Monkeypox Home

CDC Telebriefing Transcript

Update on Monkeypox and Severe Acute Respiratory Syndrome (SARS) investigations

June 19, 2003

DR. GERBERDING: I am here today to provide some update on emerging infectious diseases of interest to all of us, those of us here at CDC and also a lot of people around the country who have been contending with SARS, monkeypox and soon probably West Nile Virus infection.

Let me start with monkeypox. Today, we have a publication in the Morbidity and Mortality Weekly Report which describes an update on the monkeypox investigations in Illinois, Indiana, Kansas, Missouri, Ohio, and Wisconsin.

To date, we are investing 87 cases of monkeypox, and we have so far confirmed 20 cases in the laboratory as being definitely attributable to this virus. The cases are in Wisconsin, where 38 cases are under investigation; Indiana, where 24 cases are under investigation; Illinois with 19; Ohio with 4; Kansas with 1; and Missouri with 1.

The laboratory tests being used to identify the monkeypox virus in confirmatory status include virus isolation, where we grow it in culture; PCR, where we detect minute quantities of the virus' genetic material; electron microscopy, where we see the virus under the microscope; and finally something called IHC or immunohistochemical staining, where we look for evidence of the virus in tissue from either patients or infected animals.

We are involved in a very aggressive investigation of the animal sources linked to these outbreaks, so there are investigators looking at where the animals may have come from, which animals are most likely to have been the proximate cause of the problem and whether or not there is any ongoing risk from exposure to these animals in various settings.

We have some very important perspectives on the overall impact of the monkeypox here in this country. Unlike the situation where there have been human outbreaks in Africa, we so far have not had any fatalities, although the fact that one small child was very sick with brain inflammation from the infection certainly is of concern to us, and we are, of course, aware how difficult this must be for her family and the people who care about her to have this illness evolve to such a serious extent.

We also, to date, have not identified any cases of person-to-person transmission of monkeypox in this outbreak, although that has been observed in other parts of the world.

We have posted some very important information for pet owners on our website, which is www.cdc.gov. And we want to make everyone who owns a rodent or another pet, particularly prairie dogs, aware of this information because it has some very specific advice about what to do to protect yourself from any illnesses, and most importantly what to do if your pet becomes ill, how to protect yourself from body fluids and who to contact so that the animal can receive the proper care and evaluation.

Now, let me move on to say a few things about SARS. Right now in the world, the news about SARS is good news. We are seeing increasing evidence of global containment of this problem. Right now, only Beijing remains on advisory status--Taiwan remains on advisory status for SARS, and the other countries, besides Beijing and Taiwan, have been moved back to health alert status.

Basically, what this means is that there is less and less transmission, but in Taiwan and Beijing, there is still enough ongoing transmission in the last several days that we are not able to completely remove them from the advisory status.

The other provinces of China have been taken off the advisory status, and we think that represents a remarkable achievement on the part of all of the officials and personnel in those areas who have had to be working extremely hard to accomplish what looked like a very daunting task at the beginning.

We continue to be on the alert for cases of SARS. We have learned over and over again that it is only a missed case that can initiate yet another cascade of transmission, but as I said, in the big picture globally right now, the news is very, very good, and if we continue this level of vigilance, we may be able to achieve successful containment.

That does not tell us anything about what to expect in the future, and if we have learned one lesson from SARS, it is that our level of alertness for emerging infectious diseases, particularly those of a respiratory nature, need to become the new normal for us all.

The third emerging infectious disease is West Nile Virus. We are experiencing West Nile Virus activity now in 24 states, in either animals or birds or insects. We have not documented human cases yet, but of course we are not going to be surprised when people do become ill with West Nile Virus because if it is in the mosquitoes, it is only a mosquito bite away from infecting a person.

So the information we have coming in from the widespread surveillance efforts we have indicate that there is significant activity. It is too soon to project whether or not this summer will evolve to a situation that parallels that of last summer, whether it will be better or less severe, and we just need to be prepared.

The most important aspects of prevention are, of course, what we can do as individuals. And that includes removing any standing water from your property, when that's possible, and wearing the protective apparel to cover your skin if you go out, especially in the evenings or the early mornings, and to use mosquito repellents as advised.

The last thing I would like to address in my comments today are some follow-ups on the situation with the smallpox vaccination program. As you know, CDC has been very aggressive about achieving smallpox preparedness around our country, since President Bush announced his policy last December. We have no information to indicate that the risk of smallpox has changed since that point in time, and it is still an extremely high priority for this agency that all of our jurisdictions be capable of immunizing their populations against smallpox should a threat occur.

Now, there is no evidence of an imminent threat, but as we've said all along, the threat is certainly not zero, and we need to continue to sustain our preparedness effort. As we've learned from the other emerging infectious diseases I've been talking about today, the evolution of an infection can be unpredictable and our best defense is at the clinical interface with the patient and in the public health system.

While we have taken remarkable steps in terms of being prepared, including our ability to detect cases of smallpox to initiate the appropriate isolation and quarantine measures should smallpox emerge, and having individuals already vaccinated against smallpox, we are not finished in this effort and we will be continuing to work with our state and local health departments to achieve the level of preparation necessary to be sure that we really can protect all Americans should we have a smallpox attack.

So let me stop now and open this up to any questions from the room. Is there anyone here in the room who has a question?

QUESTION: Hi. Daniel Yee with Associated Press. I was kind of wondering, I guess, regarding monkeypox, why you think that the cases in the United States are mild compared to Africa. And in the MMWR, I was wondering about the ages of the kids infected in the Indiana daycare situation?

And one more thing--how many people have been vaccinated against monkeypox with the smallpox vaccine?

DR. GERBERDING: The answer to your last question about the use of the smallpox vaccine to protect against monkeypox, so far about 20 people have been vaccinated, and we understand a few more who were vaccinated last night may not be included in today's report.

The ages of the children affected in the various jurisdictions—that information would be obtainable perhaps through the state health department and not just CDC at this point in time.

And why monkeypox appears to have been less severe in people in this country than was reported in earlier outbreak situations in Africa is still something we don't have an answer to. It may be that we have a better overall supportive care available to individuals, but I think there are a lot of unknowns. So we have completed the investigation; we just don't have an answer to that very important question.

Let me take a telephone question, please.

OPERATOR: Our first question comes from Jeremy Manier from Chicago Tribune. Please go ahead.

QUESTION: Thanks, Dr. Gerberding, for having this. Could you--I'm not quite sure when the spread to the three other states--Kansas, Missouri, and Ohio--was reported. And are those all linked to the same dealer in Texas or Iowa?

DR. GERBERDING: All of the cases of monkeypox transmission in this outbreak are linking back to the original importation of rodents and then a spread to humans through animals that had contact with the imported animals. So these are all part of the same outbreak investigation, and they all do seem to link back at this point in time.

I'll take another telephone question. I understand there's a long queue today.

OPERATOR: We do have a question, then, from Maureen Taylor with Canadian Broadcasting. Please go ahead.

QUESTION: Yes, thanks Dr. Gerberding. What does the CDC advise local health officials to do when they see someone come into hospital with respiratory symptoms and recent travel to Toronto? And I guess I'm getting at the man in Dallas who may be held for three weeks until serology tests come back. What is your advice in those situations?

DR. GERBERDING: Let me try to correct some misinformation here. First of all, CDC recommends that any person who presents to a hospital with an unexplained fever and respiratory symptoms should be put in a level of precaution to protect from unsuspected airborne infection transmission. Usually that means for people who aren't profoundly compromised that you put a mask on the patient and ask them to stay in a private area with good ventilation until they've been evaluated to make sure they don't have something that is communicable from person to person.

That was the expectation before SARS, and it remains the expectation now. We learned that lesson in the context of tuberculosis in the past. So in the SARS era, where we know that a travel history to affected areas is an important clue to diagnosis, we initiate basically the same precautions, which is to isolate the individual with the respiratory symptoms until additional history can be elicited.

Now, if someone has an illness that is most compatible with SARS and they have a travel history to an affected area, they are put in an isolation room while hospitalized, while they need medical care in the hospital, but there are many examples where people who have been probable SARS cases are subsequently released to the hospital to the care in the home. They are advised to take the kinds of precautions to prevent spread to others in their households and so forth. But it is not necessary for someone to be in the hospital for the entire duration of their evaluation period if they are otherwise healthy. Those decisions are made by local health officials who are looking at the big picture, who know both the medical condition of the individual as well as the capacity to contain any spread in the home.

Is there another question from someone here in the room? Then let me take a phone question.

OPERATOR: Thank you, yes. We do have a question from Dean Olson with the Springfield State Journal-Register. Please go ahead.

QUESTION: Hi, Dr. Gerberding. I'm wondering, regarding prairie dogs, in ballpark terms how long do you think that this ban on the sale of the prairie dogs is likely to last? And if and when it is lifted, might there be further restraints on the future sale of these animals and other exotic animals? And two, are prairie dogs more at risk of passing on diseases than other types of pets, like cats and dogs?

DR. GERBERDING: There are many diseases that can be transmitted from household pets, and it is important to remember the principles of hygiene when handling pets in the home in the same way that we recommend principles of hygiene when we're dealing with our own infectious disease containment. Prairie dogs are susceptible to monkeypox. They're also susceptible to things like plague or tularemia. So there is a hazard of some nature with these animals, but they are by no means unique in this regard. I think what we're looking at in terms of the current ban on prairie dogs is focusing in on those dogs that were specifically potentially exposed as a consequence of the importation of the monkeypox virus.

Where we will go forward in the future with this really depends on our ability to contain this and then to work with our partner agencies to determine what, if anything, we can do to reduce the hazards that exotic animals do place on individuals and to make sure that we're not importing monkeypox or other serious infections that could be transmitted to domestic animal populations.

So there's a lot of work here, and I'm not willing to say today exactly when any changes in the current authorities will be lifted or altered.

I'll take another phone question, please.

OPERATOR: We have a question from Maggie Fox with Reuters. Please go ahead.

QUESTION: Hi. Thanks, Dr. Gerberding. I'm wondering if there's any concern over the response to monkeypox. I know this has been asked
before, but what may have happened had this been something that was more easily transmitted from person to person like SARS or like smallpox? Was the reaction considered to have been slow?

DR. GERBERDING: I think all of the people involved at the state and local level, the medical environment and at CDC certainly share in a concern that we look back on the monkeypox situation and make sure that the system worked as efficiently and effectively as it can.

In this particular situation, the initial case of monkeypox transmission was known to occur at the site of a prairie dog bite and so that certainly lowered the concern that this was a terrorism attack and it lowered the concern that it could be smallpox or some other pox virus infection that would be involved in a terrorism type event.

But we would like to know about these situations when they occur, so that we could work as fast as possible to identify the source and initiate the appropriate public health measures.

Those measures have been initiated but I think we may have been able to initiate them earlier and that's something that we want to look back on and understand what can we do in the future to make sure that we take the steps we need to take as quickly as possible.

All of this is part of a new normal of emerging infectious diseases where not only are we dealing here with, in all three cases, with SARS, with West Nile and with monkeypox, infectious diseases that were imported into the United States through various means, whether animals, people, or perhaps birds in the case of West Nile virus infection where we really don't know how it initially arrived here.

But it is a global community and all of these illustrate the tendency for a problem in one corner of the world to emerge as a problem in another corner of the world and the local health department and the local clinical at the front end has to be the strongest link in the system.

So that's part of what we're trying to accomplish at CDC is get those linkages completely seamless from the local point of contact with the first case all the way to the global environment where the diseases emerge and are ultimately spread.

I'll take another telephone question, please.

MODERATOR: Thank you. We have a question then from Jennifer Warner with WebMD. Please go ahead.

QUESTION: Thank you, Dr. Gerberding.

In light of the recent global SARS conference in Kuala Lumpur, they highlighted although a lot has been accomplished with SARS, a lot of questions still remain.

Can you give us an update on the status of the development of a accurate and rapid response diagnostic test as well as prospects for a SARS vaccine?

DR. GERBERDING: There is certainly a great deal of work going on both at CDC, at NIH, and in the Federal Government but certainly within the private/public sector domain, we have already received requests from numerous academic environments and commercial companies for SARS virus or SARS virus reagents because this kind of work is ongoing.

I think so far, 67 entities have received virus and some of the work they're doing relates to diagnostic testing. So there is a great deal of--actually that was the RNA from the virus that's been shipped to 67 places and 41 have actually received the virus. So there's an enormous effort afoot to make this happen.

The FDA has worked very hard with CEOs of various companies to expedite development. We have the technologic understanding of the basis for a test for coronavirus and even a rapid test but the biology of the virus has so far made this not yet a complete reality-based effort and I say that because there are people in the early phases of this disease who are not showing evidence of coronavirus in their respiratory secretions and it's not until they really develop the pneumonia that we've been picking it up.

So it may be, in part, we have to know where to sample first, and, in part, we need to develop tests that are just exquisitely sensitive. It's a high priority but we are not quite there yet.

Having said all that, I also think it's remarkable, the capability that we have already in our diagnostic testing. Now our expectations are so high these days, but the fact that we have several tests already at this very early, and we're just months from detecting the pathogen, that we can use to confirm that people have had this infection, it's a very optimistic perspective and I think, ultimately, we will be successful in being able to develop a bedside diagnostic test for this coronavirus and that will be a tremendous help to us here, but also globally.

There's a question over here.

QUESTION: Yes. Leslie Wade at CNN. This is a smallpox question. Will the ACIP be making a decision today about whether to recommend expanding the smallpox vaccine program from just health care workers to also emergency workers like police?

DR. GERBERDING: Let me first make sure everyone understands what the ACIP role is. The ACIP is an advisory committee and so their role is to provide advice to CDC and the Secretary about issues related to immunization and we have traditionally held their advice in very high regard and it does have a very strong persuasive impact on decisions that we make.

But it is not the only source of advice that we receive and as we've been saying all along with smallpox, this is a situation we are balancing the public health issues and the safety and indications for vaccination with a homeland security issue and our need to make sure that we truly can prepare our nation in the event of a smallpox attack.

It's tempting and I see this in many sectors. It's very tempting to conclude that somehow the smallpox risk has miraculously evaporated and that's just simply not true.

And so when we get advice from the ACIP, we will be respectfully considering it and I'm sure the Secretary will be weighing that advice in conjunction with the other input he receives.

But nothing in any of this will change the overarching goal and the overarching goal is that our nation is prepared to protect our citizens from a smallpox attack, should a threat occur.

I don't have a timeline of the recommendations from the ACIP but I am hopeful that they will have a recommendation for us some time today or tomorrow.

A question here.

QUESTION: Yes. Katherine Shugut [ph] form the Atlanta Journal-Constitution. I was actually at the ACIP meeting this morning and I understand that some of the wording on what they voted on is being finalized, but I mean I have here a copy of the draft of the resolution and they, you know, they said the ACIP feels it is unwise to expand beyond its current pre-event smallpox vaccination recommendations because of the new and unanticipated safety concerns, i.e., myopericarditis, to the extent and severity, particularly of long-term sequelae are not yet known.

So what do you think about this recommendation and the questions it raises about the safety of the smallpox--

DR. GERBERDING: Let me just iterate again, it is the job of the ACIP to look at this from a public health perspective and to weigh the information about the vaccination as well as the indications for vaccination and I know the ACIP is very committed to smallpox preparedness as well and I don't think we're going to hear anything that says stop the program.

But the question of how broad the vaccination program needs to be is something that we've all paid careful attention to.

I think it is absolutely clear that we must have preparedness in our health care community and our public health response teams if we have any hope of being able to successfully mitigate a smallpox attack and if we didn't know that before, we certainly know it after the experiences we've had with SARS and monkeypox.

That it is very difficult to contain a disease that transmits [inaudible] it's very difficult when people are frightened or otherwise inexperienced in handling a situation, to get things exactly optimized, up front. So the more people we have vaccinated the better off we'll be, and the fact that we have almost 40,000 people vaccinated is I think a tremendous step forward compared to where we were just six months ago.

So we've made enormous progress but we have more to do and I never lose the chance to emphasize that this is not about a number, it is not about should we have 40,000 people or 400,000 people, or 4 million people. It's about how do we get prepared.

And we are really working hard now to identify, through the next cooperative agreement and resources that the states are receiving for terrorism preparedness, to include measures of smallpox preparedness in that expectations, so that we will do everything we can to support all of the components of preparedness, and again that includes ability to detect a smallpox case, the ability to report that case to local health officials, the ability to isolate the case appropriately, the ability to exercise appropriate isolation and quarantine authorities in a jurisdiction and the ability to stand up in immunization clinic and vaccinate the population as quickly as possible.

So all of this is something that Secretary Thompson has been very clear about as an expectation for the cooperative agreements and we will continue to work on that. So please do not focus on numbers. That is not what this is about.

This is about making sure that every jurisdiction is prepared to protect their people.

Let me take a telephone question, please.

Is there a telephone still connected?

MODERATOR: I'm sorry. Yes, we are. We have a question from Larry Altman with New York Times. Please go ahead.

QUESTION: Yes. Thanks, Julie. Two
questions.

Dr. Heyman, at a press conference in Hong Kong, said that the U.S. is gearing up for SARS, as is every other country, and the U.S. is very concerned about this. They're making extreme plans. So I was wondering if you could elaborate on what those extreme plans are for SARS.

And, two, in Canada, Frank Plummer said that he had found SARS virus, I guess with PCR, from 120 individuals who were not on the Canadian probable or suspected case list for SARS. Could you comment on both of those, please, and how that relates to the findings in the United States.

DR. GERBERDING: Thank you, Larry.

With respect to the preparedness in the United States, I am not aware of any extreme plans that are being developed. I am aware that we are taking what I think to be prudent steps to develop a sensible national strategy for mitigation and prevention of SARS, should we have another outbreak either this year or in the next winter season.

Our plan is, including the kinds of steps that we would use for a pandemic influenza plan, and that includes the capacity to detect cases, to respond to WHO's call for technical assistance or field team assistance in various parts of the world to have reliable diagnostics available at the point where they are needed and the various other kinds of measures that we would include for managing a serious outbreak.

I think it would be foolish to not have that kind of plan available for us, and we have perhaps the luxury of some time to work with our state, and local, and clinical partners to ensure that we have a plan that makes sense and that will work. It also gives us a chance to take stock of our stockpile, so to speak, and make sure that we have the appropriate resources that we might need, should we have a much broader outbreak than we had this year.

The one area that I think is relatively new to us, and the place where I am certainly focusing a great deal of my personal attention, is on the containment in health care environments because it is clear that the common theme of most of the outbreak situations we have encountered has been spread from affected patients to the health care workers and then into the community, and we have recognized now twice in Canada that a very high degree of containment is required to protect people and that simple patient-to-patient measures may not be adequate.

So we need to at least have plans in place should we need to do the kinds of things that happened in Toronto or Singapore or Hong Kong, where hospitals, basically, cohort affected people or even reduce admissions of noninfected people into the facility and isolate the hospital or quarantine the hospital from the rest of the patients that it might ordinarily serve.

So those I would not characterize as extreme measures. I would characterize them as sensible measures, given what so far we have learned about SARS and the potential to cause widespread outbreaks in health care and other settings.

I haven't seen Dr. Plummer's most recent data, but I am aware that he has been looking at cohorts of exposed, asymptomatic, as well as unexposed, people for evidence of Coronavirus infection. And we have some hints here domestically as well that there may be people with Coronavirus infection who are asymptomatic. So this would not be surprising, given what we see with other viral respiratory illnesses.

What I do not have at this point in time is any evidence that the asymptomatic Coronavirus-infected people are linked in chains of transmission to other cases. So it may be that there's a difference in infectivity, depending on whether you are symptomatic or mildly symptomatic or profoundly symptomatic, and these are the kinds of information data points that hopefully will be coming out of the cohort studies as they unfold.

I think we have a number of these ongoing in partnerships with others in Asia, as well as some studies here in the United States, that will hopefully shed some light on this as we get all of the testing done in the lab.

Let's have a telephone conversation, please.

OPERATOR: Thank you. Yes, we do have a question then from Marilyn Marchione's line with the Milwaukee Journal. Please go ahead.

QUESTION: Hi. Thanks very much, Doctor.

The MMWR today makes clear that there are many animals and many states that are potentially exposed to monkeypox and that there's a lot of difficulties in finding many of these animals now that they have moved through swap meets and into homes. Could you please comment on whether the outbreak can be contained in your view and how we might ever know whether all of the animal reservoirs have been found.

DR. GERBERDING: I think we have optimism that this particular outbreak of monkeypox can be contained. We have so far been able to link human cases to affected animals, and they directly link back to the source that has been described already today.

But, clearly, we learn as we go, and we must continue to alert pet owners, and pet shop owners, and we will continue to work with other partners in the federal government to try to round up all of the affected animals.

I think the FDA will also be issuing some detailed information in the context of a final rule on how we will be managing animals that are borders and the movement of animals from one jurisdiction to another. So I think we have the measures in place to contain the problem. We are seeing fewer and fewer reports of affected people, but it's not over till it's over, and we are still working hard to make sure that we do everything we can to prevent further spread.

Is there another telephone question?

OPERATOR: Yes. Thank you. We have a question, then, from John Lauerman with Bloomberg News. Please go ahead.

QUESTION: Hi. Thanks for taking my question, Dr. Gerberding.

You were talking about not wanting to use numbers to determine whether or not we're prepared for smallpox, and I was wondering what measures you'd like to use. Would you like to say, I mean, is there any way for us to tell whether or not we're adequately prepared or whether we have, let's say, whether we have vaccinated enough people?

I know there's this number earlier of about a half-million health care worker or 450,000. That obviously hasn't happened yet, but if we're not going to use that number, what measure should we use?

DR. GERBERDING: I think that, as I said, there are several components to preparedness, and we have to accomplish all of them. We clearly do need some people vaccinated, and the number of people vaccinated really depends on how the plan in a given location is going to work to be able to immunize the public and get the vaccine clinics up and running, as well as take care of the initial cases of smallpox in the health care environment.

Now, we don't need people immunized in every hospital in the country. Some regions may decide that there is going to be sort of a referral hospital, just as we did with SARS, where there may be one facility that will preferentially be the place where the smallpox patients will be taken care of or a small number of facilities in that regard.

So different jurisdictions have to look at the lay of the land in terms of their facilities and the kinds of resources that they have available in the community, how quickly can they mobilize their prevaccinated people to initiate a clinic, how are they going to triage people into their clinic and so forth.

And that's really the primary reason why it's very difficult to give a round number on this because their planning has actually evolved as they've become more experienced and learned more about the realities of vaccination and have learned a lot of things, like how to do it, and what it takes, and how to consent people, and so on and so forth.

So the exercise of getting the 40,000 people vaccinated over the last year certainly has improved the efficiency and the capability of all of these jurisdictions to more quickly vaccinate larger numbers of people.

But we still want to ensure that, first of all, the detection system works so the information that the Secretary made available to all of the doctors in the country who were included in a catchment from their local boards of medical quality assurance or their state health departments that included information on how to detect and diagnose smallpox. This is critically important. People need to recognize the first patient so that they can report it.

Likewise, the experience we gained with SARS and how to exercise our isolation and quarantine authorities has certainly advanced our smallpox preparedness, but we have to go further to ensure that each jurisdiction knows where patients can safely be taken care of and who will be responsible for doing that.

So there are many elements of this, and the way we have managed this, this time around, is that the elements of preparedness are included in the expectations for states when they receive their federal dollars for bioterrorism preparedness. So the guidance and the expectations are outlined in this process.

We will be developing performance measures. We will be doing everything we can to help them be successful in all of the elements of preparedness, but we are certainly a lot more optimistic about this this year, in part, because the benefits of the SARS experience in getting us to focus in on some of the tougher issues, like isolation and quarantine.

Next question?

QUESTION: Yes. Leslie Wade, again, at CNN.

Can you clarify something for me, Dr. Gerberding. Today, at the ACIP meeting, did they recommend or did they not recommend that we go forward to include emergency workers for vaccination of smallpox.

DR. GERBERDING: Right now, the ACIP has not finalized its recommendation. Someone earlier read a draft resolution. It's being evolved. I'm sure that when it's finalized, we'll hear about it, but right now we have not received a formal recommendation for the ACIP, so it would be premature for me to comment on what it contains since I don't have it yet.

Telephone question, please.

OPERATOR: Thank you. Yes, we have a question, then, from Lynn Edrin [ph] with ABC News. Please go ahead.

Ma'am, your line is open. We are unable to hear you.

DR. GERBERDING: Can you just move on to the next question?

OPERATOR: Absolutely. We have a question from Anita Manning with USA Today. Please go ahead.

QUESTION: Dr. Gerberding, given the ACIP's expressed concern about the cardiac problems that are possibly related to the smallpox vaccine, do you agree that it's not a good idea to expand the program at this time?

DR. GERBERDING: I'm sorry. I didn't hear the last phrase, Anita.

QUESTION: Do you agree that it's not a good idea to expand the program at this time?

DR. GERBERDING: My metric in all of this is let's get prepared. Now, the concept of expansion or staging or pausing or not pausing is not something that has been part of my expectation for the smallpox preparedness program.

The only metric that I'm interested in is the metric of preparedness. We have made a giant step forward in our preparedness, but we are not done yet, and so we are going to need to work with individuals in the local health departments and the state health departments to determine what else do they think they need to do to be sure that they can successfully vaccinate their public. So that's really the way we'll be looking at it.

Now, of course, the issue of the safety of the vaccine is important to all of us. We recognize, and have recognized, from the very
beginning, that there are risks associated with smallpox vaccine. And just to clarify, I want to emphasize that it is the myopericarditis, the inflammation of the heart, that has been attributed as the consequence of vaccination. I think the news from the Department of Defense, where they have had far more people vaccinated, is that overall the safety of the vaccine program is better than we had initially expected when we went forward with it. But this myopericarditis was not something that we had initially considered as a known complication. So we learned it as we went forward and we have adjusted our information and our consent processes to account for it.

The other concern was the heart attacks that were noted in some people who had been vaccinated. Unfortunately, heart attacks in our society are fairly common events among people with risk factors and of certain age groups. The best available epidemiological information so far indicates that those heart attacks are most likely a coincidence and not directly associated with the vaccine at all.

But again, we have extraordinary measures in place to monitor the safety of this vaccine program, and we are obviously very invested in trying to do this with the best possible screening and the best possible safety record that we can achieve.

So that is, you know, in part. I have great thanks and great respect for the ACIP for really focusing in on the safety issues, and as always, we will respect their advice and balance it with the other priorities that are necessary to make a sound public health decision.

Let me just end there and thank all of you for being here and for your interest in these issues. This is the new normal of emerging infectious diseases and I think kind of an unprecedented day in the history of CDC, where we're sitting here talking about three infectious diseases that we are simultaneously coordinating through our emergency operation center. Three diseases with global importance, three diseases that are new in our society, and three diseases that all of us are working very hard to contain and prevent. So thank you.

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