CDC Telebriefing Transcript

CDC's Terrorism Preparedness: One Year Later

August 27, 2002

CDC MODERATOR, LISA SWENARSKI: We have brought together the top terrorism experts at CDC to make some remarks and really devote a lot of time to Q&A for all of your questions.

I'd also like to point out that CDC is one piece of the Department of Health and Human Services, which has a very active program in preparing for a possible terrorism event, and so I urge you all, in addition to listening to the people here at CDC, to also contact HHS and the other agencies that are very involved in terrorism preparedness and public health. And if you don't have the phone number for their Press Office, it's 202-690-6343.

Also, if you need to verify anything that was said today, it will be available by transcript on the website by the end of the day, and also later this week we will have a press kit with lots of information for you on terrorism preparedness on the web by the end of the week and some B roll for TV next week.

In addition, please look out for several MMWRs that will be coming out next week and the following week with terrorism-related articles.

If I didn't mention it, I'm Lisa Swenarski, the acting director of Media Relations at CDC. If you have any follow-up questions after this one hour, please feel free to call our press office at 404-6393.

Today, each of our speakers are going to make some very brief remarks, and then we will open it up to Q&A. I would first like to present to you the CDC Director, Dr. Julie Gerberding.

DR. GERBERDING: Thank you very much for being here today. This is really an opportunity for us to update you on some of the things that we've been doing over the last year since the terrorist attacks first began, and we're very happy to have the chance to provide this information in this forum.

It did cause me to look back a little bit on the very first day, 9/11, and I'm sure we call all remember where we were on that day which is, in a sense, the world changed for all of us. It certainly changed for CDC.

But there are a couple of other dates that are very important to us as an agency, also. One is, of course, October 4th, when we confirmed the first case of inhalation anthrax in the patient in Florida. And then on November 8th, President Bush, Governor Ridge and Secretary Thompson visited CDC, which I think sent a very strong signal to this agency that we were an integral part of homeland security, and that message, and that awareness is certainly shaping our future, shaping our priorities and shaping the directions that we're taking.

It's not a substitution for our core public health mission, but it certainly is an addition, and I think I'm pleased to say today that we are successfully embracing that addition and are very proud of some of the things that we've been able to accomplish in the last year.

We learned a lot of lessons in the fall. The purpose of this conversation is not to go into the lessons, but rather to tell you some of the things that we have accomplished and are going forward with from that point on.

We did step up to the plate in the fall, and since that time, we've really scaled up our response capacity. We've sped up the processes by which we do our work, and we've streamlined our overall emergency response operations.

The kinds of programs that you're going to be hearing about today are really those that address three major components of CDC work. One of the issues are the actual program components themselves, and I'll mention a couple of these.

The other is the people and the partnerships that are used to accomplish our work.

And the third is the practice that we do to make sure that our response capacity is optimized.

In terms of some of the highlights of the programmatic changes that we've made, the biggest and most conspicuous is, of course, the state and local grant program for terrorism preparedness and response--the $918 million that Secretary Thompson made available for state and local health departments through CDC, which really focuses on the critical components of preparedness, and already many states have achieved the benchmark capacities or are well on their way to achieving benchmark capacities in this regard.

The criteria for that program were flexibility, speed and accountability, and we are very much engaged in ensuring that we meet those criteria in all three categories.

Other programs that I think have expanded or enlarged since 9/11 include our National Pharmaceutical Stockpile Program. Not only have we added many medical assets, including new antibiotics and vaccine products to the stockpile, but also we've increased the absolute number of the push packs. These are the large containers full of medical resources that are deployed at strategic locations around the United States.

We've also increased the number of personnel involved in this program and remain fully confident that should there be another terrorist event or any other mass casualty event, we could get the stockpile to the site of need within 12 hours in the United States.

Another major component has been our laboratory capacity program, both here at CDC, as well as the laboratory response network, which now has more than 200 laboratories that are actively engaged in the detection, diagnosis and evaluation of samples that could represent a pathogen of bioterrorist origin. I think Dr. Hughes will say a couple more words about the laboratory response network.

But at CDC, laboratory response capacity has been a high priority, both for biologic agents, as well as chemical toxins, and we have expanded our capacity, expanded our throughput, and we've even opened new laboratory facilities since 9/11 to ensure that we have the full surge capacity that we need to deal with these problems.

We're not finished. We've got more expansion and more work to do in the laboratory compartment, but we've certainly taken some giant steps forward, and we're very pleased with those accomplishments.

Now talking a little bit about some of the things that people have done. We have rapid response teams here at CDC, and these are individuals who are ready to basically load and go whenever a problem arises. So they have special training. It's a mixture of people with a variety of skills, including communication skills, laboratory skills, epidemiology, whatever it takes to get to a site of a terrorist attack and start the ground investigation and ground response in quick order.

Our EIS officers have had special training this year in the field, practicing coordination of a bioterrorism event at one of our partner organizations in another state. So the EIS officers are now getting training in emergency response and will be a much more ready part of our overall teamwork.

I think the other major investment in people is the expansion of our communications capacity here at CDC. We've hired and recruited a number of new health communications experts, and we've developed an emergency communications plan which is I think an enormous change in the way we do business here, and I hope that you will identify differences as you interact with us and see the fruits of that effort that Dr. Freimuth [ph] and her colleagues have been leading in the communications arena.

Finally, let me talk a little bit about practice because I think practicing or exercising our response capacity is certainly valuable. We exercised our response capacity in the fall, and we've done a number of lookbacks at that to identify where we needed to improve. But since that time, we've also had opportunities for scenario development, for expert consultations from people from the outside. We're planning a large tabletop and have participated in some small tabletop exercises. But most recently you probably recognize that we're very involved in the West Nile outbreaks in multiple jurisdictions around the United States, and this West Nile infection outbreak experience has given us an opportunity to practice our public health response capacity. And we are, in fact, managing the West Nile outbreaks using our Operations Center. We are using our communications strategy for that outbreak, and we are deploying and managing the people in the field using the same style of leadership and the same operations concepts that we would do if we were actually dealing with a terrorist attack.

Now, in no way am I implying that West Nile has anything to do with terrorism. It is a totally natural epidemic. But I think it sends the message or illustrates the concept that the kinds of investments that we make in public health to handle natural public health problems are exactly the same infrastructure and the same mechanisms that we use for dealing with a terrorism attack. So this concept of dual functionality is not only a good way for us to exercise, but it really is how we've evolved our whole program.

We are building terrorism capacity on the foundation of public health, but we are also using the new investments in terrorism to strengthen the public health foundation. And these two programs are inextricably linked, and I think both will benefit from the efforts and the investments that we intend to make on an ongoing basis.

So let me just end by saying it one more time. We are scaling up, speeding up, and streamlining our operations. Our preparedness is very high, but we're not satisfied, and we have more work to do, and we intend to get the job done right.

Thank you.

MS. SWENARSKI: Our next speaker is Joseph Henderson, Associate Director for Bioterrorism Preparedness and Response at CDC.

MR. HENDERSON: Thank you, Lisa. Thank you, Dr. Gerberding, for those comments and providing the broad base of the activities that we're all engaged in here at CDC.

The state and local program, which I'll talk about briefly, has gone through substantial change in the past year. CDC has been working on developing capacity at the state and local level since 1999. On average, we had about $120 to $180 million a year to support state and local activities to include laboratory capacity, the capacity to enhance surveillance, disease detection, to enhance the ability to do case investigations so we can control and contain the consequences of an outbreak, whether it's biological or chemical or dealing with issues of even radiation.

Now, in the past year, of course, that's changed considerably. We have almost a tenfold increase in funds. Our extramural program, which was last year about $50 million, has gone up to about $918 million, with a lot of the responsibility falling on the shoulders of our state and local colleagues, which altogether make up our entire public health system.

I think we've made pretty remarkable advances at the state and local level. States like Florida have done some very significant work in understanding how to receive one of the push-packs that Dr. Gerberding talked about, and the push-packs themselves, which I know Dr. Jackson will probably mention, are not just a few boxes that come in through Federal Express. They're about 100 huge cargo containers and the logistics behind just getting them from Point A to Point B are difficult enough Compound that with the need to get them to distribution points in a state or local jurisdiction are very complicated. Florida has done pretty substantial work in that respect, but a lot of states obviously need to do more to understand the logistics associated with getting medicines from a warehouse into people's arms or into their bodies.

So we continue to work with our state and local colleagues to build an entire infrastructure that can improve its response capacities. People always ask me if we were to respond tomorrow, would we do a better job than we did a year ago, and there's no question we clearly could, both as an agency, but also with the state and local health departments having these resources, and clearly in a better position to respond than we were a year ago.

So we're making significant advancements working with them to include laboratory capacity, which I know Dr. Hughes will touch on. The one point I wanted to make that's important is one of the critical components of response that we're seeing evolve rapidly is the need to develop the linkages and partnerships with the existing emergency management system that's been in place in this country for many, many years. If anything, the planning which is bringing all these various groups to the table is clearly building those linkages and relationships. And I think we're making some success. We have some work to do, but clearly we're in a better situation today than we were a year ago.

MS. SWENARSKI : Our next speaker is Dr. James Hughes, Director of National Center for Infectious Diseases.

DR. HUGHES: Thank you very much, Lisa. Good afternoon.

As you've heard, we have a new way of doing business at CDC dating back to last September. We and the Department of Health and Human Services remain on extremely high alert because of the threat of another act of bioterrorism as well as the threat of infectious disease outbreaks generally. We've taken steps to improve our public health surveillance capacity to monitor for the occurrence and early detection of infectious disease outbreaks anywhere in the country and, indeed, are working with partners in other parts of the world to strengthen surveillance capacity there as well.

Some examples of some of the kinds of things that are actively being done to strengthen surveillance capacity at the local level are monitoring of emergency room visits, monitoring of pharmacy records so that use of anti-diarrheals or antibiotics can be monitored, monitoring 911 calls, monitoring calls to Poison Control Centers, strengthening linkages to the veterinary community because of the fact that some of these diseases affect animals as well as people.

As you've heard, we've also strengthened our laboratory capacity. We've made large investments in the Laboratory Response Network, or LRN, which is a national network of public health laboratories in collaboration with the Association of Public Health Laboratories, and there's at least one of these laboratories now in each of the 50 states.

This network played an integral part in the response to the anthrax attacks last fall. Members of this system tested over 125,000 clinical specimens during the response to that attack and over a million environmental samples.

As you've heard, we now have an Emergency Operations Center. We're using that right now to help manage the response to the West Nile outbreak, which is, as you know, a national problem. But this has greatly increased our ability to work in a timely with partners around the country.

Finally, we've put a great priority on educating health care workers, particularly doctors and nurses, but other health care providers as well. These individuals need to learn considerably more about the clinical aspects of diseases that may result from bioterrorism, start with anthrax and smallpox, but clearly there's a broad range of other threat agents that health care providers need to be educated about.

We've to date educated thousands of health care providers around the country, but we have much more to do, and so let me conclude by reinforcing the comments of others. I hope you can tell we are no complacent about these threats that we face.

Thank you.

MS. SWENARSKI : And our next speaker, Dr. Richard Jackson, Director of CDC's National Center for Environmental Health.

DR. JACKSON: Good afternoon. Thank you, Lisa.

On September 10th, or before September 11th, CDC had an ability and were mandated by Congress to look at radiation risks around nuclear events, weapons sites, and the rest. We had a mandate and a responsibility to look at chemical residues in people. What are the risks from various chemicals in the environment? You probably heard about the Fallon investigation and the matter that we've been working on.

We had a mandate to set up a stockpile and to have antidotes and antibiotics in the stockpile and ready to be distributed throughout the country on short notice. And we had a mandate and responsibility for emergency response for CDC. We were the intake function for calls about emergencies.

That's all there, but a whole lot more since September 11th. First of all, fixing up the ability to intake information, alarms, and calls, we now have two people on duty around the clock. We are--we have a temporary but high-quality Emergency Response Center in place Operations Center, and with Dr. Gerberding's leadership and Tommy Thompson's leadership, by the end of the year there will be a state-of-the-art Emergency Operations Center. We've brought consultants in from both--we've dealt with both the Pentagon and FEMA to help us design that Operations Center so that it would really be top-flight and be able to turn information around.

Our chemistry laboratory, which is focused on chemicals in people and does specific studies, has been tooled up, and we can now look at 150 toxic chemicals in human beings that could be used as chemical weapons. And so we get a specimen from a human. We don't look at environmental specimens. We get human specimens, blood or urine, from a site, we can tell you what were the chemicals being used within about 24 hours, and we can ramp up. All of our people in our laboratory have been trained to put down what they are doing and transfer immediately to handling terrorism-related specimens in a chemical event. And by the end of about three days, if we know which chemicals we'll be looking at, we can handle thousands of specimens a day.

So we've really changed the laboratory in its focus and its activity, and we're working very closely with FBI, EPA, CIA, and the other federal leadership agencies on this. You can't do this kind of stuff in isolation.

And, last of all, in the radiation arena, it was important to do a retrospective look at threats, but we have asked our nuclear physicists and others to think about prospective threats. What are the worst things that you can imagine? How would you prepare for these? And we brought in, in the middle of June, about 50 experts, hospital leaders, emergency room docs, radiation specialists, and the rest, who have given us guidance about how you would set up hospitals, how you would prepare them, how you triage people, how you set up centers outside the hospital to deal with persons injured in a radiological or nuclear event.

So the bottom line that I want to convey here is, yes, bioterrorism is important and bio--CDC is working hard to prepare for it, but CDC also must respond to all threats, and that includes chemical and radiation as well.

Thank you.

MS. SWENARSKI: Dr. Kathleen Rest, Deputy Director of NIOSH, the CDC's National Institute for Occupational Safety & Health.

DR. REST: Thank you, Lisa, and good afternoon, everyone.

The World Trade Center and the anthrax attacks highlighted more than ever before in recent history the importance of worker safety and health in this country. The employees in the World Trade Center Towers, the emergency responders at Ground Zero, the employees in the media and government offices that were targeted for the anthrax attacks, as well as the postal workers who worked all along the route of those letters faced a severe risk of injury, illness, and death because they were at work and on the job.

When a disaster occurs, we rely in this country on our emergency responders to put themselves in harm's way and to come in and to protect the public that is involved in the incident at hand. It's up to us to make sure that the emergency responders have the tools that they need in order to protect themselves so that they can go in and do their vitally important work.

Now, as you all know, the National Institute for Occupational Safety & Health is the agency within HHS and CDC that does work on research and prevention of work-related injury and illness, and I wanted to give you just a couple of examples of some of the work that we've been doing post-9/11 and post-anthrax.

During those times, of course, we were with our CDC colleagues and responded, providing technical assistance on-site in New York and in the various postal facilities. But what I wanted to do today is tell you a little bit about what we've done since these times back in the fall.

Since September 11th, we've worked very actively with the emergency response community, with workers and employers, and our partners to do a number of things.

One is that we convened a national workshop of firefighters and other first responders, government agencies, manufacturers and stakeholders to identify needs relating to personal protective equipment like respirators and other protective ensembles that our emergency responders need to protect themselves when they go into these situations. We've issued a report, it's in writing, it's on the Web, and we're happy to make that report available to you of this workshop.

We've also issued new certification standards for classes of respirators so that emergency responders can know that when they go into a terrorist incident, they will be protected from chemical, biological, nuclear and radiological agents. NIOSH has certified respirators for industrial use. So, drawing on the experience that we've had, we are now actively pursuing certification programs for respirators and personal protective equipment to protect against these new agents.

As you may know, we're supporting a consortium of occupational health clinics in New York to provide some baseline medical screening for the workers, emergency responders, rescue and recovery workers that were involved in the 9/11 effort that will be able to help us determine whether they are suffering any adverse consequences because of their work.

We're conducting a variety of field studies also in New York of people that worked around the World Trade Center site in office buildings, transit workers, school employees proximate to the site, who were exposed to airborne dust to find out if they're suffering any ill event.

And, also, I guess, finally, we all realized after 9/11 and the anthrax attacks, that we are vulnerable to potential attacks to commercial buildings, government buildings and others to radiological, chemical, biological agents. So we have been working with partners and experts in other federal agencies to try to develop some practical guidelines that building owners can use to help harden their buildings and protect themselves from the vulnerability that they may have with their air intake systems. Again, there's a report available that we'd be happy to make sure that you have.

So, in closing, I think that we at CDC, and in HHS and in NIOSH really recognize the unique contributions that we need to make in terms of worker protection relating to terrorism. Because one thing we do know, that any and every future disaster, whether we're talking a terrorist disaster or a natural disaster, will involve workers in some way, and we have to be actively continuing our work to be able to make sure that these workers have the information and the tools that they need to respond in the way that we need to them to.

Thank you.

CDC MODERATOR: Thank you, everyone.

We'll open it up to questions and answers now. We will alternative between questions from the room and questions from the telephone. Please state who you're directing your question to, and those of you on the telephone, if you have a hard time hearing the questions from the audience here, please let us know, and we'll repeat the question.

First question?

QUESTION: Hi. [Inaudible] from CNN. I've got a question about smallpox vaccine. CDC recently had issued a recommendation. My question is what is the recommendation of CDC now; who should be vaccinated, how many first responders, 15,000 or 500,000, and when we will we hear when the decision will be made, and then how will the vaccinations occur, [inaudible] or mass vaccination?

DR. GERBERDING: Let me, first of all, make a point of clarification. CDC has not issued new guidelines on smallpox vaccine. An Advisory Committee to CDC made some recommendations, and that's a very important distinction because--

QUESTION: Well, CDC recommendation. I didn't say--I didn't say that you had issued guidelines.

DR. GERBERDING: Yes. CDC has not made recommendations on smallpox vaccine. An external body of people have done that, and we have responded to the recommendations from that Advisory Committee. We're working with Secretary Thompson and the experts in the Department of Health and Human Services to make a final determination of the federal policy in the context of homeland security and national security.

So we've gone forward with the public health perspective, but that's being weighed in the light of the other events that are unfolding. We don't have a final plan yet, but I can assure you that we are working almost around the clock to get the plans finalized and to make sure that we understand the logistical implications and the resource implications, as well as the human implications of any decisions that are made.

QUESTION: If I may follow up. [Inaudible.] If I were asking you, for the people out there, the normal people, not in the media, [inaudible], why can't I get it? So, from the CDC perspective, what do you think should happen?

DR. GERBERDING: One of the things that it's important to appreciate is that the vaccine products that we have available right now today, we have a vaccine that we can use in an emergency, but it's an investigational vaccine, and it requires informed consent, and it's best to think of it more or less as a research protocol, and so we don't generally make things available to people on a research protocol unless there's a strong reason for it.

As we move into an era when the vaccine is licensed and we know more about the new products that we're purchasing from the manufacturer, I think we can revisit this issue of whether it's appropriate for people to have voluntary access to the vaccine, but it's premature at this point.

CDC MODERATOR: It appears our friends on the telephone cannot hear the questions from the audience, so in the future I will be repeating your questions.

We'll take the first question from the telephone, please.

AT&T OPERATOR: Thank you. That will come from the line of Deidre Henderson with the Denver Post. Go ahead.

QUESTION: This question is for Dr. Gerberding.

In light of the CDC's current handling of the West Nile outbreak as a proxy for how the Agency would handle future bioterrorism attacks, I have a question about the timeliness of CDC turnaround of human specimens.

The Agency has said that given its experience with past West Nile outbreaks, it is expected to see a ramp-up in suspected human cases in August, but despite that, there's been an increasing lag time between the time the CDC receives the human samples and the actual confirmation.

Are there any strategies for a quicker turnaround on those confirmation tests?

DR. GERBERDING: Actually, we've been doing--thank you for bringing that up. We've been doing an evaluation of the time from a patient presenting with the symptoms or signs of West Nile infection and the time that the laboratory at CDC is able to document that that's the source of the infection. And there are many components to that period of time. One of the biggest is the time it takes for the clinicians taking care of the patients to order the test and get it to the state laboratory. Then there are turnaround times in the state laboratory that add several days to the equation, especially if the sample is not obviously positive. And sometimes early infection, it's an equivocal test result, so it has to be repeated.

CDC does not confirm all of the West Nile tests that are done at the state labs because over the last couple of years we've learned that the state labs are quite proficient. So when there's a new case in a new jurisdiction, often they'll send the specimen to us to do the special confirmatory test, and we're happy to do that and actually appreciate the opportunity because it helps us. But we are not in the business of confirming every West Nile test once the state has documented that the infection is there and they know they're having an outbreak because they're very competent and proficient at doing them themselves.

Where we come into play is when the test is confusing, and sometimes this happens in a state where the test result is ambiguous and there's a special test that we have to do called the plaque neutralization assay, and it takes a week to ten days to get the results from that test because it involves growing virus in a petri dish. It's not a rapid test.

So that's part of the reason why you see a delay in the CDC lab, because we're being called in when it's complicated and we have to use the special assay.

MS. SWENARSKI : Next question from the audience.

QUESTION: Can I continue with the West Nile? Here in Georgia we have six cases that were confirmed by the state but never confirmed by the CDC. Have you confirmed those or will you be confirming those?

DR. GERBERDING : Again, the verification of the West Nile case is left to the jurisdiction of the state. So when we report verified cases, these are cases that the state has reported to us as having been tested and verified and have entered into the surveillance system.

Sometimes we hear rumors about other cases, and clinicians are confused about CDC's role in doing the actual confirmatory testing. But the bottom line is it's really the state call.

In Georgia, we were asked to look at some samples and to confirm them, and the evaluation of both samples is ongoing as we speak.

MS. SWENARSKI : We'd be happy to set you up with our West Nile experts if there are any questions on West Nile afterward. We'd like to devote this precious hour to terrorism-related questions.

So the next question from the telephone, please?

AT&T OPERATOR: That will come from C.C. Connelly with the Washington Post. Go ahead, please.

QUESTION: Yes, thank you. Dr. Gerberding, I wanted to follow up a little bit on the questioning regarding the smallpox vaccine. First, I'm wondering if CDC has been able to assess and weigh in on liability questions around administering that vaccine. You mentioned an IND. Do you need to file any additional IND if the policy is for a broader vaccination policy?

DR. GERBERDING: The IND, investigational new drug, status of the vaccine products that we can currently use would not need to be modified based on expansion of who we would be offering pre-immunization or post-immunization vaccine to. Our protocols and our application status has accommodated for that--accommodated that.

And the liability issue is one that the department and CDC, FDA, and others are actively pursuing.

QUESTION: The reason I ask that is my understanding that when you had the fairly large-scale swine flu vaccine, liability ended up being fairly costly. I'm wondering if you can give us some insight on whether or not there are lessons to be drawn from that experience. And just to be clear, when you said the IND status would not need to be modified, is that true even if you're talking about a half a million people?

DR. GERBERDING: The IND is not based on the number of people who are vaccinated. It's based on the protocol used to do the immunization. So that is--that is a correct statement.

In terms of the importance of liability, anytime you go forward with a vaccine or any other product that has investigational status, liability is a very, very important question. It was an important question for swine flu. It was an important question for anthrax vaccine. And it's an important question for smallpox vaccine. And it's one that we are not taking light.

MS. SWENARSKI : Next question from the audience, [inaudible].

QUESTION: A question for anyone on the panel. Mike Tobin with the Atlanta Constitution. You've outlined quite a number of changes you've made in the last year in response to the anthrax attacks. I wonder if you would attempt to balance the changes that you've made against the knowledge that you've gained from what was an extremely limited and apparently not particularly well coordinated effort at biological warfare. Do you personally feel more or less secure today than you did a year ago?

MS. SWENARSKI: The question is we've gone over some changes that we've made in the last year, and Mike Tobin, Atlanta Journal Constitution, would like to know if we could balance the changes we've made with the knowledge we've gained in bio-warfare and do we feel more comfortable now than we did a year ago.

DR. HUGHES: This is Jim Hughes. Let me make some initial comments.

The anthrax attacks through the U.S. postal system last fall was unprecedented. It was tragic. It had an enormous impact on the country. Nevertheless, as the questioner noted, it was a small attack, and it's important to note that it could have been much worse. It could have been much more complicated in many ways. It's one of the reasons why we are not complacent at all.

We certainly learned many lessons from the response to that attack, and a number of them have been enunciated already in this session. We are putting them to use in the response to the West Nile epidemic showing the dual utility of these investments.

One of the areas where we've definitely made improvements is in cooperation with partners, and hopefully in communication. So I would say that we're substantially better off today in responding to this year's West Nile national extension in a much more effective way now than we would have been absent the experience in responding to the attacks.

MS. SWENARSKI: Next question from the telephone, please.

AT&T OPERATOR: Thank you. That'll be from Adam Marcus with Health Scout. Go ahead.

QUESTION: I imagine this is for Dr. Gerberding. I'm curious what percentage of the CDC budget is now devoted to terrorism preparedness, and have there been other areas of the CDC's more conventional mandate that have seen a percentage drop in their budget? And do you think that that's led them to suffer in any way?

DR. GERBERDING: You know, you're asking me a question that, on the one hand, would be straightforward by just looking at how the pie is divided up and how it comes in to CDC. But, in fact, the point I made earlier about building terrorism programs on the foundation of public health is a complication that makes the answer to your question not so straightforward.

In other words, we have existing systems for conducting surveillance of emerging infectious diseases in a number of jurisdictions, including the state health departments. That is a very important foundation for terrorism preparedness and response, but it's not paid for out of dollars that are earmarked as bioterrorism dollars. So we have dual-purpose programs, but we also leverage our investments to get dual functionality out of them.

So I can't really answer your question. It is important to note that the state and local grant program for terrorism preparedness and response is $918 million. We have an additional increment of resources for intramural programs, some of which also goes out for research and for other programs. Dick can speak to the investments in the stockpile and the medical assets that are kept there. But we are not taking away from other programs to enhance terrorism, but we are trying to make these investments have as much impact overall as we can.

QUESTION: Am I still on?

MS. SWENARSKI: Do you have a follow-up?

QUESTION: I do. One way, instead of looking at dollars, might be to look at person-hours. Do you have the same level of staffing that you did a year ago? And if so, how are they allocated? And are more people working on terrorism and less on other things?

DR. GERBERDING: The answer to your question is we have more personnel. One of the most important new additions to our staff is sitting next to me, Dr. Joe--Mister--excuse me. I've done that twice now--Mr. Joe Henderson, who's Associate Director for Terrorism Preparedness and Response, who's really coordinating all of our activities. And we are hiring a number of people to support the extramural grant program as well as the expanded capacities internally. But, again, the existing personnel are also contributing to our terrorism response capacity, and the biggest evidence of that occurred in the fall, and we basically called upon skilled people from across CDC from all centers and components of our organization to contribute. So this is part of our core business, and we use part of our core staff to accomplish these tasks.

MS. SWENARSKI: Next question from the audience?

QUESTION: Yes, Rick Blaylock (ph) from Channel 11 [inaudible]. Recently, a couple days ago, I guess, Vice President Cheney talked about [inaudible] Iraq, the President's talked about it. Some people are questioning whether that's a good idea because of the fact that if we go to war with Iraq, the possibility of further warfare here in this country or [inaudible] anthrax or other type of biological war would happen.

Is CDC prepared or are we ready to handle the consequences [inaudible] if we ended up in a situation like this? And, secondly, my question would be: How much consultation has CDC provided the White House [inaudible]?

MS. SWENARSKI: Just to preface it, obviously we have a big enough mission without having to get into foreign policy at CDC. But certainly Dr. Gerberding could talk about where our preparedness level is. The question, for those of you on the telephone, from Channel 11 is that there has been in the news some discussion about possible war with Iraq, and is CDC ready for a bioterrorism event that might be related to that? And how much has CDC advised the White House in relation to that?

DR. GERBERDING: CDC's mission is to protect public health, and so we look at both domestic and international events from the standpoint of what is necessary to protect the health of the public. And so that is our role, and that would be our role with any kind of major event, a natural epidemic, a terrorist attack, or even a war. And so from that standpoint, we are, of course, very invested and concerned about thinking through the potential consequences to public health.

Fortunately, war per se is less likely to be a public health issue than some of the other terrorist kinds of activities that we've been talking about.

QUESTION: [inaudible] ancillary things that could happen as a result of [inaudible] war in terms of [inaudible] you know, and the things [inaudible] so forth. [inaudible] should something like that occur as a result of the United States maybe being involved in--do you understand what I'm saying? If we attack Iraq [inaudible] public health issue. Have we [inaudible] any issue consulted the White House [inaudible]?

DR. GERBERDING: There's a subtle distinction between bioterrorism and bio-warfare. We are addressing both of them in our state of preparedness.

MS. SWENARSKI: Next question from the telephone.

AT&T OPERATOR: We will go to the line of Bill Welsh with Washington Technology. Go ahead.

QUESTION: Hi, Bill Welsh with Washington Technology. My question is about state health alert networks, and it's for the gentleman that was discussing state and local coordination whose name I didn't catch. And the question is this: Are any of the state health alert networks up and running right now? We've been told that Texas was the first to go live when it launched August 9. Is that accurate?

MR. HENDERSON: Yeah, this is Joe Henderson. I think we can say beyond a shadow of a doubt that the health alert network across the country is far-reaching. I can't think of too many local health jurisdictions which number in the thousands that don't have some connectivity to the health alert network. I know all the states have connectivity. It's a pretty robust network, and it exists across the spectrum of our public health system right now.

As far as Texas being the first up, you know, I have not heard that before. I was always under the impression that many states came live or were able to receive health alerts almost simultaneously. So that's new information to me.

DR. GERBERDING: I'll just add that on 9/11 we sent a health alert, and it went to every state in the country. What you may be talking about is the level of penetration into the clinical community. So we can get to health departments that we want to be able to put that information throughout the entire response system, including the clinicians on the front line who need to have that information to respond to patient issues, and there are still some gaps in the alert system to get to those people instantaneously. That's why we're developing other mechanisms involving other partners, including medical associations, to make sure that we get down the last common denominator of the response team.

MS. SWENARSKI: Next question from the audience, please.

QUESTION: I have a question [inaudible]. If something happened [inaudible] how would the CDC respond? What would be different? I remember when in the fall [inaudible] very quickly [inaudible] press conferences were held at the postal facility where later on it was found to be contaminated, and it might not have been [inaudible]. So given [inaudible] if something happened today, what would [inaudible]?

MS. SWENARSKI : Let me repeat that question for those on the telephone. CNN is asking if we had another situation like last fall related to anthrax happen today, what would differ in CDC's response?

DR. GERBERDING : Let me just start, and then I would like to Dr. Hughes to chime in here.

I think one of the most important things that would be different this time around is that we would prepare people for the fact that we learn as we go, and what's going on today is not likely to be the same as what's going on tomorrow because we will have new information and we will be learning something. So in a sense, our capacity to communicate up front, this is what we know today, this is what we don't know, this is what we're going to do to find out, and tomorrow we will update you again. I think that will be a very major difference.

Jim, maybe you had some other perspective.

DR. HUGHES: Yes, this is Jim Hughes. Let me just add a little bit to that. We would also be very alert in our response to another attack should it occur. Obviously, we've experienced one attack. Terrorists know how we responded to that, and they might take that into consideration in whatever their modus operandi turns out to be. So although we would be much better prepared to know how to use nasal swabs, for example, than we were a year ago, we would not want to get into a cookbook response to this outbreak because of the possibility that the nature of the organism might be different, that there might be antibiotic resistance that would be more of an issue.

So we would be alert and more efficient in our response. We would want to characterize very, very rapidly the organism that is responsible, and all this hinges on active surveillance systems and alert clinicians who are in frequent communication with local and state health department authorities because this attack in the fall was recognized at a very local level, and we suspect that that will be the case in the future as well.

DR. GERBERDING : Dick, do you want to add something?

DR. JACKSON: I think one--this is Richard Jackson. One other significant change is the upgrading of the Emergency Operations Center. Prior to 9/11, we had a rather small ad hoc activity, and in order to manage thousands of specimens, dozens, hundreds of people in the field, requires an operational center that's physically set up to manage that kind of thing--large screens, satellite connections, secure communications and the rest.

With the help of the CDC Foundation, the Marcus Foundation and others, as well as help from the department, that is in place temporarily, but by the end of this calendar year, we will physically have an operations center that is the quality of anything in the world.

DR. GERBERDING And Joe I think has an important point to add also.

MR. HENDERSON: This is Joe Henderson. Just one final point. I think it's an important lesson that we learned last year and we continue to learn in the anthrax investigation, is the coupling of the epidemiological investigation, the investigation of the disease outbreak and the response, with the criminal investigation that's being conducted by the FBI and local law enforcement.

In the fall, in some cases that worked very, very well, and in other cases we could improve that relationship. And I think it's going to be an ongoing issue for us, especially if we have a communicable disease, which anthrax is not. And we've learned a lot, and we continue to learn. Working with them is just an ongoing process.

DR. GERBERDING: I have to just add one more thing because it's an exciting thing for me. When you're involved in an outbreak or the intense investigation that we were involved in in the fall, it's really hard to step back away from it and retain your scientific perspective and your big picture.

One of the lessons we learned is that we need to set aside some scientists at CDC and outside of CDC who aren't involved in the day-to-day things but are there to second-guess or ask questions or go to the library or, you know, get answers to things that come up on a moment's notice. And during this West Nile exercise right now, we have a team of people, sort of the Team B, who are not involved in managing the West Nile operation but who are looking at the research questions, identifying the information needs, going to external experts for input and advice, and really keeping that balanced perspective. I think that's also a very, very helpful component of an effective response system.

MS. SWENARSKI : Next question from the telephone.

AT&T OPERATOR: That would be from Laurie Garrett (ph) with Newsday. Please go ahead.

QUESTION: Thank you very much. First, if I may make a quick comment regarding improving communications, which I think all of us in the media would greatly applaud, I only received notification of this about five minutes before the press conference started, and I don't--and I got it third-hand. I don't know how notification has been done, but it would be really, really great if we could set up some more formal system of establishing sort of getting to know you between those of us in the media that are on this feed on a routine permanent basis and the new press team there at CDC. That's just a suggestion.

Meanwhile, two quick questions. One, all of you have mentioned the FY--I believe 2002 figure of $918 million for local and state preparedness. Where do we stand with the FY 2003 figure, or is that 918 the FY 2003? I just want clarification on--FY 2003's approaching.

And then the second real quick question for Julie. I understand that--or Dr. Gerberding. I understand that the CDC will shortly be announcing a gigantic epidemiological prospective study that will involve 200,000 New Yorkers potentially exposed to Ground Zero air and take place for a 20-year period. I also understand that so far in terms of all the meetings set up to determine who will be in that 200,000 people surveyed, it specifically only includes residents of Manhattan, though the plume from it went directly on 9/11, according to NASA space shots, to Brooklyn and the primary residential exposure was Brooklyn, not Manhattan.

I wonder if you have any plans to include anybody other than workers who happen to live in Brooklyn but worked at Ground Zero, any residential environmental exposure cases from the borough of Brooklyn, or will it remain as currently designed, exclusively for residents of the borough of Manhattan?

DR. GERBERDING: With respect to the first question about funding, the dollar figure that you're citing, the 918, is the amount of money that HHS made available to state and local health departments for FY02 supplemental funding. So it represents money that was added into the budget basically for supplementing some of the things that already existed. And we're very optimistic that the budget in 2003 will be at the same level or better, although we are not able to disclose those figures at the moment because the budget is not yet approved.

With respect to the other question, I believe what you're talking about is the registry project which is going on with ATSDR and the investigators in New York, and I do not know the details of the eligibility criteria, so I'm looking at the panel to see if others might know what the criteria are for inclusion. We can follow up on that and get back to you.

MS. SWENARSKI : Laurie [inaudible] I'll have someone [inaudible] call you, and also we sent the media advisory out yesterday at noon to our regular beat reporters [inaudible] sure we have it.

Did anybody else have a problem getting the advisory in time?

QUESTION: I guess I'm not on your list of regular beat reporters --

MS. SWENARSKI: Next question from the audience.

QUESTION: I have a question, I guess, for Dr. Hughes or anybody else on the panel, and it's about health care workers. Are health care workers really ready if something were to happen [inaudible] emergency room workers? And if [inaudible] monitoring and making sure, and doctors are very busy, how are they fitting this into their schedule?

MS. SWENARSKI : Okay. The question is: Are health care workers ready for [inaudible] incident? And what is CDC doing in terms of training in that area?

DR. HUGHES: This is Jim Hughes. As I mentioned in the opening remarks, clinician education is a very high priority for us. Remember that the visas that are those of greatest concern from the standpoint of terrorism, which are anthrax, smallpox, plague, tularemia, botulism, and viral hemorrhagic fevers are diseases that either don't occur at all in the U.S. or in the world, in the case of smallpox, or occur, but at a very low level.

So they are diseases that clinicians, physicians, nurses, other health care providers are not familiar with. They may have heard a little bit about them back in medical school, but they certainly, by and large, haven't had to deal with them since.

So we're starting at a fairly basic level, and there are a number of approaches that we've used. We've used some satellite video conferences through the Public Health Training Network here at CDC that has reached a large number of clinicians during the response to anthrax. Subsequently, there have been courses on smallpox, and we had one recently to provide clinicians and other health care providers with information on clinical manifestations of West Nile encephalitis, again, a disease that's not familiar to clinicians in this country.

We've used our website. We've used publications. We've worked with professional societies and other groups who are also very interested in reaching out to the clinical community. We had a meeting here back in January, where we brought members of professional societies together. We're working with them to try to standardize some of the information.

This is an area that's been of great interest to Dr. Gerberding, too, and she may want to elaborate.

DR. GERBERDING: Yes. We really do look at the information needs from the standpoint of the just-in-case information, and that is what do people need to know just in case they see a patient who looks like they might have a toxic exposure or an infectious exposure, and then the just-in-time information, which is what do people need when something is happening, and they are likely to be managing or need to be updated on a day-to-day basis about the evolving guidelines.

The just-in-case information system, we just had two more consultations with experts who participated in that over the last week, and it's moving along in a rapid pace. It includes, for the Level A providers, which is basically anybody at the front edge: What does the common syndrome look like, the important syndromes; what do you need to do in terms of ordering tests; what isolation is necessary if it's an infectious agent or a toxin that could contaminate others; and how do you report it?

And it's that linkage between the suspicion, the lab, and the reporting mechanism that we're really trying to emphasize the most, but we also want people to get help. So, if they're suspicious, they're going to call and consult, and that brings us to Level B, which is how do we educate the infectious disease export or the neurologist or the dermatologist so that they have the expanded knowledge they need to provide appropriate clinical consultation.

And then Level C is really the teachers. Who are the peer experts that will be going out and doing the continuing education for the clinician community? Most of those people are in the professional organizations that have been coming in and really serve as credible and respected experts from the medical community who can provide that layer of education.

So I think we're well on our way. And one of the great examples of this, and I know Jim has been experiencing over the last several months, is we get calls periodically from people, for example, with a fever and a rash, and there's concern that it's smallpox.

And so the clinicians in that locale are vigilant. They're looking for these problems, and when they're concerned, they're calling their health department, they're calling CDC. We're evaluating, sometimes through telemedicine, sometimes we go on-site and get samples and so forth, depending on the level of suspicion.

But we're practicing and exercising our capacity, but it's also telling us that the message is hitting home because the clinicians are calling us when they're concerned. So I think we're making good progress here, and we love those false alarms because it tells people are alert and they are looking.

QUESTION: Is that the only way you have to know if they're getting the message, and if they're getting the education that they need to [inaudible]? Is that the only way you have to monitor?

DR. GERBERDING: We're not involving the clinicians in a surveillance system, but we certainly know who we're training, and who's watching, and how many of us are out on the trail giving lectures and continuing education courses, slides, the Web. We have a number of media that are involved in this, as well as many societies; for example, go to the American Academy of Dermatology website because they have a phenomenal set of images there to teach dermatologists about the clinical presentation of the select agent.

So there are a lot of multi-media efforts going on.

DR. HUGHES: This is Jim Hughes. Just one additional, quick comment.

Your point is well-taken about the need to evaluate these approaches, and we are developing plans to do that.

DR. JACKSON: This is Dick Jackson.

I just want to add that one thing, that it is important to do the cognitive training, to give people information. It is also important to take people through the drills and give them the experience of how you respond, particularly in a chaotic and difficult situation, and we are planning both that kind of emergent training for our own senior staff, and that will happen very, very soon, as well as extensive training for 600 to 1,000 state, city and local leaders for the management working with emergency response agencies and the medical community.

QUESTION: What about the public [inaudible]?

CDC MODERATOR: We do just have time for one more question from the telephone. Please keep in mind that if you have any remaining questions, just call our Press Office, and we'll connect you to the people you need to talk to.

Thank you.

Next question from the telephone?

AT&T OPERATOR: That'll be from John Lauerman [ph] with Bloomberg News. Go ahead, please.

QUESTION: Hi. Thanks very much for having this.

Today, Secretary Thompson said that he felt that HHS was quite well-prepared to deal with a bioterrorist event. Since we're sort of assessing, in a way, where we are, I'd like you to, if possible, talk about whether by using a percentage number or using other qualitative description of where we are right now. Obviously, we're farther along than we used to be, but how close are to where we need to be?

Thanks.

DR. GERBERDING: Well, I agree with Secretary Thompson. I think we are quite well-prepared, but I know he's also said that we're not done yet, and we can always continue our preparedness efforts, and we intend to do that.

It's not something that can be quantified with a number or a scale. Preparedness is not all or none, it's a continuum, and we will continue to make investments and work aggressively to do as much as we can, as fast as we can, scaling up, speeding up and streamlining.

Thank you.

CDC MODERATOR: That concludes our briefing today. We really appreciate your coming, and please call us if you have more questions.

Thank you, everyone.

[End of Media Briefing.]

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