28 March 2003
U.S. SARS Patients Getting Better, CDC Reports
(Fast spreading virus still cause for great concern) (4620)
Officials with the U.S. Centers for Disease Control and Prevention
(CDC) reported March 27 that some 50 U.S. patients suspected of having
severe acute respiratory syndrome (SARS) are improving, and do not
appear to be developing the serious pneumonia that has taken the lives
of patients in Asia and elsewhere.
That said, SARS is still "a very severe illness," according to Dr. Jim
Hughes, director of the CDC's National Center for Infectious Diseases.
At a CDC briefing held at the agency's Atlanta, Georgia headquarters,
Hughes said the disease's potential to escalate into a fatal condition
and its rapid transmission to 13 countries demonstrate "the complexity
of the situation and the nature of the global microbial threat."
CDC officials counted 51 cases of suspected SARS in the United States
as of March 27. The World Health Organization reports 1,485 cases
developing worldwide from February 1 to March 28, with 53 deaths. The
global numbers made a dramatic leap March 27 because of a report from
China that close to 800 cases and 31 deaths had occurred in Guangdong
Province since February. Chinese health officials had earlier
described the occurrence of a condition similar to SARS infecting
several hundred patients starting last November, but reported that the
outbreak had abated.
An international coalition of medical experts and agencies has been
involved in the effort to identify the cause of the disease. Consensus
seems to be building in favor of a hypothesis that originally emerged
from CDC and has since been substantiated by other laboratories'
findings. The leading theory now is that SARS appears to be caused by
a previously unknown virus of the corona virus family -- related to
the cause of the common cold.
Hughes remained cautious about the certainty of that analysis at his
briefing, and said the investigation continues. Besides identification
of the cause, researchers are also attempting to develop a test to
confirm a diagnosis of SARS. When that is achieved, Hughes speculated
that some cases included in the current count will be disqualified.
CDC has further information available at
http://www.cdc.gov/ncidod/sars/
Global information on the disease is available at
http://www.who.int/csr/sars/en/
Following is an excerpt of a CDC briefing transcript:
(begin excerpt)
U.S. Centers for Disease Control and Prevention
CDC Telebriefing Transcript
Update on SARS and Smallpox Vaccine Program
March 27, 2003
MS. TELFER: Good afternoon and thank you for waiting. I'm Janet
Telfer, Acting Director of Media Relations for the Centers for Disease
Control and Prevention, and we welcome you to what is becoming a
continuing series of news briefings on breaking news and updates
related to severe acute respiratory syndrome, or SARS, and smallpox.
Today, we're bringing you two topics. First will be severe acute
respiratory syndrome. Then we'll break at 12:30, switch speakers, and
bring you an update on smallpox. . . .
I'd like to introduce Dr. Jim Hughes, who is the Director of the
National Center
for Infectious Diseases.
DR. HUGHES: Thank you very much, Janet. Good afternoon, everyone.
Thank you for coming and thank you to the others for dialing in. CDC
continues to work with the World Health Organization and other
national organizations to investigate an ongoing emerging microbial
threat, referred to as SARS. This is a major challenge, but is also an
excellent illustration of the kinds of threats that microbes can pose
and the rapidity with which they can move around the world.
The number of cases of suspected SARS continues to grow, both in the
U.S. and worldwide. In the United States today we're reporting 51
suspected cases of SARS. That would be an increase of six cases from
yesterday, from 21 states. And increase of one from yesterday. So far,
happily, there have been no deaths attributable to SARS in patients in
the United States.
Of these 51 cases, 44 are associated with travel to areas where we
know transmission is occurring. Five cases are occurring in people who
have had contact with people who are ill with SARS, and there are two
health care workers who are I'll as a result of caring for one patient
with a suspected case.
Internationally, WHO is reporting 1283 suspect or probable cases,
exclusive of those from the United States. Now, I've not yet seen
today, because of the timing of the conference, the case counts for
WHO today. So I would urge you to consult with their website this
afternoon for an update on that information. Those cases come from 12
countries and a total of 14 geographic areas that have not changed
from yesterday.
There are a total of, the case fatality ratio for cases
internationally is 4 percent.
We're encouraged that many of these patients with SARS are improving
over time. In spite of that, we know that this is a very severe
illness. We know it is causing great concern for patients, for family
members, and for health care workers. So, it is quite understandable
that people are concerned about this, and I'd like to assure you that
we and the World Health Organization and national authorities are
doing everything possible to move this investigation forward, just as
rapidly as possible.
CDC is participating on teams assisting in the investigation in Hong
Kong, in Hanoi in Vietnam, and Taiwan, and in Thailand. We're also
conducting very active surveillance and prevention activities in this
country, working with numerous partners at the state and local levels
of clinicians and public health officials.
We've set up a special investigative team here in Atlanta to focus on
international aspects of this investigation, which is quite
complicated. And I would refer all of you to the morbidity and
mortality weekly report article that's released today and will be
available on the web.
For those of you in the room, there's a figure that appears in that
MMWR. And what this figure shows is the linkage of many of the cases
of SARS, certainly not all, but many of the cases of SARS, to a
specific hotel in Hong Kong. When you have a chance to look more
closely at that figure, you'll be able to see how patients infected
with whatever it is that is causing SARS through their travels moved
this infection to other countries. Again, a very vivid illustration of
the complexity of the situation, but also the nature of global
microbial threat.
Much laboratory work continues here at CDC and in a WHO-supported
network of laboratories working worldwide, to continue to try to sort
out the cause of this illness. The evidence in favor of this illness
being caused by a previously unrecognized virus in the group of
viruses known as corona viruses continues to mount. I'm not prepared
that we're ready to say it's definitive evidence yet. Much work
remains to be done. But the preponderance of the evidence as it
evolves here and in other laboratories around the world is consistent
with a previously unrecognized corona virus playing an important role.
We have taken action to meet aircraft returning to the United States,
bringing passengers to the United States from other parts of the world
where SARS is occurring. We're providing disembarking passengers with
information in terms of the nature of the illness and what to do if
the individuals develop such an illness. This is part of our overall
national surveillance effort on the one hand, and reflects our
interest in early-case identification, so that proper infection
control measures can be implemented.
With that in the way of a quick overview, let me stop and open this to
questions, and we'll try and alternate between people in the room and
people on the phone.
Let me take the first question here in the room.
QUESTION: Thank you, Dr. Hughes. Betsy McKay [ph] from the Wall Street
Journal. I have a couple of questions. One, I'm just wondering at this
point, with about 50 deaths around the world, and 13 or 14 hundred
people I'll, could you put this outbreak in context for some other
outbreak? You know, how large is it compared with other outbreaks?
What particularly raises the alarm felt here versus, say, a simple flu
outbreak?
Secondly, I understand there is a movement to rename this disease from
SARS to CPD, I believe? And or CVP. And I wonder if you could just
comment on whether you all have adopted that name, as well. Thanks.
DR. HUGHES: Okay. Thank you. Several questions there.
First, the size of the outbreak. This outbreak is obviously no where
near as large as the global epidemic of HIV infection, for example.
Nevertheless, it is certainly significant. A number of people have
been infected, the case counts continue to increase. This is an
infection that certainly is contagious, though it does appear that
proper, prudent infection-control products and practices can
dramatically reduce the risk of transmission. So, although it's not
huge, it's getting bigger and it has the potential to get bigger still
if it is not aggressively addressed.
I would take some issue with your comment that influenza outbreaks
were simple. Influenza outbreaks are actually quite complicated. And
I'll use this to remind everybody that you've heard us and others talk
about the stress posed by the next pandemic or worldwide epidemic of
influenza. And this is a good example of many of the issues that we
would face when the--we will face when the next influenza pandemic
begins.
In terms of what this will ultimately be called--ultimately, if we can
agree on the virus causing this syndrome, assuming it is a virus, that
virus will have a name and the clinical syndrome will have a name. I
think we're still learning as we go. Evidence is accumulating. I
think--my personal reaction is that any name right now that includes
pneumonia is too--that limits the syndrome to pneumonia is too
restrictive because at least many of the suspect cases in the U.S. so
far don't have evidence of pneumonia. So I would say stay tuned on
virus identification, virus name, and syndrome name.
CDC MODERATOR: Given the number of callers on the phone, we're going
to take our next two questions from the telephone.
MODERATOR: We do have a question from the line of Seth Borenstein with
Knight Ridder. Mr. Borenstein, your line is open if you have a first
question.
QUESTION: Yes, thank you so much for taking this. In terms of the
growth of the outbreak, there was a lot of hope a week or so ago that
it was starting to peter out. And even if you take out the Guangdong
numbers, it doesn't seem to be the case. Can you address the issue of
whether you think this--whether with the infection control that's out
there, do you feel like you're getting a handle on stopping its
growth?
And then the other question I have, obviously 50 is a small number in
the U.S., but is it unusual that we haven't seen any deaths or
extremely critical ill patients, given the mortality rate?
DR. HUGHES: Well, first of all, we're extremely gratified that we've
not seen any deaths from this syndrome in this country. Now, remember,
we're working with a surveillance case definition. And that case
definition in fact is evolving as we learn more about the illness.
What the case definition currently lacks is a laboratory component so
that we can confirm cases of SARS. When we have that and we're able to
test all these suspected cases, my feeling is that some will be
confirmed and some will be eliminated. So I know it's frustrating to
follow case counts, but you're going to have to bear with us on this.
In terms of changing numbers internationally, there's the potential
for swings there in part because of the recent report from China with
reference to Guangdong Province, and the number of total international
cases increased dramatically yesterday with the reporting of those
cases from Guangdong. I would also just remind you that there's a
WHO-led international team that we at CDC have two individuals
participating in, working with Chinese colleagues in Beijing right
now, looking at much of the data that they have developed over the
past few months. So I would just say stay tuned, watch the WHO
website, watch our website, and you may well see some changes in these
numbers in the near future.
MODERATOR: We have a question from the line of Jeremy Manier with the
Chicago Tribune.
QUESTION: I apologize. Could I pass and save my question for smallpox.
MODERATOR: Thank you. We have a question from Laurie Garrett with
Newsday.
QUESTION: Is anybody talking about or trying to initiate any kind of a
case control study anywhere that might begin to answer some questions
about transmission and, you know, explain how transmission might have
occurred in the hotel, for example.
And the second is, Jim, we've talked about it before; I want to ask
you again about these two clusters and then scattered reports across
the country of sudden onset pediatric respiratory deaths in American
children that occurred in January and February and whether or not CDC
is actively investigating any possible link to SARS.
DR. HUGHES: Thank you, Laurie. Let me address the questions in the
sequence you asked them. First of all, your question about case
control studies is an excellent one. As with any evolving, emerging
infectious disease, there are many research questions that are raised
immediately. Some are critically important in the short terms; others
are critically important in the longer term. But right now, much of
the focus is on better definition of the precise mode of transmission
of this agent and the risk factors for transmission. So yes, we are
working, in the United States particularly, to look at health care
workers and household contacts to see if we can better define risk
factors for transmission in those settings. Similarly, in the
international setting, case control studies and other studies are
being organized and are getting under way.
In terms of the clusters of unexplained deaths associated with acute
respiratory infections--and there were at least two that we were
involved in, going back six, eight weeks ago in the U.S.--severe
unexplained infectious disease-like illness occurs not infrequently in
the United States and around the world. Many people haven't in the
past realized that even with aggressive diagnostic workups for people
that die with syndromes that look like they may be infectious, you're
often lucky if you find cause in maybe half of the cases. So there are
other unknown causes of infectious diseases out there.
When clusters occur, we assist state and local authorities in
investigating them when we're asked to do so. We recently did that in
two different states. We were able to identify the cause in many of
these cases as being influenza, and in one case Group A streptococcal
disease.
Now, for those who didn't have an explained etiology, we do have
specimens remaining, and as time goes on we will be looking back to
see if there was any evidence of this disease occurring in the U.S.
prior to early February.
MODERATOR: We have a question from Jennifer Coleman [ph] with KYM-TV.
Ms. Coleman, your line is open. Do you have a SARS question?
QUESTION: Yes. I think you touched on this a little bit. I know that
right now there's only 51 suspected cases in the U.S., but how are the
cases in the U.S.--I mean, I guess I'm just wondering if it's better
medical care or if--you know, why there's no deaths at this point
reported.
DR. HUGHES: Well, we're concerned that there are as many as 51 cases
in the U.S. We're extremely pleased that there have not been any
deaths. I suspect in part that reflects early recognition and good
clinical management and we continue to urge good, prudent
infection-control practices as well. We haven't had very many of these
suspect cases having real severe disease, fortunately. Of the 51, 14
have had pneumonia and only one has required ventilatory support with
a respirator.
So we're seeing among our suspect cases milder illness overall than
people in Asia are encountering. So we're fortunate in that, but I
think we're also fortunate that we're well-positioned to provide good
clinical care to the patients who need it.
MODERATOR: We have a question from Robert Bazell from NBC News. MR.
Bazell, your line is open. Do you have a SARS question?
QUESTION: Thank you. Dr. Hughes, since the emergence of HIV and other
than influenza, have you had an emerging infection that you can recall
that's caused you so much concern?
DR. HUGHES: Well, there was that one that you recall, Bob, as well as
I do, back in 1993, Hantavirus Pulmonary Syndrome. That was a severe,
unexplained, acute respiratory disease that was recognized in
previously healthy young people on the Navajo Indian Reservation in
the Southwest. That was astonishing, to say the least, in a similar
way that this current outbreak is astonishing in terms of its
complexity and challenges.
These microbes have continually illustrated that they will continue to
challenge us. You'll never see better examples than that Hantavirus
situation and the current situation to drive home the important points
made by the recently issued medicine report on global microbial
threat, which points out the critical need to continue to rebuild
global response, global surveillance and national and local infectious
disease surveillance and response capacity, and to address the many
research questions, the training needs, and the communication issues
that these challenges pose.
CDC MODERATOR: Next question, please.
MODERATOR: We do have a question from the line of Maggie Fox at
Reuters. Miss Fox, do you have a SARS question?
QUESTION: Oh yes. Thanks, Dr. Hughes. The authorities in Hong Kong
seem to be a lot more confident than you are that corona virus is to
blame. Can you address that and the possibility that the corona virus
and the paramyxovirus may be acting in concert?
And also how unusual is it to find samples of both these viruses in
tissue?
DR. HUGHES: Okay.
Let me say that I thought I had said earlier that the weight of the
evidence, as far as we're concerned, continues to build in support of
the corona virus having a causative role in this syndrome. We're not
ready to be totally definitive about that? There is more work to do.
You have to be cautious. It doesn't do anyone any good to jump to
conclusions prematurely when you're investigating a problem as
complicated as this.
Labs in many countries now have found evidence of corona virus
infection in these patients. That's in contrast to just a few days
ago, you may recall when metapneumovirus was clearly the leading
candidate. I would say corona virus likelihood is going up;
metapneumovirus likelihood is probably going down. We're not willing
to take it off the table yet. We keep an open mind in these things.
And the possibility of their being some co-infection, at least in some
patients, and have that play a role in the overall presentation of
this illness has to be kept in mind.
CDC MODERATOR: Next question, please.
MODERATOR: We do have a question from the line of Larry Altman with
New York Times. Mr. Altman, do you have a SARS question?
QUESTION: Yes. It was along the lines of Maggie's question. But could
you put this in a little more perspective in terms of the evolution of
paramyxo and then the subset of metapneumovirus, and then the
emergence of corona virus. Can you just outline the steps as how this
has evolved over time?
CDC MODERATOR: Jim?
DR. HUGHES: Yes, thank you, Larry.
Actually because Dr. Larry Anderson is here and is an expert in both
these groups of agents, let me seize the moment and ask Larry to come
up and make some comments.
DR. ANDERSON: Thank you.
It's actually been a very interesting progression of laboratory and
clinical and epidemiologic findings. I think some of the early
suggestions came from electron microscopic studies, when they noted
paramyxovirus-like particles in respiratory secretions. Around that
time they also identified evidence of the human metapneumovirus in
respiratory secretion specimens in Hong Kong. This virus has also been
identified in specimens from some other countries as well.
We pursued that, but continued to look for other agents. A group in
Hong Kong and Germany identified some other particles and secretions
that were suggestive of probably not a paramyxovirus by size. And we
and other groups isolated or found evidence of cytopathic effect in
tissue culture material. Our electron microscopist identified corona
virus-like particles in this tissue culture material. We then used
molecular techniques to look at the genetics of this virus and
confirmed that in fact it was a corona virus. And then developed tools
to look at additional specimens, and then provided the tools for other
laboratories to look at this finding as well.
So that's been the progression. And I think as in any investigation,
you develop hypotheses and then test the hypothesis to see if it fits
with the clinical and epidemiologic characteristics of the disease,
and we're kind of trying to finish up the linking to disease at this
point.
DR. HUGHES: So let me just follow on and point out again to remind
everybody, this remains a work in progress, and there will continue to
be new data and new observations that are important that will be made.
CDC MODERATOR: Next question, please?
MODERATOR: We do have a question from the line of Bob Stein with The
Washington Post. Mr. Stein, do you have a SARS question?
QUESTION: Yes. Thank you very much.
I'm trying to get a little bit more information about the 51 suspected
cases. First of all, I was wondering, are they all being held, or kept
isolated? And if so, is it homes, or in a hospital? And of the five
cases that appear to have been the result of close contact, were they
all family members, or were they some other kind of contact?
DR. HUGHES: Okay, to get to the second question first. Three of them
were family members, and two of them were health care workers. The
infection control precautions that are recommended for these patients
are in addition to standard precautions recommended for everyone. We
call for contact droplet and airborne precautions. And that's being
prudent, because the bulk of the evidence suggests that this infection
spreads through close contact between patients and others who are
unaffected.
We have to keep an open mind here in terms of exactly how this
transmission occurs. Whether it's by physical contact or by large
droplets that spread over short distances, or possibly through
contamination of articles in the inanimate environment that might be
handled. And then finally we have to keep open the possibly that this
is transmitted at least in some cases by the airborne route. There's
no evidence of that today but we are keeping a very open mind in that
regard, I assure you.
So patients that are ill with this syndrome are kept on these
isolation precautions throughout the course of their hospitalization.
And because we just issued, last night, some additional infection
control guidance, and because Dr. John Jernigan from our Division of
Health Care Quality Promotion is here with us today, let me ask John
to come up and just briefly comment on that one specific aspect of
your question. John?
DR. JERNIGAN: Sure, Jim. We issued some guidance last night to
hospitals in the United States on some more detail on how to handle
infection control procedures in the hospital, and specifically how to
handle health care workers who may have been exposed to patients while
they were taking care of them. And we have no reason to believe that
people can transmit this disease when they don't have symptoms. So
what we've recommended the hospital, since they close track of health
care workers who are caring for SARS patients, and do surveillance and
touch base with the very frequently to make sure that they don't
develop signs of illness. And if in fact they do develop signs of
illness, we are recommending that they probably should not be taking
care of patients in the hospital.
We are not excluding, not recommending exclusion from duty if people
do not have respiratory symptoms. Again, the weight of the evidence
that we have so far suggests that the infection cannot be transmitted
from asymptomatic people. We are monitoring that situation closely and
we are in close collaboration with our international folks who have
had a lot of experience. And the bulk of the evidence suggests that as
well.
To date, all the patients with SARS in the United States have been
either in persons with history of foreign travels, or transmission
with close contacts. And so we're pretty comfortable with those
recommendations that we put out last night for health care
institutions.
CDC MODERATOR: Given that we have two important topics to cover today,
this will be out last question on SARS.
MODERATOR: We do have a question from the line of Qeta McPherson [ph]
with Star Ledger. Please go ahead.
QUESTION: Thank you.
My question concerns the investigation itself. I was wondering, Dr.
Hughes, for my readers who are not scientists, what tools do you have
at your disposal this time that you didn't have when the AIDS was
breaking out, and maybe even more recently? And does this reflect an
investment that's more towards bioterror precautions?
DR. HUGHES: Thank you. I thought you were going to ask, perhaps, what
tools do we have today that we didn't have back in 1993 when we
encountered the Hantavirus situation. But you went way back 23 years
ago to the recognition of HIV infection. And you might recall that it
took three or four years to identify the cause of that syndrome. So
keep that in perspective.
We have much more sophisticated tools today at the national level and
at the state level and in clinical laboratory settings to diagnose
infections disease as compared to, certainly, the situation 23 years
ago. We've made dramatic progress. The Institute of Medicine report
that I mentioned points that out, but it also emphasizes the fact that
we need a much broader array of diagnostic tests. In many cases of
pneumonia, a positive agent is only found in roughly 50 percent. And
many of these tests that do exist take a long time to conduct.
One of the major problems that we're facing nationally and globally
now, if you move SARS, is the problem of antimicrobial resistance. I
mention it because it's a big problem for clinicians and public health
officials. But it also is one that illustrates why it's so important
to continue research to develop rapid, sensitive, specific diagnostic
tests that can be used both in clinical and public health settings.
So yes, we have better tools today. We don't have all the tools that
we need to sort these things out as rapidly as we need to. And we
don't have all the highly trained people with the range of skills
needed to address these issues that we need as well. So keep that in
mind.
Let me stop there. Thank you all very much for your continuing
interest, and again, I ask you to stay tuned.
(end excerpt)
(Distributed by the Office of International Information Programs, U.S.
Department of State. Web site: http://usinfo.state.gov)
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