CDC News Conference Transcript

First Reported Rabies Transmission from Organ Transplants

July 1, 2004

OPERATOR: Good afternoon and thank you all for holding. I’d like to remind parties that your lines will be in a listen-only mode until the question and answer portion. At that time, you will be able to press star one to ask a question. Today's call is being recorded. If you have any objections, you may disconnect at this time. Now I will turn the call over to your moderator, Mr. Tom Skinner. Thank you, sir. You may begin.

MR. SKINNER: Thank you, Rose, and I want to thank all the reporters who have taken time to join us here today. What we're going to be doing is having Dr. Mitchell Cohen, the Director of CDC’s Coordinating Center for Infectious Disease, provide you a brief overview on something that CDC’s reporting today, and that’s the first cases of rabies transmitted through organ transplantation.

Dr. Cohen will provide a brief overview of the situation to date, and then we will take your questions and answers. Also joining Dr. Cohen will be Dr. Virginia McBride, a public health organ donation specialist with the Health Resources and Service Administration, and Dr. Daniel Hayes, an organ transplant expert at United Network for Organ Sharing. At this time, I’ll turn the call over to Dr. Cohen.

DR. COHEN: Thank you. And thank you all for joining us today. My name is Dr. Mitchell Cohen, and I'm the Director of the Coordinating Center for Infectious Diseases here at CDC. CDC is working with a number of states to investigate the circumstances around the deaths of three individuals who died after receiving organs from a person who had rabies. This is a very sad and tragic situation, especially for the families of those who lost a loved one. It's also very scary for all the health care workers and family members who may have come into contact with the disease and who are concerned about their health. But they should know that CDC is working with the hospitals and the state health departments in four states involved to make sure they're taken care of. Let me tell you what we know now. The organ donor was a previously healthy male Arkansas resident, who presented to a hospital emergency department in Texas with severe mental status changes and a low-grade fever. The neurologic imaging revealed a brain hemorrhage, which progressed and caused the person to die 48 hours later. Donor eligibility screening and testing degree did not reveal any

contraindications to transplantation, and the family agreed to organ donation. The patient's lungs, kidneys and liver were donated. The liver and kidneys were transplanted at a transplant center in Texas on May 4th. The lungs were transplanted into a patient in an Alabama hospital, who died during the procedure. The three transplant recipients were later hospitalized with various symptoms, including lethargy, seizures, hypertension, respiratory problems and

neurologic symptoms. The hospitalizations were in their respective home states. All three patients subsequently died. After a series of laboratory tests over the past several weeks, CDC confirmed yesterday that all three transplant recipients were infected with a strain of rabies commonly found in bats. CDC is working with all the states and hospitals involved to determine who came in contact with the donor and the recipients and who might need shots to prevent rabies. Let me be clear here. We are learning as we go. And as new information is made available, we will provide it to you. This has never happened before. Human rabies is extremely rare, and we see only a few human cases each year. And that is usually in people who are bitten or scratched by certain types of bats and who often don't know it. The risk of health care-associated transmission is considered to be extremely low, and transmission of rabies virus from infected patients to health care providers has never been documented. Human-to-human transmission of rabies among household contacts is also very rare and has been reported in only two cases, both in Ethiopia, and neither case was laboratory confirmed to be rabies. In both cases, the route of transmission was reported to be direct contact with saliva, a bite and a kiss. In addition, no cases of rabies have been reported in association with transmission by environmental sources. However, as a precaution, we are examining the exposures of some people, and we'll determine whether or not they need to receive shots to prevent rabies. Before I close, I'd like to add a few very important points. Once again, this has never happened before, but we need to do whatever we can to prevent it from happening again. The Health Resources Services Administration will be carefully reviewing what happened and working with CDC to see if are there steps that can be taken to further reduce this very small risk. It's also important to remember that organ donation saves thousands of lives each year. And there are thousands who are waiting for transplants that will die if they don't receive them. The consequence of not receiving a donation far outweighs the risk of acquiring a disease. Health and Human Services Secretary Tommy Thompson has made organ donation a high priority in this department, and I hope we all take and encourage others to take this life-saving step. Thank you.

MR. SKINNER: Rose, with that, I think we'll take questions from the media, please.

OPERATOR: Thank you. At this time, if you would like to ask a question, press star, followed by one on your touch-tone phone. You will be announced prior to asking your question. If your question has been answered, you may withdraw your question by pressing star two. One moment for our first question. Our first question comes from Miriam Falco from CNN. You may ask your question.

QUESTION: First of all, are all the doctors present M.D.s or Ph.D.s? And that's just something for me. Can you go through the -- what the patient, the Arkansas resident in Texas presented with again? I'm a little confused. Is his status something you would not normally recognize as being rabies? Is there no way to test for that, or is it just that it’s seen so rarely, he wasn't tested for it?

DR. COHEN: Well, the patient presented with an illness that was diagnosed as being a brain hemorrhage. His presentation was very consistent with that, so that rabies would not have been thought of as a likely cause of his illness.

OPERATOR: Thank you. The next question comes from Anita Manning from USA Today. You may ask you question.

QUESTION: Thank you. I have a couple questions just about rabies in general. Between the time of exposure to rabies and the onset of symptoms, what length of time is that? And I also wanted to ask about what -- when you take organs from donors, are there routine tests that are done that would have picked up rabies? I guess not. But what tests are done? And will this cause any change in the testing?

MR. SKINNER: I think Dr. Cohen can take the first question, and then we’ll ask

Dr. McBride to take the second question. Dr. Cohen?

DR. COHEN: Most cases usually occur within the first several months after exposure, but the cases actually can occur as long as one year after exposure.

MR. SKINNER: Dr. McBride?

MS. McBRIDE: If the questioner actually knows that I am not Dr. McBride, that I am a Masters-prepared nurse, which I think is worth two doctors on any given day. But I do want to let you know that screening for organ donors, routine screening is for HIV, for hepatitis B and C, for HTLV-1, for RPR, which is a test for syphilis, and the cytomegalovirus, also known CMV. Those are the tests that are done routinely on every organ donor in the United States. Testing for rabies is not routinely done on any donor in the U.S.

MR. SKINNER: Next question, please, Rose?

OPERATOR: Thank you. Robin McGlohn from ABC, you may ask your question.

QUESTION: Yes, talking about the patient from Alabama, you said he died during the procedure. Was that because of complications, or was that because of the actual rabies in the organs?

DR. COHEN: Yes, this is Mitch Cohen. That death did occur as a complication of the procedure.

MR. SKINNER: Next question, please, Rose.

OPERATOR: Thank you. Joanne Silberner, you may ask your question.

QUESTIONS: Two questions -- One is, what was the age of the Arkansas patient? And then following up on the previous question about whether testing will change, is this enough to add rabies to the list of things that you'll test for?

DR. COHEN: This is Mitch Cohen. We do not know the actual age of the patient. With respect to the issue of testing, we would be working with our partners in the other federal agencies to talk about what are the steps that are necessary to take next to look at this and make a decision.

MR. SKINNER: Next question, please.

OPERATOR: Thank you. Sherry Jacobson, you may ask your question.

QUESTION: Yes, I was wondering if you could give us the rundown again of those three patients who died and anything else you might know about them.

MR. SKINNER: As we're doing that, let's go to the next question, and we'll come back to that one.

OPERATOR: Thank you. Dr. Mona Khanna from CBS News, you may ask your question.

QUESTION: Yes, thank you. My question is, how many people may possibly be involved if you now have to screen? Is it hundreds, the health care workers and the family contacts and friend contacts? And are there any -– how many hospitals are involved?

DR. COHEN: This is Mitch Cohen. There are five hospitals that are currently involved, and the various state and local health departments, public health officials are involved in determining who are the folks who potentially would need this type of preventive treatment.

MR. SKINNER: Next question, please.

OPERATOR: Thank you. Mandy Gardner from HealthDay, you may ask your question.

QUESTION: Have you -- Are these three recipients that you're discussing all of the recipients of organs from this particular donor, and what are the actual risks for family members and other contacts?

DR. COHEN: This is Mitch Cohen again. Yes, these were the only organs that were transplanted from this particular donor. The risks for both the health care workers and family contacts are very low. But the part of the public health response is to determine whether or not there might have been the type of exposure that would indicate a need for using treatments to prevent rabies.

MR. SKINNER: Next question, please.

OPERATOR: Thank you. David Wahlberg from the Atlanta Journal-Constitution, you may ask your question.

QUESTION: Yes, hello. I’m wondering if –- what sort of questions are asked during donor screening that may ascertain whether somebody had contact with an animal or a bat? And do we know if this person, retroactively now, do we know whether he did? And, also, I'm wondering if you have any more information about age and gender of the three recipients?

MR. SKINNER: I wonder if Ms. McBride might take a first crack a question at the question.

MS. McBRIDE: Sure. All organ procurement organizations ask a series, a lengthy series of questions similar to blood donor screening, about donor past, medical and social history. It is my understanding, and Dr. Hayes might want to speak to this directly, that there are some organ procurement organizations who do specifically ask whether or not a donor has been potentially exposed to rabies. And we will be doing a review to determine whether all OPOs are engaging in this practice. Dr. Hayes, you might want to just say a few words.

DR. HAYES: Sure, Ginny. There are some OPOs that do specifically ask the question of whether or not the potential donor has been exposed to rabies or treated for rabies within the last year. Again, that is not a national standard and may be hit and miss across the country.

MR. SKINNER: Next question, please.

OPERATOR: Thank you. Susan Dentzer from “NewsHour with Jim Lehrer,” you may ask your question.

QUESTION: Yes, this is back again to the patients who died. It sounds to me, and please verify this or contradict it, that two kidneys and one liver went to the three patients in Alabama who died. Again, if you could confirm that. And secondly, if you can give us any more information, particularly names, given the high level of media interest in this case. And then finally, are you confident that you've put your hands now on all the organs and tissues from this donor, or are they elsewhere in the health care system at this point?

DR. COHEN: Let me provide a little extra information, because some of the particulars about the patients and the hospitals and potential contacts, this might be helpful in this and other questions. But let me first comment that, at this point in time, the only organs that we know of were transplanted were the ones that were identified. There were no other organs that potentially went to other recipients. So it essentially was the lungs, the liver and two kidneys. But let me also point out that CDC is working with health officials from Texas, Alabama, Oklahoma, Arkansas and other public health partners to evaluate potential contacts of the transplant recipients and the donor to determine who needs shots to prevent rabies. Those persons include family members, as well as health care workers who cared for the organ recipients and donor at the following hospitals: Baylor University Medical center in Dallas, Texas, University of Alabama Birmingham Hospital in Birmingham, Alabama, Christus Saint Michael Health Care Center in Texarkana, Texas, Wadley Regional Medical Center in Texarkana, Texas, and Good Shepard Medical Center, Longview, Texas. Individuals whose contact is determined to have placed them at elevated risk of exposure to rabies virus will be advised to receive a series of shots, which will prevent them from becoming ill and that they should receive these shots as soon as possible. The kind of contact that we’re talking about is contact of primarily with the patient's saliva. And that contact would be the contact with saliva with a wound or in a mucous membrane, for example, an eye or the nose. There is a risk if they were exposed to neural or brain tissue from these patients, but those type of risks are generally very limited to a very small group of people.

MR. SKINNER: Next question, please.

OPERATOR: Thank you. Otesa Middleton from Dow Jones, you may ask your question.

QUESTION: Yes, can you please tell me what is the incidence rate of rabies in the U.S. and describe a little bit more what the standard preventive treatment is? You said it's a series of shots, like, how many shots, where and how long it takes.

DR. COHEN: This is Mitch Cohen again. There are usually one to three cases that occur in the United States a year. It is extremely rare. The strategy to prevent rabies in someone who has been exposed, and it's usually an exposure to a bite of a mammal. That's the most common type of exposure. The strategy is to give them a shot of an immune plasma and then to give them five shots of vaccine in a 28-day period. So the strategy involves those series of shots that provide passive protection and then to generate antibodies by giving them the vaccine.

MR. SKINNER: Next question, please.

OPERATOR: Thank you. Daniel Yee from Associated Press, you may ask your question.

QUESTION: Oh, hey, thanks for doing this. I wanted to just clarify, was the cause of death in the two cases primarily from rabies? And I also wanted to ask, what can you say to reassure the public about the safety of organ donation?

DR. COHEN: This is Mitch Cohen again. The three patients who died all died of rabies. That has been confirmed. Again, this is extremely rare. The benefits of receiving organ transplantation far outweigh the risks of any infectious disease acquired through transplantation.

MR. SKINNER: And wonder if Ms. McBride might allude to the safety of these procedures.

MS. McBRIDE: Well, I think, actually, Dr. Cohen said it very well. But I think the important thing to note here is that there will always be risks associated with transplantation, but that there are nationally established policies and procedures in place to minimize that risk to the highest degree possible, to promote the safety of transplant recipients.

MR. SKINNER: Next question, please.

OPERATOR: Lynn Adrinne from ABC News, you may ask your question.

QUESTION: Thank you very much. Number one, are we talking about four patients altogether, in terms of the number of patients that died, one that died during the procedure and three others that died from rabies? And the second question is, are you doing screening in the area where the donor came from to find out whether there is a bigger problem with rabies and rabies infection in that area?

DR. COHEN: The first question was about the number of cases. There were three individuals -- there were four individuals who received organ transplantation. One of those individuals died during the surgical procedure. The other three died of rabies, and the initial donor died of rabies, as well.

MR. SKINNER: And what was your second question? If we've lost that caller, we can go back to them. Can we take the next question, Rose?

OPERATOR: Thank you. Eva Ayala from Ft. Worth Telegram, you may ask your question.

QUESTION: Yes, I wanted to clarify exactly where the donor -- what hospital the donor was, where he died. And, also, I think the other question I had just got cleared up. And, oh, how long was it from the transplants to the deaths of the other three patients after their transplants?

DR. COHEN: This is Mitch Cohen. The hospital that the donor died at was Christus Saint Michael Health Care Center in Texarkana, Texas. There was some additional information requested about the potential cases. Again, the donor was from Arkansas. The lung that came from the donor was received and transplanted at the University of Alabama at Birmingham. The liver and kidney were transplanted at Baylor in Dallas, Texas. And the liver recipient patient lived in Oklahoma.

MR. SKINNER: Next question, please.

OPERATOR: Thank you. Judith Rusk from Infectious Diseases, you may ask your question.

QUESTION: Hi. Yes, I’m in infectious diseases in children. Just to clarify, the lung went to Alabama, and the liver and kidney went to Baylor. Did the liver and kidney go to one recipient or to two? And, also, has anyone to date received any postexposure prophylaxis?

DR. COHEN: Okay, this is Mitch Cohen again. The liver and kidney went to separate patients. And in regard to a previous question, the sequence of deaths were that the liver recipient died on June 7th. The first kidney recipient died on June 8th, and the second kidney recipient died on June 21st. With respect to the question about prophylaxis, we're not certain whether or not actual prophylaxis administration has begun, whether or not people have started receiving immune plasma and vaccine. But it certainly is something that we'd like to happen promptly.

MR. SKINNER: Next question, Rose.

OPERATOR: Thank you. Larry Altman from New York Times, you may ask your question.

QUESTION: Yes, Mitch, there are several things here that are not clear. First of all, there are two lungs, and they are often transplanted with the heart. You didn't mention the heart. So was there only one lung used, or was there another lung and a heart involved? Two, what was the date of death of the donor to get the, in essence, incubation period for the recipients? And how did this all -- who made the first diagnoses of rabies? How was rabies diagnosed here? You haven't told the story here.

DR. COHEN: Okay, well, let me see if I can get all of these questions. The heart was not recovered. There was one lung that was transplant -- there were two lungs that were transplanted into one patient. Okay. The death of the donor was -- we know that the transplants occurred on May 4th. So the actual date of death I'm trying to find, but I think it's very close to that date. So the –- again, the death in the recipients were June 7th, 8th and 21st, outside of the one who died during the surgery itself. With respect to the diagnoses, since rabies was not anticipated based on the presentation of the donor, and since rabies is an extremely rare occurrence, it is not something that involves routine screening and examination. So, as part of the public health investigation of these deaths, specimens were collected and examined for various possible causes, including the presence of the virus that causes rabies. And the confirmatory tests were obtained on these individuals that demonstrated both from looking at the tissue, which gave a potential clue that this might be rabies, and then the confirmatory tests that actually showed the presence of the virus.

MR. SKINNER: Next question, Rose.

OPERATOR: Thank you. Jennifer Warner from WebMD, you may ask your question.

QUESTION: Yes, has the caused of the infection of the donor been determined? It was said it was consistent with something that would have come from bats, but has that been determined in terms of the source of infection?

DR. COHEN: This is Mitch again. No, that has not been determined. We are able to, in a sense, fingerprint some of these organisms, and the fingerprint of this particular organism would be consistent with it being a bat. And as part of the public health investigation, there will be efforts to try to determine how this exposure might have occurred.

MR. SKINNER: Next question, please.

OPERATOR: Thank you. Jim Killackey from The Daily, you may ask your question.

QUESTION: Can you release the names of all these individuals? And can you go through where each one died? But I need the names of these individuals, the organ donor, the names of all the recipients and where each one of them died and what date.

MR. SKINNER: You know, for sake of patient confidentiality, obviously we can't give you the names. And beyond what Dr. Cohen has already provided you, in regard to the information from each state, we will be coming out this afternoon with an article in our Morbidity and Mortality Weekly Report, the MMWR, that will have even more details than what Dr. Cohen's already provide. Next question, Rose.

OPERATOR: Thank you. Mitch Mitchell from Ft. Worth Star, you may ask your question.

QUESTION: How difficult would it be to implement a testing program prior to transplantation that would uncover this particular disease?

MR. SKINNER: Ms. McBride, would you like to take a stab at that, please?

MS. McBRIDE: Well, I can start, based on my knowledge of the organ donation process, but keep in mind that I am not knowledgeable about rabies testing procedures. So the CDC colleagues may have to fill in on that. But what I can tell you is that testing for organ donors must occur between the time that a donor is pronounced brain-dead and the organs are removed for transplantation. That's a very brief period of time, and we usually try to allow a window of about six hours from the time that a blood specimen is received at a lab for the testing to be complete and reported to the transplant centers prior to the donation taking place. So we have a very narrow window of time to work with. And it relies on the 24-hour availability of laboratories to perform the tests. Often, donation procedures and donation evaluations are conducted after routine hospital working hours. And we rely on labs to be available to us 24 hours a day. So if rabies testing were to take place, if that was a recommendation that came out of this, we would need to have laboratories available to us 24 hours a day, seven days a week to do that. And I don't know anything more than that about the rabies testing.

DR. COHEN: I think that once the investigation is complete, we will want to work with the other federal agencies to determine what would be the most appropriate path.

MR. SKINNER: Next question, Rose.

OPERATOR: Thank you. Marilyn Marchione from Milwaukee Journal, you may ask your question.

QUESTION: Thank you. I have two questions. First, were any other tissues harvested from this donor? And my second question is, has there ever been a documented case of rabies transmission through blood donation?

DR. COHEN: I missed the first part of your question, but there has never been any transmission of rabies by any blood products or any -- the only other transmission has been in association with corneal transplants. There have been eight other episodes of that, one of which was in the United States.

MR. SKINNER: Next question, please.

OPERATOR: Thank you. Elizabeth Suh from United Press, you may ask your question.

QUESTION: Hi. I was wondering if you would be able to, again, outline the sequence of events of everything, even if it were just the simple outline you presented us earlier. And, also, what were the involvements of the various medical centers that you mentioned? Were they the places specifically where people died, or how were they involved?

MR. SKINNER: You know, I think that that is going to be detailed in the article that will we will be putting out imminently this afternoon. We can go into those details through that article. I'd rather reserve this for other questions. Rose, next question, please.

OPERATOR: Thank you. Paul Shin from New York Daily News, you may ask your question.

QUESTION: Thank you for taking my call. Has the lung recipient -- does that recipient have rabies?

DR. COHEN: The person died during the operative procedure. So, although they would have been exposed, there wouldn't have been time for them to actually develop rabies.

MR. SKINNER: Next question, please.

OPERATOR: Thank you. Terry Murray from Medical, you may ask your question.

QUESTION: Yes, it's Terry Murray from The Medical Post in Toronto, Canada. Just -- I’ve got two questions. One is about the blood supply. Does this case, or do these cases have any implications for the blood system? And then the second question, I can ask either now or after that one gets answered.

MR. SKINNER: Go ahead and ask it now.

QUESTION: Okay, the other question is, I recognize that transplant patients and, to a certain extent, blood recipients are immunosuppressed, but is it possible to treat rabies once it becomes clinical, once the symptoms develop?

MR. SKINNER: Ms. McBride, do you want to take the first question, in regards to the blood supply?

MS. McBRIDE: No, our office is not responsible for oversight of blood.

DR. COHEN: This is Mitch again. There is not a presence of a virus in blood, so there is not a risk of transmitting rabies by blood transfusions. The other question that had to do with treatment, this disease, unfortunately, once the disease actually becomes symptomatic, is pretty close to being 100% fatal. There is no effective treatment that can be documented to show that it reversed the course once it actually begins to develop symptoms.

MR. SKINNER: Next question, please.

OPERATOR: Thank you. Miriam Falco from CNN, you may ask your question.

QUESTION: Hi. I’ve got two quick questions. Number one, was the original donor, the person who died who was from Arkansas, died in Texas, had he signed a donor card so that somebody could have taken a patient history, or did the family, after he passed away, give the okay? And then the second question I have is concerning how long he was infectious. You say it could be anywhere from a couple of months to up to a year, in which case, it seems like the window for passing this on, even though it's very rare, is quite large.

DR. COHEN: We're still finding out some of the information that you requested. The window potentially is a thoroughly large window, so that this individual could have been exposed several months prior to the onset of symptoms.

MS. McBRIDE: This is Ginny. I can take the first part of that question. Signing a donor card or joining a donor registry does not trigger an action regarding evaluation of a person, of someone who wants to be a donor for their suitability as a donor. Actions to evaluate a donor for suitability occur only after a patient has died. So a series of questions about whether the patient is a medically suitable donor and diagnostic testing are done only after death has occurred.

MR. SKINNER: Next question, please, Rose.

OPERATOR: Thank you. David Wahlberg from Atlanta Journal, you may ask your question.

QUESTION: Yeah, two quick questions. If we know that there was transmission of rabies through cornea implant, why isn't there universal testing or questions asked about exposure to animals potentially with rabies? And the second question is, you were saying there's no chance of transmission through the blood supply, but we didn't think there was any chance of transmission through organs. Does this now suggest that the virus may be in other parts of the body besides the central nervous system?

MR. SKINNER: I wonder if Dr. Hayes might want to address these. The second question at least.

DR. COHEN: I can talk about – well, here, let me, while Dr. Hayes is getting ready to answer that question. The way the disease progresses is that following an exposure, let’s say a bite. Let’s say, if the bite occurred in the hand, that the virus would reproduce and would travel up the nerves and eventually infect the central nervous system. And so the virus then could come back and involve the organs by again traveling down the nerves, but it doesn't enter the vascular system. And it doesn’t -- it isn't associated with a viremia or presence of the virus in the blood. So there isn't any evidence that that would occur in individuals who are infected with this disease.

DR. HAYES: And the answer to the first part is that, even though there was one case of a corneal recipient in this country infected, you have to remember that there are probably 40,000 corneal transplants in this country every year. There last year were a little over 25,000 organ transplants. And if you extrapolate that over years, there have been hundreds of thousands of corneas and organ transplants with only -- prior to this, only one documented case of transmission. So I don't think that such a rare event should trigger any kind of widespread panic or reaction to do testing on a disease that is so infrequent.

MR. SKINNER: Next question, Rose. I think we have time for just a few more questions.

OPERATOR: Thank you. Eva Ayala, you may ask your question, from Ft. Worth Telegram.

QUESTION: Yes, I was unclear, the person who was from Oklahoma that was -- received the transplant at Baylor in Dallas, did that person die in Oklahoma, or did they die in Dallas? And do you have the genders of these patients?

DR. COHEN: We can tell you that the individual died in Dallas. And the gender would be potentially identifying information, and, again, we need to protect patient confidentiality.

MR. SKINNER: Rose, next question?

OPERATOR: Thank you. Cheryl Silver from Genome News Network, you may ask your question.

MR. SKINNER: Next question, Rose.

OPERATOR: Thank you. Anita Manning from USA Today, you may ask your question.

QUESTION: Hi, thanks. I have two quick ones. One, is –- so then, is rabies transmitted only by saliva? And I still don't understand, if it's not in blood, how did it transmit from organs into these -- how did it get carried in organs? It was the in the nerves in the organs? And then the other thing is, if you could give us some kind of public health -- put this in context, in terms of public health. Is there a public health concern here? You know, what's the take-home message? Thank you.

DR. COHEN: Yes, I think, actually, you explained it quite well that the virus does travel by nerves. So it's likely it would have been in the nerves in those organs. I think, again, the public health message is this is very rare. As with the infections that can occur with transplantation, the benefits of transplantation far outweigh those. So that we're working with state, local and other federal officials to determine if there are other things that we need to do to continue to make things safer. But, again, donation and transplantation are very critical for health.

MR. SKINNER: Last question, Rose.

OPERATOR: Thank you. Dr. Mona Khanna from CBS News, you may ask your question.

QUESTION: Yes, my question is, are you only infectious after you become symptomatic?

DR. COHEN: There is not a lot of information about that. The potential could be that people -- since the virus is in various parts of the body, that there could be a potential for the disease to be transmitted. That's one of the reasons why we try to look at the type of exposure that people have, as well as the time frame of when the individual was sick, to determine whether we need to use the vaccine to prevent them from becoming ill.

MR. SKINNER: Rose, I want to remind everyone again that an article in our MMWR about this will be coming out around 4:00 today. So that will have additional details. And should reporters have follow-up questions, they should feel free to contact the CDC press office at 404-639-3286, and we'll do the best we can to assist them. Thank you.

OPERATOR: Thank you. Today's conference has concluded.

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