CDC Telebriefing Transcript

West Nile Virus Investigation Update

September 27, 2002

CDC MODERATOR: Good afternoon, everyone, and thank you for joining us. I want to just introduce briefly who we do have on the line to talk today. Dr. Lyle Petersen, West Nile virus expert, International Center for Infectious Diseases here at CDC. We also have on the line Dr. Jesse Goodman. He's deputy director of FDA's Center for Biologics Evaluation and Research. And also joining us today is Dr. Matthew Boulton. He's a state epidemiologist, Michigan Department of Community Health.

We're going to begin our presentation with Dr. Petersen making a brief statement. Then we will take questions from the media.

I also want to mention to you folks that we are doing a special MMWR, which will be available later this afternoon on our website.

Dr. Petersen?

DR. PETERSEN: Thank you.

As of the 26th of September, the total number of West Nile virus cases reported to CDC reached 2,206, with 108 deaths. Additionally, 32 states and Washington, D.C. have reported human cases of West Nile virus in 2002. The state of Michigan is now reporting 314 human cases.

Data suggests that the epidemic peaked in the southern states during August and probably within the last two weeks in northern states. Infections continue to occur, however.

We are reporting today additional cases where blood transfusion is being investigated as a suspected cause of West Nile virus. In one case, two individuals in Michigan who received blood products from the same donor both contracted West Nile virus infections. Both patients received transfusions, but only those from the common donor tested so far were found to carry West Nile virus. This case provides additional proof that the virus can be spread through blood products.

The latest investigation of apparent West Nile virus transmission from the blood of a single donor of two recipients who developed West Nile virus infection provides additional proof that the virus can be transmitted through blood and blood product transmission.

Additionally, CDC investigations of West Nile virus cases continue to yield new information about the virus. For the first time, laboratory analysis shows that genetic material from the virus can be found in human breast milk. Further study is under way to confirm whether or not the virus can be cultured or grown from a breast-milk specimen.

The case involves a nursing mother from Michigan, one of the two cases previously cited, who contracted West Nile virus infection. The woman has since recovered, and the child remains healthy. The CDC, working in conjunction with the Michigan State Department of Health will conduct follow-up testing of the infant and conduct additional testing on blood donors.

Now I'd like to make a few important points about this new finding in regard to breast milk. First of all, we know that breast feeding is extremely beneficial to mother and infant. We do not know if West Nile virus can be transmitted through breast milk, and these findings do not suggest a change in breast feeding recommendations.

The only two infectious conditions where infants should not be breast-fed are when the women have--when the mother has HIV infection or human T-cell leukemia virus type 1. Lactating women with documented--and I emphasize "documented"--West Nile virus infection may wish to consult their physician about breast feeding.

Thank you.

CDC MODERATOR: Thank you, Dr. Petersen. We now will take questions.

AT&T MODERATOR: Our first question comes from the line of Miriam Falco with CNN.

QUESTION: Hi. Thanks for doing this for us. Could you tell me a) what's the age of the child; and b) if the woman was symptomatic when she--if you could give a little bit of detail when she got the--when you think she got West Nile virus, was she breast feeding before or afterwards; and why would you not--you could be asymptomatic, therefore not know that you have West Nile virus. Why would you not want to recommend that women who are asymptomatic and therefore don't know it shouldn't breast feed either? I mean, it seems very vague. Is there--do you know--do you think that women who are symptomatic have more West Nile virus in their system than if you're not symptomatic?

And then if I can ask one third question; that is, what have you learned from other countries in the past where there were breast-feeding mothers? Were there higher incidences of children having West Nile virus?

DR. PETERSEN: That's quite a bunch of questions.

QUESTION: I'm sorry.

DR. PETERSEN: Why don't I turn this over to Dr. Boulton who can talk a little bit more about the specifics of this case?

DR. BOULTON: Yeah, why I don't give you some information on the specific case. This was a 40-year-old female who delivered a healthy infant on September 2nd. That same day she received a transfusion of a single unit of blood, and the following day she received another unit of blood. She had an examination by a neurologist. She had a fever during her hospitalization; was subsequently discharged on September 4th. Did not feel well and had intermittent fever during that period of time, and some headaches, and then was readmitted on September 17th.

She had a spinal tap on September 18th, and the cerebral spinal fluid was submitted to our laboratory for West Nile virus testing. The patient was then discharged about three days later and is doing well. And the patient was confirmed as West Nile virus-positive yesterday.

The infant at this time is doing well clinically, and a blood specimen is being submitted for testing today.

QUESTION: And what about the volume of virus in asymptomatic versus symptomatic people? And obviously you might not be able to tell us about the breast milk, but just in general what you know about the virus in the body. And then also the historical evidence you have from the old world, as you guys always call it.

DR. PETERSEN: There is not enough information right now available to determine how long people become viremic or asymptomatic versus symptomatic. Most of the information about West Nile virus viremia comes from old studies done in the 1950s, where cancer patients were purposefully injected with West Nile virus as a potential cancer cure. And these are not normal people.

Among this group of people who were injected with virus--and again, these were injections of virus--the--if you take the group of people who were least sick--they all had cancer, but if you take the group of people who were least sick, the average duration of viremia was about four to five days. But we do not have very good data on the durations of viremia of asymptomatic versus symptomatic people simply because these kinds of studies would not be ethical to do at this point in time.

CDC MODERATOR: Thank you, Dr. Petersen. Next question, please?

DR. PETERSEN: I think there was one more part of this.

The other part of the question was what do we know about other countries? From other countries we have no evidence that West Nile virus can be transmitted via breast milk. However, where West Nile virus is endemic, namely, in parts of Africa and Western Asia, there is ongoing transmission to children via mosquito bite, which is going to be by far the most common route of transmission. So it's very difficult to sort out breast milk versus mosquito bite, but all of the data we have right now would suggest that mosquito bite would account for all of the, or pretty much all of the infections in these endemic countries.

We need to clearly--what these data tell us right now is that we need to study the potential role of breast milk in West Nile virus transmission in the future.

AT&T MODERATOR: We now go to the line of Seth Borenstein with Knight Ridder. Please go ahead.

QUESTION: Yes. To continue on this, I want to make sure. You did find nucleic acids in the breast milk and you will be able to find out if the--the results of the infant test, I'm wondering when that will be?

And the second question, to step back further, looking over the 2,000 some case that you now have, it is still skewing a little younger than in previous years. Is there any explanation still on why that is? Is it perhaps related to more possible non-mosquito-oriented infection, such as transfusion?

DR. PETERSEN: To go back to your question, what are we--I think your question is, is what are we doing right now to further clarify this case? There are two things we are doing. One is, is that we are testing the infant right now for the presence of antibody against the West Nile virus or against--IGM antibody. If the infant has IGM antibody, that would indicate that the infant was in fact exposed to the virus.

The second this we are doing is, is we are attempting to culture the virus from the breast milk. We, as you picked up on, we've only detected viral genetic material in the breast milk. We do not know if this indicates live virus or not. So we are attempting to culture this. We--and we are also testing additional breast milk specimens from this patient as well.

QUESTION: Well, I guess my questions were timing. When will you be able to know the results of the test on the infant, and when will you know the results of being--whether you can grow, culture the virus from the breast milk? And then the other question was taking a look at the age group overall of the 2,000 cases this year.

DR. PETERSEN: Right. The results on the antibody testing from the state lab of the infant, Dr. Boulton can attest to. I can attest to the culture results. We have put these samples on culture. And they're on a cell culture, which is called zero cell culture. And what is happening right now is the breast milk appears to have a toxic effect against the cells that we're doing the cultures on, and this is a laboratory problem.

Normally what would happen is we would get a culture result within 5 or 6 days, and so we should have a result next week if all goes well, but I can[?] guarantee that there will not be problems with the culture for the reason I just described.

Dr. Boulton, do you want to talk about the antibody test results?

DR. BOULTON: Sure. I understand the mother came back as a confirmed case yesterday, so this has all developed very quickly. We plan to obtain specimens from the child and additional breast milk from the mother today, and would anticipate that results would be available at the beginning of next week, and I'm talking about the child there. We'll be testing breast milk here and sending breast milk on to the CDC for additional testing, per Dr. Petersen's comments.

DR. PETERSEN: Now, regarding the age distribution of the cases this year versus previous years, the age distribution of the cases this year is younger than previous years. This is due to the fact that a larger number of West Nile fever cases have been reported than in previous years. In previous years nearly or all of the cases reported had meningitis or encephalitis. This year only about 75 percent of the cases have meningitis or encephalitis. The remainder have West Nile fever.

The fact that West Nile encephalitis or meningitis occurs in older persons accounts for this age distribution between this year and previous years. So because we have more West Nile fever cases it's bringing down the average age. If you look at only cases associated with West Nile meningitis or West Nile encephalitis, the average age is exactly the same as it was in previous years.

The other point I would like to bring out is if you look among children less than 1 year of age, there's only been four children reported who are younger than one year of age out of these 2,206 persons reported. This would suggest that the risk of West Nile virus infection due to breast milk among infants is going to be low, if there is any risk at all.

CDC MODERATOR: Thank you, Dr. Petersen.

Next question, please.

AT&T MODERATOR: The next question's from Adam Marcus with Health Scout. Please go ahead.

QUESTION: Forgive me if you've already addressed these questions, but do you have the gender of the infant, and do you know whether the woman contracted West Nile through a blood transfusion or a mosquito bite?

DR. PETERSEN: Dr. Boulton?

DR. BOULTON: We do not have the gender of the infant. We're attempting to protect confidentiality here. And, no, we don't know whether the West Nile virus infection was acquired through transfusion or through mosquito bite. I think that's what we're attempting to ascertain through our trace-backs of the blood supply, but that will continue to be a question.

DR. PETERSEN: Again, this patient was one of the two patients that we've described that had a common donor and both of the recipients developed West Nile virus infection following transfusion, and this blood sample taken at the time of donation, stored blood sample, subsequently was found to have evidence of West Nile virus genetic material. This would indicate that our patient here and the other patient had gotten West Nile virus from a transfusion, but as Dr. Boulton has pointed out, we can't rule out without certainty that mosquito bite could have been a cause of infection in these two people.

CDC MODERATOR: Thank you, Dr. Petersen.

Next question, please.

AT&T MODERATOR: We go to Lauren Neergaard with the Associated Press. Please go ahead.

QUESTION: A couple follow-up questions here. First of all, if you do find the IGM antibodies in the baby, you don't actually know when the mom was infected, do you? I mean there could be maternal antibodies, couldn't there?

And the other question is, just so that you can be really clear in the message to consumers here, because I imagine a lot of new moms will start to worry if they're in some of these heavily infected areas. If a new mother is sick with these types of symptoms, what is the actual advice when it comes to breast feeding? And what was the advice given to this mother? Did she actually temporarily quit breast feeding? I know you said you're going to get new samples from her, so she couldn't have for terribly long.

And the samples that you're testing, the original samples, did she have some frozen milk or something?

DR. PETERSEN: Yeah. I'd like to answer your first question, and then turn this over to Dr. Boulton for the question specifically about this patient.

Our recommendation is, is that people who are sick and think they may have West Nile virus infection, go to their physician to get the proper laboratory testing to determine if they in fact do have West Nile virus infection. Lactating women with documented West Nile virus infection may wish to consult with their physician about breast feeding. That is our recommendation.

QUESTION: But what is your recommendation to the doctors to tell them? I mean is there a reason to tell them no?

DR. PETERSEN: We do not have sufficient information yet to determine whether West Nile virus can be transmitted via breast milk. Therefore, other factors would have to be taken into consideration in advising the women about the decision to temporarily discontinue breast feeding.

Factors would include, for example, the illness in the woman. If the woman has severe disease and cannot be breast fed--or not breast feed easily and provide sufficient nutrition to her child, we would certainly in that case recommend that a supplemental feeding would take place.

On the other hand, breast feeding has many beneficial effects that are extremely well documented, and the decision to discontinue breast feeding is a big one, and must be taken in account with the whole situation of the patient.

QUESTION: And, Dr. Boulton, can you answer the question specific to the patient?

DR. BOULTON: Yes. The patient initiated breast feeding on the day of the birth of the baby on September 2nd, and continued to breast feed through the second day of her readmission, which would have been September 19th, so breast fed for a little more than 2 weeks. At that time, in discussions with her personal physician, they made a decision that she would stop breast feeding. And she continued pumping, however, at that time, and we were able to obtain a breast milk specimen from her, and in fact, we're again in the process of obtaining a second specimen from her as well.

She has not at this time resumed breast feeding.

AT&T MODERATOR: We now go to the line of David Brown with the Washington Post. Please go ahead.

QUESTION: Yes. Dr. Petersen, the normal route of acquisition of West Nile virus is obviously parenteral, it's through the skin into the bloodstream. Is there any evidence that's either experimental or observed that it actually can be acquired through the [inaudible]--

CDC MODERATOR: Excuse me, David, you're breaking up on your question. We can barely hear you.

QUESTION: Okay. Is there any evidence that West Nile virus can be acquired orally, even experimentally; and is there any evidence that viruses like it, like yellow fever or other normally blood-transmitted viruses like hepatitis B and C can be acquired through an oral route, which is not their usual route of transmission?

And unrelated question, can you just say something about the 27-year-old person who died in Louisiana--it was reported yesterday--and whether that person had some immuno-suppression? Because that seems quite young to die.

DR. PETERSEN: Let me just answer your last question. I cannot answer the question about the 27-year-old who died in Louisiana simply because I don't have the information here. If you want to contact our press office about this later, we'd be happy to try and answer your question.

The other question about the normal routes of West Nile virus transmission, this is an excellent question. I'm glad you asked it.

Tick-borne encephalitis and Kyasanur Forest disease, and Powassan virus, are related flaviviruses. These have been shown to be transmitted in animal milk, and large epidemics of tick-borne encephalitis in humans have been documented with oral transmission by drinking cow's or goat's milk. These are flaviviruses that are normally spread by ticks. We are talking about a flavivirus that's spread by mosquitoes. Whether that makes any difference or not, I'm not sure.

As I mentioned earlier, we have no evidence that West Nile virus can be transmitted to humans by the oral route, but there is a lack of data about this. The epidemiology of the virus in this country suggests that it remain mosquito-borne.

Now, the only data about West Nile virus and oral transmission is that we've done experimental studies in birds and have demonstrated that West Nile virus can be transmitted to birds via the oral route. We have no data from humans.

AT&T MODERATOR: We go to the line of Phil Green with ABC News Radio.

QUESTION: With mosquitoes obviously being the main carrier, the standing water in Louisiana following Hurricane Isidor and that area in general seeing so many cases, how big a threat, increased threat is that standing water?

DR. PETERSEN: Thank you for that question, Phil. It is also a good question and one that I think people should ask. What tends to happen after tropical storms or hurricanes is it actually temporarily may decrease the risk. It sounds paradoxical that, to put it in laymen's words, it basically washes everything out.

This is a mosquito that likes to breed--mosquitoes that spread West Nile virus are mosquitoes that like to breed in small containers of water. So big floods, at least for the short run, actually may decrease transmission instead of increase it.

CDC MODERATOR: Next question, please?

AT&T MODERATOR: We go to the line of Denise Grady with New York Times.

QUESTION: I'd like to know if there's any more information about whether or not illness is more likely to result if exposure comes via blood transfusion than via a bite. You know, is there any more risk or higher doses of virus or more vulnerability by a transfusion? Would you see a higher rate of people infected from transfusions than you would see from bites? Is that known yet?

DR. PETERSEN: Yeah, Denise. This is a question we really would like to try and find out. One of the confounding factors here is that persons who receive transfusion, many of them are not--may have impaired immunological systems to begin with. For example, cancer patients or patients with leukemia or other chronic diseases may have an impaired immune system, and these are actually the people more likely to get transfusions, as well.

So it's hard to sort it out right now at the present time. And it's one of the reasons why we're doing all these investigations, is to help sort this issue out.

QUESTION: Thanks. Can I ask a follow-up, just one other question on that?

DR. PETERSEN: Sure.

QUESTION: It's actually unrelated. Could you please say again when you would expect to have a result on the baby's test for West Nile?

DR. PETERSEN: As far as the viral culture, we would hope to have a result next week. And as I mentioned earlier, there may be a problem with culturing, the viral culture on the breast milk and we may have to try a couple of different techniques to do it. So I don't want to promise a result in a week, but if all goes well, we should have a result by next week.

QUESTION: But is that on the baby or on the milk? What about just on the baby?

DR. PETERSEN: That's on the milk.

QUESTION: Yeah. What about on the baby?

DR. PETERSEN: Well, we wouldn't expect the baby to have a positive viral culture because--at this point in time.

QUESTION: Okay.

DR. BOULTON: This is Dr. Boulton. We're obtaining a blood specimen on the baby for testing, which we would expect to have a readout on that at the beginning of next week.

QUESTION: Thank you.

CDC MODERATOR: Thank you, Dr. Boulton. Next question, please?

AT&T MODERATOR: We go to the line of Steve Wilcox with Fox 2 Detroit.

QUESTION: Thank you very much. First of all, you mentioned there were two cases. I don't think we've talked at all about the second case. From my understanding, it is a 12-year-old from the Detroit area, Oakland County. And if you can tell us--because being here in Michigan, obviously Oakland County's been where the majority of cases and deaths have occurred--is this mother, can you give us any location geographically as far as the location for the case involving the mother as well?

DR. BOULTON: Yeah. All we'd say is that the mother's located in southeastern Michigan. Actually, the second case, which Dr. Petersen summarized at the beginning of this call, is a 47-year-old male rather than the 12-year-old female that you're referring to. And the 47-year-old male was a recipient of a liver transplant and multiple transfusions and was subsequently diagnosed with West Nile virus. And again, we're investigating that from a common donor source with this 40-year-old female who delivered the infant.

AT&T MODERATOR: We now go to the line of Sarah Fruman [sp] with NBC News Channel.

QUESTION: I'd like to clarify if in fact tests confirm that there are--the West Nile virus has been found in more samples of this mother's milk. Would it be safe for her to continue breast feeding at this point, assuming that the child has not been infected?

DR. PETERSEN: Well, first of all, I'd like to emphasize that we do not, you know--that we've only detected viral genetic material in the milk. At the present time, we do not know if there was live virus in these milk samples. And until, I think, we can determine that, it's hard to answer your question. However, we would expect that the virus in the breast milk would be present in the breast milk for a very short period of time. And we'd expect, if there is any risk, that risk would become negligible within a very short period of time. But I don't think we have enough data yet to answer your question.

Dr. Boulton may want to comment further.

DR. BOULTON: Well, as I said earlier, this patient, in concert with her personal physician, elected to stop breast feeding during her second hospitalization, and has also decided that she is going to continue to pump but not use the breast milk pending further testing on her baby. And then she'll be making a decision in concert with her physician again as to resuming and when to resume breast feeding.

And again, I think it's an important thing to emphasize, is that there are well-documented benefits of breast feeding. And to echo what Dr. Petersen said, we really have insufficient evidence to make any type of recommendation altering those recommendations for breast feeding.

CDC MODERATOR: Thank you, Dr. Boulton. Next question, please?

AT&T MODERATOR: Next question comes from Anita Manning with USA Today.

QUESTION: Hi. Can you hear me all right?

DR. PETERSEN: Yes, I can.

QUESTION: Okay, thank you. Several of the questions that I had have already been answered. But the one remaining is given this extra evidence of transmission through blood transfusion, Dr. Goodman, I'm wondering if the FDA is considering any steps imminently, any kind of further warnings or anything more to safeguard blood transfusion.

DR. GOODMAN: Yes, you know, certainly as this and other case investigations and evidence is considered, we are considering whether and when we may need to take additional steps. I should say that we really had already concluded that blood transmission was very likely, and we really have been acting on that conclusion and that this latest report, I think, even significantly strengthens the support for that conclusion and for taking action.

I think one of the most important things right now is that we are urgently working with manufacturers and others with potential blood screening tests to try to really facilitate their availability. And these discussions have been, I would say, extremely promising. And the continuing information we're receiving is just, you know, causing us to really redouble those efforts and continue them on a fast track.

But we are, yes, you know, concerned about these latest results and considering some of the other possible actions at all times. As we discussed before, we are communicating continuously with the blood organizations trying to improve, and will provide formal guidance on post-donation illnesses that occur. We're working very hard with CDC and other partners since the study to try to determine the real prevalence of infection in the donor pool and the actual risk of infection. And we do have on the table the other measures in terms of if we should need to take other actions with respect to donors. This is a very active process. We're discussing this continuously, but at the moment, other than pushing very hard ahead on the testing issue, I don't have something new to report.

CDC MODERATOR: Thank you, Dr. Goodman.

Next question, please.

AT&T MODERATOR: That comes from Rob Davadek with Infinity Broadcast. Please go ahead.

QUESTION: Hi. This is Pat Sweeting, WWJ, also asking a question on behalf of Rob.

I would like to ask a question of Dr. Goodman in reference to the blood transfusions. What do you say to the public to keep them from becoming overly concerned about receiving blood that is tainted with West Nile virus?

DR. GOODMAN: Well, I think we're trying to give a balanced message at a time when the level of our information about how small or great the risk is, you know, is still uncertain. And I think a fair way of putting this is that we believe that this virus can be transmitted through transfusions. And this is based on a small number of cases which are undergoing investigation, some of which we believe will be proven to have been related by transmission, or maybe not proven in the strict scientific sense, but where we highly suspect that, others of which may not.

We think people should be aware of this risk and aware that we are continuing learning more about its potential degree. I think--and we've given this message before, that given this [inaudible] individuals are concerned, can think about their medical options with respect--those who have options with respect to transfusion or elective surgery, people with those concerns should discuss them with their physicians.

You know, there is a potential I certain circumstances for storing one's own blood, called autologous blood transfusion, for using specific surgical techniques which we in certain cases reuse the patient's blood, or for people who are very concerned and in areas where there's active transmission going on, to consider with respect to elective surgery the timing and whether they want to have it at that point.

I think--you know, so we're trying to be open at this point at a time when we're concerned about the risk, and let people make--take their own way forward and make their own decisions based on the information which really is available to us.

We do try to also provide the perspective that for people for whom a blood transfusion or an organ transplant is a lifesaving procedure, although this risk is there and we're concerned about it and we don't know everything about it yet, the benefits for those patients are likely to outweigh the risk.

This is, you know, a number of cases now that are under investigation, but the universe they occur from is something like 4-1/2 million individuals receiving blood products in a year. So I don't want to either understate it in that we're learning more on a daily basis, but I also think people do need to keep it in that overall perspective.

Another important point about this is that we are not aware of a long-term chronic carrier state for West Nile virus. We're not--there has not been evidence that an individual is infected for life or for months or anything like that, so it's not as if this should remain in donors and pose the kind of risk to a donor pool that some chronic infections like hepatitis do.

Again, we're taking it really seriously. I think what has happened is that in the context of really a record epidemic of West Nile disease and probably increasing amounts of involvement of human and mosquito--excuse me--of bird and animal and mosquito populations, that the human bystanders have been affected to a degree never before, and we're seeing that spill over into some transfusion and transplantation issues.

It's a problem because we expect blood to be highly safe, but you know, we are taking very seriously and acting on, and we will do everything we can to intervene effectively as quickly as humanly possible.

CDC MODERATOR: Thank you, Dr. Goodman.

Next question, please.

AT&T MODERATOR: Reginald Ryan with Script World. Thank you. Please go ahead.

QUESTION: Yes. This question really is for Dr. Jesse Goodman. Today at the ICAAC [ph] meeting there was a paper presented by [inaudible] saying that now they have preclinical data on a vaccine. And the question I have is what is FDA doing about this? Are you trying to accelerate its approval?

DR. GOODMAN: Well, you know, FDA, by law cannot comment on confidential matters from companies that might or might not be under review at the Agency. What I would tell you is that we place an extremely high priority on West Nile virus as a public health problem.

And you've got the right person on the phone, because the Center for Biologics which handles blood issues, also is responsible for reviewing the efficacy and safety of vaccines. And we encourage sponsors with any potential vaccines or treatments or blood tests for that matter for this disease to talk with us, even informally and very early outside of their process of applying for a license. And then when they do interact with us, we would view this as a very high priority for us right now and we would do everything we could to expedite development of such a product.

With respect to that particular company or vaccine and any interactions that they might or might not have with the FDA, I would ask you direct your questions to them.

CDC MODERATOR: Thank you, Dr. Goodman.

We have time for at least two more questions. Next question, please.

AT&T MODERATOR: And that comes from Karen Mellon with Chicago Tribune. Please go ahead.

QUESTION: Yes. I just was wondering, how many cases are you talking about for potential infection from transfusion or transplant, and what have been the outcomes for the patients? We had the one death from the southern man but--

DR. PETERSEN: Right. Right now through our investigation we have very strong evidence that there are four transplant-patient-associated West Nile virus infections, one of whom has died, and three transfusion-associated cases of West Nile virus infection, the two in Michigan that we've discussed today, as well as the one in Mississippi that we've previously discussed. All three of these persons are alive and doing well.

QUESTION: Thank you.

CDC MODERATOR: Next question, please.

AT&T MODERATOR: We go to Barbara Hyde with ISIC [ph] Meeting. Please go ahead. Barbara Hyde, your line is open.

[No response.]

AT&T MODERATOR: And we'll move on to the line of David Brown with Washington Post. Please go ahead.

QUESTION: Yes. Dr. Petersen, can you just name those [inaudible] viruses again and whether there's any other ones other than tick-borne encephalitis in which the disease has been transmitted orally through milk to human beings?

DR. PETERSEN: There's two: tick-borne encephalitis virus, and Kyasanur Forest disease. And that's K-y-a-s-a-n-u-r Forest disease. These have been shown to be transmitted in animal milk to humans.

QUESTION: Okay, thanks.

CDC MODERATOR: I'd like to thank both Dr. Petersen, Dr. Goodman and Dr. Boulton for joining us today and discussing this.

I remind the callers that we are doing a special MMWR, which will be up on our website later today. If there are further questions, please contact the press office at CDC.

Thank you and have a good afternoon.

[End of teleconference.]

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