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Steps Taken to Contain SARS in Canada, U.S.

Aired April 22, 2003 - 14:05 KYRA PHILLIPS, CNN ANCHOR: I am told now we are going to take you live to the CDC, where that press conference is getting ready to begin. Right now, with regard to the SARs epidemic -- let's listen in. DR. JULIE GERBERDING, DIRECTOR, CDC: (UNINTELLIGIBLE) is also reporting a total of 229 deaths and a case fatality rate of 5.9 percent. Looking at SARS from the international perspective, we remain sobered by the ongoing transmission in Hong Kong, China, and probably Singapore. We also see countries where there has been at least some successful containment. And it looks like progress is being made in a number of fronts in that regard. Here in The United States, we are continuing to cast a very broad net in terms of decisions about isolation. So although we have distinguished between probable and suspected cases in our reporting format, we are continuing to recommend the same standard of isolation for both suspect and probable cases to be sure that we get everybody properly isolated as early as possible in the course of their illness and do everything we can to prevent transmission to others. And let me just review for you what the domestic priorities are for us at this point in time. First and foremost, case detection remains an extremely important component of all of this. So we are continuing to alert inbound travelers to the United States from the areas of the world where ongoing transmission is still occurring. And that includes travelers incoming from mainland China, from Hong Kong, from Taiwan, from Vietnam, from Singapore, and from Toronto, Canada. Specifically with respect to Toronto, we are working with the Health Canada officials to provide an alert to travelers coming into the country -- who have been in the Toronto area. This alert is being distributed at Toronto International Airport, and over the next week, we anticipate beginning the process of providing this alert to people traveling by land across the major highways connecting U.S. and Toronto. And we'll also be looking at if and when we need to be doing that for train passengers as well. This is the mechanism to simply alert people to the fact that that is a community where SARS is being transmitted and that if an individual becomes ill within ten days of their last point of contact, they should contact their medical provider. That's one very important component of identifying, at the earliest possible moment, people who might be coming down with SARS. The next very important component of our containment here in The United States is initiating the appropriate isolation of SARS patients as soon as they are suspected. And we are specifically advising travelers or others who know they have been in contact with SARS patients to not just show up in the doctor's office but to call ahead and alert the healthcare delivery systems so that the infection control precautions can be ready for them when they arrive and that healthcare workers will not be unprotected at the point of first contact in the medical care environment. This is working well already. We have been hearing reports about medical care facilities that have put up large signs in the emergency room and immediately assess patients with a travel history and institute the isolation steps -- prior to obtaining the full medical history so that they can be sure that the healthcare providers are afforded the best possible protection and that the individual patient is given the best possible timely care in the medical environment. Another very important component of our containment here is to make sure that household contacts or other face-to-face contacts of patients with SARS are in an active monitoring program during the ten- day period of time after their last exposure, where they might possibly come down with the illness. And so we have asked health departments across the country to develop methods for actively monitoring exposed persons. We're not asking exposed persons to be quarantined but we are asking that they participate in some kind of a regular evaluation so that if they develop any of the early symptoms of SARS, they will contact a healthcare provider and then go through that process of coming in and getting seen. The earliest signs of SARS include not only fever but, in addition, other evidence of respiratory illness, including dry cough, headache, fatigue, muscle aches, and so on and so forth. So those could be the earliest signs in someone who has traveled to one of the affected areas. That would be an indication for further assessment or at least a call to a clinician. We are also interested in getting some input from our expert advisory committees about whether there are any circumstances where additional quarantine measures or additional precautions need to be taken. For example, if a healthcare worker has unprotected exposure to a SARS patient -- for example. while inserting a ventilator tube for mechanical ventilation, which would be a procedure that could involve direct face-to-face contact with infectious body fluids -- there may be additional steps for those healthcare workers to take during a period of potential incubation to be absolutely sure that they don't acquire the infection or don't have a risk of passing it on to others. So we have already provided some advice for managing potentially exposed healthcare personnel, but we are going to be asking for input today and this week to see whether or not there are additional steps that should be taken to assure that we're doing everything we can to limit any spread of this illness here in the states. But also, I would like to say that we talked a little bit about this epidemic. We still have no capacity to predict where it's going or how large it's ultimately going to be. I think the good news is that we do see effective containment in some areas, and some measures do seem to be very successful. I think we're also very sobered by the ongoing transmission in parts of the world, including Hong Kong where very, very appropriate public health steps have been taken, and yet the epidemic is continuing to evolve there. So it's too soon to predict where it's going to go. We must remain vigilant here. The last thing that we can do at this point in time is relax and say, well, thank goodness we don't have very many probable cases in The United States and, therefore, maybe we're not ever going to have any subsequent spread so that we don't need to be doing the things that we're doing now. This is exactly the time where we need to continue to do what we're doing and learn our lessons from what we are observing in the other countries who are working on this problem. And I would say -- just not entirely parenthetically -- that the Canadian health officials are doing an absolutely outstanding job in Canada. Today, a team of experts from CDC have gone, at the invitation of Health Canada, to provide additional technical support for the efforts underway in Toronto, and these individuals will be specifically focusing on protection in the healthcare setting and looking at the kinds of isolation and safety precautions that would be most useful there. We have also a large number of evaluations and assessments going on at CDC in conjunction with our state and local health partners across The United States -- as well as in conjunction with the WHO teams in the various countries that are affected. And these projects are really trying to answer some of the really important questions that will help us understand where is this going to go and why is it unfolding the way it's unfolding. Some of those questions include -- why are some patients apparently more infectious or more capable of serving a source of infection to others than most patients are? How long does a person remain infectious after they acquire the illness? What are the factors that determine who gets very sick and develops the full-blown pneumonia and who has the relatively mild form of the illness? What's the long-term followup of patients who have recovered from SARS? Do they fully recover? What is their health status on an ongoing basis? And I think, also importantly, what are the things that we as a public health agency can do to be effective at communicating common sense and prudent recommendations from a public health perspective without causing unnecessary fear and panic or overreaction in the public? And what can we be doing to address the stigma and the bias that's still ongoing in some of the affected communities? So we are working very hard to get these questions answered. At the same time, we're working with the private sector and our partners in the federal government to continue to test anti-viral compounds and to initiate additional strategies for identifying a test protocol for the infection. A lot of progress has been made very quickly, but there still is a great deal to learn and a great deal to do. And unfortunately, we're not out of the woods yet. So we will be continuing to provide you updates on an ongoing basis as we move forward. Let me take some questions now from the reporters on the floor -- Marin (ph). MARIN MCKENNA, REPORTER, "ATLANTA JOURNAL-CONSTITUTION": Thanks for doing this. Marin McKenna, "Atlanta Journal-Constitution." Two questions springing from the outbreaks in Hong Kong and Toronto. First, Health Canada is saying today that they've been given results of the study conducted by CDC that indicates that the SARS virus survives on surfaces for up to 24 hours, and I'm wondering if you could address that study and tell us some more about those results. And secondarily, both Toronto Public Health and the Hong Kong Department of Health have said that they're seeing very high rates of diarrhea in their patients, 24 percent in Toronto and over 60 percent in the Aimway (ph) Gardens outbreak in Hong Kong. And I'm wondering whether you are contemplating making any changes in your case definition or addressing that particular aspect of the clinical presentation. GERBERDING: Thank you. Before I answer your question, I just wanted to alert the people who are trying to call in on the phone that we understand there has been some delay in reporters being able to access through the phone system, so we'll take that into consideration and do our best to make sure they get a chance to queue in for Q&As. With respect to the your question about the longevity of Coronavirus on surfaces, we've known for a long time that Coronaviruses can survive on external surfaces for several hours. And I'll ask Dr. Hughes to amplify the data on that particular point from the NCID perspective. While he's preparing to do that, I'll take your other question -- which relates to diarrhea. We have known that diarrhea could be a symptom of this illness from the very first cases that were presented. I think the initial report showed something like a 10 percent prevalence of diarrhea in the early reports. Coronaviruses in many animal and bird species, actually, primarily cause gastrointestinal infection and diarrhea so it's not surprising to see that in here. The problem is, like some of the other symptoms, diarrhea is a very nonspecific finding. I'm not aware that we've seen it as the only presentation. So it's part of the constellation of the fever and the respiratory illness. A variable proportion of patients have also had diarrhea, and I think that is worth noting and something that we'll be looking at in our case control studies to see whether that correlates with any clues about how it's being spread or what the risk factors for severe disease are. But for right now, it's not in and of itself an important component or an indication for changing the case definition. Let me introduce Dr. Jim Hughes, the director of the National Center for Infectious Disease, who will provide some more perspective on the first question. DR. JIM HUGHES, DIRECTOR, NATIONAL CENTER FOR INFECTIOUS DISEASE: Yes, thank you. The question relating to environmental survival of Coronaviruses -- there has been limited studies over the years looking at other Coronaviruses that cause colds in humans, and reports have indicated that one of those viruses has been able to survive on a surface for up to three hours and the other one for up to an hour. That was one study. There is work now in WHO collaborating laboratories -- and some of them looking at persistence of this agent. We haven't done that yet here ourselves. But in one of the other WHO labs, that work has been done that suggested perhaps a longer period of survival in the environment. But I understand that study is actually being repeated at the moment. So I would say -- stay tuned. We don't have definitive data yet. But it is an important question that needs to be addressed. GERBERDING: Take a question there. JOHN SHIREK, REPORTER, WXIA, CHANNEL 11, ATLANTA: Thank you, Dr. Gerberding. I'm John Shirek with WXIA, Channel 11 in Atlanta. Regarding your information about the notices that are going out to travelers at the airport in Toronto, what consideration have you had about giving notices to people who are traveling to some of the affected areas -- for example, people here at Hartsfield Airport who might be going to Toronto or Singapore or Hong Kong? GERBERDING: There is a difference between the message that's for the outbound passengers -- as opposed to the message for the inbound passengers. The yellow alert card that looks like this is the standard format that we're using for arriving passengers. And this is the message that says you've been someplace where SARS is a problem, and if you get sick, see your clinician. And likewise, there is a message to clinicians here. In addition to that, CDC and the State Department issue various kinds of advice to outbound travelers. One kind of advice is called a health alert. And that's just simply a heads up. There's a health problem in the area where you may be traveling. You need to be aware of it. Perhaps there are some special things that you need to do to protect yourself if you're going there. And we have issued a health alert to travelers to Toronto, Canada. And that health alert basically says -- no reason to stay home. But if you're going there, be aware that SARS is present in some settings in the community and you may wish to avoid the hospital environment or the health care environment, for example, because that's one of the places where there has been transmission. So it is not advice to not travel but it's simply information and some practical measures that people can do to protect themselves. A different level of advice to outbound passengers is a travel advisory. And we also have travel advisories for SARS. These are now in effect for China, including mainland China, as well as the Hong Kong special administrative region, Hanoi, and Singapore. And these outbound advisories right now are saying please avoid non-essential travel to these areas because there is ongoing transmission in the community that is not linked back to the initial cases. We can't exactly predict where the cases are present or where the hazard might be. And, therefore, it's in your best interest to not go there if you don't need to. Let me take a telephone question, please. UNIDENTIFIED FEMALE: And thank you. And we do have a question from the line of Helen F. Brunzwell (ph) with the Canadian press. Please go ahead. HELEN F. BRUNZWELL (PH), REPORTER, CANADIAN PRESS: Thank you very much for taking my call. You sent a team of people up to Toronto today, I guess. A couple of weeks ago, the Toronto health authorities were saying that they were asking -- had made a request a couple of times to have assistance from the CDC and that hadn't been acquiesced to. And I'm wondering what's the difference now. I'm also curious about the Coronavirus. We heard this morning from the head of the National Microbiology Laboratory in Winnipeg -- that they're only finding evidence of Coronavirus in about 40 percent of speciments from people who have probable or suspect SARS, and they're finding it in some people who don't have any signs of the disease. So I'm curious if you could give us an idea of what kind of figures you're finding in your labs and why you seem to really really believe that the Coronavirus is the causative agent. GERBERDING: First, to answer your first question, which is the timing of the arrival of the CDC teams in Toronto. First of all, very early on Health Canada from a national perspective assigned a Canadian to the operations center at CDC, and we, in turn, subsequently assigned a CDC employee to work in the operation in Canada so that we would have a communication exchange and be able to share information rapidly. In addition, there was, at various levels, some requests from Toronto for CDC technical assistance, but our system of exchanging scientists works through the federal government in Canada, and so Health Canada made a request to have additional technical assistance, and we are certainly willing to do what we can in any way that we can to assist. So it's a difference between working through the province and working through the national system. And our responsibility at CDC is to work through the federal health officials in Canada. With respect to the second question about the association of Coronavirus and the condition known as SARS, there are several reasons why not all patients have evidence of Coronavirus. First and foremost is probably because they don't have SARS and they don't have Coronavirus infection. They have some other respiratory illness that's caused by something else. Another explanation is that although we have tests that can identify it when it's present, we don't know how sensitive they are. If they are not very sensitive, there may be patients who really have infection but the test is negative because it just doesn't have the sensitivity to pick it up. Another reason is the timing of the specimens. We know, for example, even with influenza, which is an illness that we have very good tests for, if we don't do certain tests early in the course of influenza, the tests are too negative. They're just simply done too late. So there are many reasons and, of course we want to get answers to those questions. One test that will probably help us out in the long run is the antibody test because, in general, antibody tests are a good marker of actual infection with an agent, but these tests don't tell us that information until several weeks after the infection is already present. So it's going to take us awhile to get all those samples and put all of the different test results together with the clinical conditions of the patient and come up with a more precise understanding of the utility of the test but also the spectrum of illnesses that present with the SARS syndrome, which may or may not actually be caused by this virus. Let me take another telephone question. Then, I'll come back to the reporters on the floor. Thank you. Question from the phone, please? UNIDENTIFIED FEMALE: Yes, ma'am. And we do have a question from the line of Kelly Patrick with the "Toronto Globe and Mail." Please go ahead. KELLY PATRICK, REPORTER, "TORONTO GLOBE AND MAIL": (UNINTELLIGIBLE) tell me a little bit more about your plans to issue advisories at the land crossings -- as opposed to just the Toronto International Airport. If you would tell me where you intend to issue those handouts and when you intend to start doing it. GERBERDING: Yes. The question about the health alerts for travelers coming to the United States from Ontario and Toronto. The airport has been doing this for some time, and we will be initiating at land crossings a form of alerting that will utilize the same card and the same information. There are two very large bridges between Ontario and the U.S. I think those are in Detroit and Buffalo. And there are two smaller major thoroughfares where the majority of traffic back and forth moves. And so those four intersections between the two countries will be the primary place for distributing these health alerts. At least that's the plan right now. It's going to take a little while to get these organized and printed and moved and translated and get the mechanisms up in place to distribute them. But if we -- if all goes as we plan -- we should be able to initiate that later this week. Let me take a question here. BETSY MCKAY, REPORTER, "THE WALL STREET JOURNAL": Thanks, Dr. Gerberding. Betsy McKay from "The Wall Street Journal." I was wondering if you could update us on the question of treatment -- if you could give us a little more detail about what treatment options are being considered in terms of anti-virals and what, if anything, seems promising. Along with that question, there seem to be some reports from Hong Kong that the treatment of ribavirin and steroids may be harming some patients more than helping them. I am just wondering if you could comment -- anything you know about that. GERBERDING: Right now, we don't have any scientific evidence to suggest that any form of specific treatment for SARS is effective. There were initial reports primarily from Asia that seemed to indicate patients might do better if they'd receive ribavirin and steroids. But in retrospect, that was very anecdotal information and probably not supportable by the broader experience that they've been having there recently. And ribavirin is a drug that does have some serious side effects -- including hemolytic anemia and other complications. We also know from the early results of the viral testing studies that there doesn't seem to be any activity of ribavirin in the methods that are being tested right now against this particular Coronavirus. So far, we don't have any leads on an anti-viral compound. But the Department of Defense laboratory and the NIH are working in partnership with us to look at as many compounds as we can very quickly. And so, if we get any clinically promising compounds, we will -- of course -- work hard to get them into a clinical trial or an investigational drug protocol so that we can check them out. This is not going to happen fast. I think there was a question here also. TRACY FLANAGAN, REPORTER, FOX 5 NEWS, ATLANTA: Yes. Hello, Doctor. I'm Tracy Flanagan with Fox 5 News in Atlanta. I have two questions. First of all, could you hold up the yellow card again so we can get a shot of that? GERBERDING: We can even give you one. The yellow card looks like this. It comes in several languages. And the cards that are in print right now have expanded from the various Asian languages that are on here to include Spanish and French as well so that we're trying to get them out in as many different formats as possible. FLANAGAN: The other question I had was... PHILLIPS: The last thing we can do is relax -- those words from CDC chair, Dr. Julie Gerberding. If you're just tuning in, you've been watching a live press conference from the CDC in Atlanta, Georgia. It continues to be an uphill battle. That's how officials are describing this attempt to get a handle on the spread of SARS. Just can't predict where it's going, according to Dr. Gerberding. Right now, China and Hong Kong report at least 10 more deaths from the Severe Acute Respiratory Syndrome. Just today in The United States, we're told, there have been 39 suspected SARS so far. No deaths reported.   ET



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