canada to make sure that our

information exchange is complete and that we are in close collaboration and are

aware of the situations in both countries as they evolve.

 

So I think we are learning from Canada as we go and we are keeping a very close

watch on the situation there.

 

Can I have another telephone question.

 

MODERATOR: Yes. We have a line from the question of Tom Maw [ph] with Los

Angeles Times. Please go ahead.

 

QUESTION: Can you give us a brief overview of the evidence that now supports the

idea that this is in fact a coronavirus.

 

DR. GERBERDING: I'll take a stab at that and I'll ask Dr. Hughes to chime in.

Dr. Hughes is the director of the National Center for Infectious Diseases. The

evidence comes from a convergence of many types of laboratory investigations

ongoing in many of the laboratories that are part of the WHO collaboration,

including CDC.

 

First, we have isolated the coronavirus

from two patients, here, in the United States and this work is going on

elsewhere additional isolations are reported. We are using PCR or polymerase

chain reaction technology to identify very specific pieces of the coronavirus in

the secretions and fluids from many, many of the case patients.

 

We have developed an antibody assay which detects antibodies to this new

coronavirus with a high degree of specificity and I think very compelling, some

of the patients who have negative antibody tests at the beginning of their

illness, subsequently, in paired [?] serum have demonstrated new development of

antibody within days after their infection occurred. So they are developing an

immunologic reaction to this new coronavirus and that's really strong evidence

of infection.

 

It doesn't necessarily mean the infection is a cause of the pulmonary infection

or the respiratory symptoms, but, clearly, that's very solid evidence that

disease is occurring, the body is responding to it, specifically, and I think

that is a very important source of information, and I'll let Dr. Hughes add the

breaking information about what's probably coming out of the lab today.

 

DR. HUGHES: Well, many laboratories here at CDC, as well as around the world,

have been hard at work at this for some period of time. A week ago today, there

were no antibody tests which could be used to diagnose this infection. It's a

result of considerable hard work. We now actually have two antibody tests that

look quite promising and seem to be reproducible in different laboratories, and

among the things we're doing is working to get ready to transfer diagnostic

testing capacity to public health laboratories around the country, so that

before too long, I'm hoping that tests will be available much more locally.

 

I should also say that we know that laboratories in at least seven other

countries now have evidence for coronavirus, looking like it plays an important

role in causing this syndrome.

 

So the preponderance of evidence in support of coronavirus as the cause

continues to mount.

 

QUESTION: You had mentioned the screening process that's going on at the ports

in the various countries.

 

What about the United States? Is there any screening being done on ingoing or

outgoing passengers?

 

DR. GERBERDING: Let me first just offer a point of clarification. The WHO just

issued this advice to the involved countries and recommended some steps they

should take for departing passengers and you can find that on the WHO Web site.

 

Since I'm not aware, at this point, how much implementation has occurred

already, I think there are going to be some difficulties in getting this

implemented at every airport, and that's why we are continuing to alert the

arriving passengers from these areas, to make sure that they are included in our

catchment.

 

What really is the situation here is that arriving passengers are alerted. If we

have people who are travelling to those areas, we're not issuing an

airport-specific alert but we are putting the usual kind of guidance that goes

up on our Web site and, you know, it's actually our travellers Web site is the

most frequently sought component of the CDC Web site, so we know that that is a

common place where people go for information when they're traveling abroad, and

travelers clinics would also have this information and advice as people go in

and prepare for their vaccinations or whatever is out there, leaving for

whatever travel they're taking.

 

So our approach is primarily alerting people on their way back home, or on their

way to the United States from these areas, and secondarily, to issue the generic

statement that if you're traveling to this region you may wish to defer elective

travel until such time that we know more and can do a more thorough assessment

of what risks are present.

 

We are not medically screening incoming passengers but if a passenger is

identified as having illness on a plane or a ship, they are met by the health

authorities in that state, in conjunction with the CDC officials, and they are

evaluated and we have done that several times.

 

So if there is evidence of a symptomatic person, on arrival they are assessed,

and if necessary, the other passengers are evaluated and they're monitored

prospectively, to make sure that they haven't been exposed as they go forward

through the incubation period.

 

A telephone question, please.

 

MODERATOR: We have a question from the line of John Kerry with Business Week.

Please go ahead.

 

QUESTION: There have been sort of conflicting views of where we are in the

epidemic, whether it's continuing to spread or under control, and it may vary as

to what country you're in. I was just hoping you could sort of address the big

picture here and say what you think about where we stand, and also what lessons

have been learned so far about the ability of the public health infrastructure

to respond to this sort of thing?, and again, that may vary by country as well,

I would think.

 

DR. GERBERDING: Well, from the standpoint of CDC, I would say that we are very

concerned about the spread of this virus, particularly in Asia. We recognize

this as a epidemic that's evolving differently, in different geographies, but

nevertheless, it is a respiratory virus, it does appear to be transmitted very

efficiently, and what we know about respiratory viruses suggests that the

potential for infecting large numbers of people is very great.

 

So we may be in the very early stages of what could be a much larger problem as

we go forward in time. On the other hand, this is new, we don't know everything

about it, and we have a lot of questions about the overall spread.

 

The patterns of transmission in the individual countries vary, depending on

where the primary foci of transmission is occurring.

 

In Hong Kong, the situation is particularly alarming because we have several

hospitals that are affected, and there are so many health care workers in each

of these hospitals that could have been exposed or who are developing SARS, that

there's already a multiplier in the community. Every health care worker has

household contacts, those contacts, when they become ill, have had other

exposures.

 

So we are very concerned about the speed and the amplification process in Hong

Kong. On the other hand, the health officials there are taking extremely

efficient and aggressive steps at this point in time to contain spread in that

community, including closing schools and closing hospitals, and cohorting health

care workers and patients.

 

So it remains to be seen whether or not those measures will attenuate the

spread. The biggest unknown is of course what is going on in China and we are

desperate to learn more about the scope and magnitude of the problem there,

because that really I think will be the biggest predictor for where this will be

headed over the next few weeks. Yes?

 

QUESTION: Returning to the issue of for how long patients are contagious, and

whether there's an asymptomatic contagious state, could you discuss whether

you've been able to start any studies yet and what sort of studies there are.

 

DR. GERBERDING: There are studies going on to try to define the period of

infectivity or the timeframe in which an asymptomatic person could have the

virus, not yet be sick and transmit it to someone else.

 

One of the important studies going on is to look at passengers who traveled in

airplanes with SARS patients, and so already we have three separate cohorts of

passengers who traveled on the same plane with someone we knew was incubating

SARS or had SARS during their travel experience.

 

So far, those studies have not identified evidence of transmission before people

become sick but the numbers are small and we can't draw any conclusions at this

point in time.

 

Likewise, when we have the test that Dr. Hughes was talking about, the antibody

test, we'll be able to evaluate household contact of patients and measure their

antibody response to see whether or not they were exposed and actually didn't

get the full spectrum of disease but had evidence of asymptomatic infection, and

that will help us calculate the attack rate or the proportion of exposed people

who actually develop infection.

 

These are fundamental aspects of understanding any epidemic and we are just in

the early phases of getting those pieces of information pulled together from

across the world.

 

The WHO has been incredibly helpful in supporting all of these collaborative

efforts.

 

Let me take a telephone question, please.

 

MODERATOR: Our next question comes from the line of Elizabeth Cohen with CNN.

Please go ahead.

 

QUESTION: Hi, Dr. Gerberding. I have two questions. The first one, I know it's

very hard for you to be real specific about this but this is what has everyone

freaked out, so I feel like I need to ask you because people are asking me.

 

Could, if you're in an elevator, on the other side of an elevator with someone

who has SARS, could they spread it to you? If you're three steps behind in an

escalator. If you're on the same step of the escalator. I mean, what kind of

distance are we talking about, because people are really anxious about that.

 

DR. GERBERDING: You're breaking up a little bit but I think I caught your

question, which is basically what is the risk from brief encounters, in public

settings, of acquiring this from someone who has the illness, examples of the

escalator or the elevator.

 

The bottom line is that we don't know but what we can tell from looking at the

epidemiology and the patterns of transmission so far, there is not evidence, at

least in this country, to suggest that those activities are posing any risk.

 

Concerns that I mentioned earlier focused on droplet transmission, so if you

were in the elevator and an infectious person literally coughed on you, it's

conceivable that you could acquire a respiratory infection, including SARS,

through that mechanism.

 

On the other hand, most of the information suggests that fairly prolonged

contact, on a face to face basis, is typical of the transmissions.

 

There are anecdotal reports, that we haven't confirmed yet, of much briefer

contact. There's been a concern expressed about the potential for airborne or

surface contamination in the apartment in Hong Kong, and these are all open

questions that we are aggressively pursuing here.

 

So we will learn as we go and as we said from the very beginning, we are erring

on the side of taking extra precautions because we can't be confident that we

are offering the best protection without taking those kinds of steps.

 

In environments where those infection control precautions have been implemented,

there's been a dramatic reduction in spread to health care personnel, so it is

possible to contain the infection through these measures but we don't know if

that will be a 100 percent effective and we don't know which of the measures is

the most important at this point in time.

 

Can I have another telephone question, please.

 

MODERATOR: We have a question from the line of Larry Altman with New York Times.

Please go ahead.

 

QUESTION: Yes. This is a follow-up question that I should have asked earlier,

Dr. Gerberding. Are the new guidelines going to be on the Web site right now?

 

DR. GERBERDING: They are likely to be up as we speak. They were issued, they're

out, they're in the process of being put out through the health alert network,

and as soon as we can get the Web button pushed, they'll be up.

 

QUESTION: Thank you.

 

QUESTION: I was wondering if you could offer us three pieces of demographic data

of related cases here in the U.S. The first would be how many of those cases are

in the Chinese community; second, how many in New York? Third, which state has

the highest incidence of SARS.

 

DR. GERBERDING: Let me see if I have my state listing with me. So I will check

on that. I know I'm not going to be able to tell you the race and ethnic

distribution of the case patients in the United States at this point in time.

 

In terms of today's assessment, we had three cases added to our list overnight

and so I don't have them segregated, by state, on my documentation, but right

now the largest number of patients are in California. That's not surprising

since California is one of our largest states. But that's also a point of a lot

of travel to Asia and so it makes demographic sense, that that would be an area

where there would be perhaps an increased risk.

 

I think you would probably want to contact the state health department to get

the latest update on that. We can get back to you after this with that

information.

 

Let me take a telephone question.

 

MODERATOR: We have a question from the line of Kida McPherson with Star-Ledger.

Please go ahead.

 

QUESTION: Thank you; thanks, Dr. Gerberding.

 

My first question was: Just could you please repeat the number of American

cases. It broke up and I couldn't hear that number. My second question is: You

mentioned at the very beginning of this briefing that Dr. Urbani of the World

Health Organization had passed away.

 

I would think that he would have had access to, you know, the best knowledge

about how to protect himself, so I'm wondering--unfortunately, did you learn

anything? Was he exposed in a way that you hadn't expected? Is there any kind of

insight into that?

 

DR. GERBERDING: Thank you. I would take your first question. There are 62

patients in the United States under evaluation for SARS right now.

 

Two of those are health care workers and five of them are contacts of SARS

patients, household contacts of SARS patients.

 

With respect to the mode of transmission to Dr. Urbani, at this point I can't

tell you the best hypothesis for that, but I will say that he is the person who

went into the hospital where the affected patient was in Hanoi first. He was the

first investigator to be there and he arrived at a time when infection control

precautions were not in place, so there are opportunities for him to have been

exposed before the contagion was recognized and the capacity to implement

state-of-the-art infection control had been developed in that facility.

 

I'll just take one more question from the phone, please.

 

MODERATOR: The last question comes from the line of Miriam Falco with CNN.

Please go ahead.

 

QUESTION: Hi. A couple more questions. Number one, do you have any more clues

about why there was a 90 to 10 percent breakdown in severity of disease, really,

that was mentioned either in the MMWR or in the WHO?

 

And will these tests that Dr. Hughes was talking about be able to be used to

determine if all of these 62 patients are actual confirmed cases?

 

Or is this a lower type of test, just to see what it might lead to for

treatments?

 

DR. GERBERDING: I'm sorry, I did not understand your first question.

 

QUESTION: Well, it was either in the MMWR or the WHO report, that 90 percent of

the patients get sick but then they recuperate. Ten percent of the patients have

a severe illness and why is there such a difference in the cases? If you know

anything about it.

 

Could it be that there might be other viruses involved as well?

 

DR. GERBERDING: Certainly, there could be other cofactors involved such as

viruses or underlying illness, but this is just atypical pattern for any

infectious disease. If you get pneumococcal infection, many people have

completely asymptomatic. Some people get a mild disease and some people have a

full blown, very, very severe illness from the infection.

 

So this is a typical pattern for respiratory illnesses, not something that we're

surprised about. In fact if there's any good news in SARS right now, it's that

the majority of patients do appear to recover and that the death rate is

actually lower than what we see with epidemic influenza, about 3.5 percent of

the patients have died from the illness. That is still a tragic occurrence for

the people who are affected, and their families, and I would never mean to

minimize it. But it is fortunate that it is not even more severe.

 

With respect to the issue of the diagnostic test, no, as Dr. Hughes said, we

have only had this antibody for about a week, and so the fact that we've come

this far so far means that there's still work to do to really know is it

sensitive, in other words, does it pick up every case? and is it specific? Is it

negative when somebody doesn't have SARS?

 

So we've got to do the validation and one way of doing that is to use the test

in the people that we're highly confident have the condition and compare the

results to people with intermediate probability and then those that we're sure

have something completely unrelated, and that will give us some basis for

assessing the reliability of the test, and that will help us then know whether

or not we can use it to rule in or rule out SARS in the majority of people that

we're dealing with.

 

So there's a lot of work to be done very fast but I think it's a remarkable

achievement. Dr. Hughes and his team at CDC as well as the WHO collaborating

investigators, should be applauded for the scientific rigor and the speed with

which they have been able to accomplish so much in so little time.

 

Thank you for being here today and we look forward to updating you as we learn

more.

 

Listen to the telebriefing

 

 

 

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