Transcript for CDC Telebriefing: EIS Conference

OPERATOR: Thank you all for standing by. Welcome to today’s conference call.  At this time, all lines are on listen only for today’s conference until the question and answer portion of our call.  At which time you will be prompted to press star one on your touch tone phone.  Please ensure that your line is unmuted and record your name when prompted so that I may introduce you to ask your question.  Our conference is being recorded and if you have any objections, you may disconnect at this time.  I will now turn the conference over to our host, Dr. Patricia Simone.  Doctor, you may proceed.

DR. PATRICIA SIMONE: Thank you. Good afternoon. I’m Dr. Patricia Simone, the acting Principal Deputy Director of the Centers for Disease Control and Prevention. Before I introduce our speakers, I would like to welcome those of you in the room and those joining by phone.  CDC works around the clock and around the globe to protect people from health threats.  And EIS officers, like the four participating in this media briefing, are on the front lines of those efforts.  These disease detectives are often first on the scene when a public health emergency occurs, stepping up at a moment’s notice to investigate threats ranging from Ebola in West Africa to Zika virus in the Americas and food borne outbreaks in the United States.  They support more than a hundred field investigations each year in the U.S. and worldwide.  And it’s not just disease outbreaks.  EIS officers also provide boots on the ground response to natural and manmade disasters, such as hurricanes, earthquakes, mudslides, extreme heat or winter with weather and chemical releases.  Last year alone, EIS officers battled Zika virus, the opioid epidemic, antibiotic resistance, unintentional injuries, health care associated infections, food-borne illnesses and chronic diseases.  I’m honored to be joined today by four disease detectives doing extraordinary work.  Following brief remarks from each one, we will take questions from the media in the room and on the phone.  From left to right, Dr. Paige Armstrong has spent her time at CDC researching a variety of fungal diseases, both domestically and abroad.  She recently led an investigation about histoplasmosis in tunnel workers in the Dominican Republic and worked alongside the ministries of health in El Salvador and Nicaragua to evaluate their national Zika surveillance system.  She will discuss her experiences investigating Candida auris, an emerging multidrug-resistant fungus that has caused hospital-associated outbreaks with high mortality in several countries.  Next will be Dr. Tracy Ayers.  She’s an EIS officer with the division of viral diseases who has supported surveillance activities and outbreak response for infectious diseases including mumps and Zika.  She will share behind-the-scenes insight into acute flaccid myelitis, a rare polio-like illness that has no known cause to date.  Next you’ll hear from Dr. Emilio Dirlikov who has researched outbreaks ranging from tuberculosis control in China to dengue in Burkina Faso and Ebola in Guinea. He is currently posted to the Puerto Rico department of health as a team lead for the Guillain-Barre Syndrome or GBS. Today he will discuss his research into the link between Zika and Guillain-Barre Syndrome in Puerto Rico. Finally, you’ll hear from Dr. Victoria Hall.  She’s a field-based officer in Minnesota.  She has worked with outbreaks involving food borne illnesses, zoonotic diseases, tuberculosis and vaccine-preventable diseases and has previously traveled to countries in Africa, Europe, Southeast Asia, and Central America to provide for expertise for infectious disease issues impacting both human and animal health.  Today, she will discuss her investigation into opioid deaths in Minnesota using the state’s unexplained death surveillance system, which shows we may be underestimating the number of opioid deaths.  While all of these topics are drastically different, they share a common theme, the real impact disease detectives have on improving public health, which is the theme of our conference this week.  The investigations they conduct provide good data, which is the bedrock of everything we do.  Because of their efforts, we are able to recommend appropriate prevention and control measures and implement strategies to protect people worldwide from injury, disability, illness and death.  Now I’d like to turn it over to Dr. Armstrong.

DR. PAIGE ARMSTRONG: Thank you, Dr. Simone. Like Dr. Simone mentioned, I’m here to speak about an investigation that we recently conducted in Colombia on a multidrug- resistant fungus that’s emerging throughout the world and it’s called Candida auris. Few people had heard about it a year ago and since then, it’s really sprung up and we’ve become much more aware of it than we ever had been. One of the things that caught our attention most about the Colombia investigation and one of the things that we got particularly concerned about and prompted us to go down there, was this report that there were two neonatal intensive care units experiencing outbreaks.  And so we’re talking about small babies that have just been born, at times premature, at times not very premature at all.  So some of the most vulnerable people, as you can imagine, being affected by this and babies even succumbing to this illness.  So when we got word of this and heard that it was very difficult to address, to contain, to curtail, we immediately responded and went down to Colombia.  We worked alongside our partners, the Instituto Nacional de Salud, which is like the CDC’s equivalent of Colombia.  We went to four hospitals in three different cities, those that experienced the most and most recent cases of Candida auris and we investigated.  Not only did we look at the characteristics of the patients being affected by this, but we also went and did extensive sampling.  At the time we went down there in September, this was still and still is for that matter, but was still an emerging fungus that people knew very little about and so we were trying to answer these questions that were very pertinent.  Such as where does this fungus exist, what can we do to get rid of it and is it being transmitted from person to person, and if so, how?  So we took 500 samples down there.  We had lab colleagues that were with us.  It was an incredible undertaking and we worked with the laboratory down there to help us process and get results from the samples.  What we were able to find out is that, in fact, it is colonized in people even after you get treated with anti-fungal medications, people still have it on their skin.  And so this is something that we’ve never seen before with a fungus or I should say we don’t usually see with a fungus.  There are very few.  These are things that we typically see with emerging or resistant bacteria.  And so in Colombia, we were able to establish those key pieces, key fundamental pieces of information about this new emerging fungus, to tell us that we really need to be careful about things, basic things like hand hygiene, washing your hands, making sure people that are touching one person that might have this fungus on them aren’t going on and touching someone to potentially spread it.  We also found that it exists in the environment.  In very high concentrations on the beds and things closest to patients, but then also even in the crevices and the corners of the room, meaning that we really need to focus on cleaning with the right things, disinfecting to kill this organism.  So stepping back just a little bit, this fungus has now been reported in over a dozen countries worldwide.  We have seen cases in the United States and that just further emphasizes how important information we gain and gathered in Colombia was at developing recommendations and trying to curve and curtail any cases that we see popping up in the United States.  We like to talk about Candida auris as having three main components.  One is that it’s affecting vulnerable populations.  So whether that be neonates or babies or people in long-term care facilities or ICUs, those that are already sick and maybe receiving treatment for cancer that are then developing this infection that can kill at very high rates.  The second thing we like to talk about is it the fact that it has the ability to develop resistance that is very rare in fungals. And there are only three main classes of anti-fungal medication.  So once you become resistant to all three of those, there’s very little that can be done.  And the third thing is that it’s causing outbreaks in hospitals, which can, again, is something we typically contribute to bacteria.  This is an emerging multidrug-resistant fungus that is acting like a bacteria, it’s acting like a super bug, things that have really been taking off and without appropriate infection control and really a rigorous response could lead to even more cases in the United States.  So I think with that, I’ll wrap it up and turn it over to you.

DR. TRACY AYERS: Thank you. Hi. I’m going to be talking about acute flaccid myelitis, AFM, which is characterize by a sudden onset of a limb weakness, meaning an arm or a leg may lose weakness or may be difficult to move. Sometimes there’s facial drooping, sometimes there’s difficulty swallowing.  So there was an investigation in 2016 that I was a part of to go to Arizona to investigate a cluster of these cases that were popping up in children.  And when I got there, I was able to speak to some of the parents on some of the cases and interviewed them.  And the idea was to explore as much as possible with these open-ended questions so we could learn as much as possible.  They also recounted the onset of illness because this is such a new disease for us.  So just learning how it progresses and how the onset is something for us to understand.  And so one of the parents described the — you know, the emergence of her child having to go to the ER and she said this was the onset: during day, she was fine, but she was gradually kind of not feeling good, kind of weak.  And by the time it came time to go to bed, the bed hurt.  Everything hurt to touch.  She couldn’t touch anything. So the mother put her in the bathtub because that felt better to have the water on her skin.  At that point, she lost even more muscle tone and her head went a little floppy, as well.  So the mother was holding her in the bathtub, very scared, as you can imagine as a parent and not knowing what to do.  That’s when she immediately took her to the emergency room and that’s often how these cases happen and how they’re detected is at that point of paralysis and going to the emergency room.  At the time that I met the little girl, she was regaining a little bit of strength in her upper arms and everything so she had done a couple weeks of physical therapy.  And, unfortunately, she was only one case out of 134 for 2016.  So there were more cases.  And we’ve done extensive laboratory testing.  We’ve tested for over 250 different organisms that potentially could be the cause of this.  And we haven’t found a consistent organism to sort of say this is what’s causing this at this point.  So we’ve expanded a lot of our laboratory testing now.  We’re thinking about things that are maybe non-infectious, as well.  We’re also partnering with outside agencies to sort of learn more about the long-term outcomes because of right now this is such a brand new disease, we don’t know what the long-term outcomes are.  There’s very few cases and very brand new.  So we’ll learn more through that.  And then we’re also working very closely with our state and public health partners because what we really want to do is make sure we have awareness for the — in the forefront of all clinicians minds and so that they’re reporting and collecting specimens as early as possible and suspecting AFM and making sure that we’re getting as many reports and as much information as possible.  It is such a rare disease, but it’s such a severe one that we need as much information as possible so we can learn more about what may be causing this so we can prevent this for other families, as well.

DR. EMILIO DIRLIKOV: Buenos tardes. Thank you very much for having me here. I think you know as EIS officers, we’re known as boots on the ground shoe leather epidemiologists. And for me, as the Guillain-Barre syndrome or GBS team lead under the Zika emergency response in Puerto Rico, it’s certainly been true. I want to drop you into a story of a patient I interviewed last June.  She had just gone off the mechanical ventilator.  So even though her voice was still rather hoarse, it was difficult for her to pronounce some of the words.  She wanted to make sure that she was giving us clues to discover what had led to her having a very rare form of temporary paralysis known as GBS.  So she described to me that after a year, her first year of college at 21, she had returned back to her grandmother’s house in the foothills of a suburban area in the central part of the island.  There she noticed that she developed a rash.  And even before she was able to get concerned about the rash, it self-resolved.  Meeting up with her friends, she realized one day while trying to drive to a party that she wasn’t able to step on the gas properly.  She lost some mobility to step on the gas.  Later on that night, she realized in trying to get out of bed, to go to the bathroom, she wasn’t able to support her weight fully.  The following day, she went to the emergency room where she was turned away with a suspicion of just being a little bit tired from the first year of school.  She was a little stressed out, the doctors had told her.  And so it went on like this for a full five days until she ended up at a major reference hospital in the San Juan metropolitan area and she was diagnosed with this rare autoimmune disorder known as Guillain-Barre Syndrome.  Unfortunately for this patient, she then progressed and had difficulty breathing, so she had to be mechanically ventilated.  So all these different clues that she allowed us to — had insight into the progression of what maybe had caused the Guillain-Barre syndrome.  Guillain-Barre generally happens after an infection.  And we see that most patients will have symmetric weakness on both sides of the body.  That usually progresses, such as this her case: it started in the feet and moved forward.  And for some patients, unfortunately, they can have more severe forms, including difficulty breathing.  In Puerto Rico last year, we started to get more concerned about Zika virus because we were listening to what other jurisdictions that were affected by Zika virus had been experiencing.  That’s countries like French Polynesia, Brazil and Colombia, who saw at the same time they were experiencing Zika virus, they were having an increased number of people diagnosed with Guillain-Barre syndrome.  So indeed, in Puerto Rico, we reported our first Zika infection in December 2015 and among our first 30 Zika virus infections was a patient with GBS.  So very early on in our response locally, we were concerned the same pattern could happen in Puerto Rico.  So starting in February 2015, the Puerto Rico department of health with CDC’s support implemented a surveillance system so that providers throughout the island could report cases of GBS so we could better monitor what type of trends were happening and so we could provide Zika virus testing at the CDC’s dengue branch located in San Juan, Puerto Rico.  In addition to this, because we weren’t sure about what possible associations there might be between Zika virus and Guillain-Barre, we conducted an investigation.  So essentially once a provider would report one of these patients with Guillain-Barre, we would go interview the patient at the hospital and then go to their communities to recruit willing healthy participants. And in that comparison between the person who developed Guillain-Barre and the person who was still healthy that might have been exposed to similar exposures in the community, we do an analysis to see what was the difference.  And just as a sneak present preview to my talk tomorrow, I can say that we did find that Zika virus is a risk factor for developing Guillain-Barre.  And this goes because some of the investigations that had been done previously and sets us up towards doing more investigations to really pinpoint what it is about Zika virus that’s causing these increased number of people to develop GBS.  Thank you.

DR. VICTORIA HALL: Good afternoon. I’m Victoria Hall. I’d like to start with a case.  So in early spring, the Minnesota Department of Health was notified of an unexplained death: a middle aged man who died suddenly at home.  Two days prior, he had seemed ill to his family, but he didn’t want to go to the hospital.  He was also slurring his words some.  He was on long-term opioid therapy for some back pain and his family was a little bit concerned that he was abusing his medication.  So on autopsy, the medical examiner was quite concerned about pneumonia in this case and that’s how the case was referred to the Minnesota Department of Health unexplained deaths program.  Further testing diagnosed an influenza pneumonia, but also detected a toxic level of opioids in his system.  However, on the death certificate, it only listed pneumonia and it listed no mention of opioids.  So this death wasn’t counted in the state opioid surveillance death system.  This case was detected because of the Minnesota Unexplained Deaths and Critical Illness program, also called UNEX.  So an unexplained death surveillance was started in 1995.  This was started by CDC in many states.  Today, Minnesota is the only state that has maintained the program.  It was developed to constantly be on the lookout for these new and emerging health threats, particularly infectious diseases.  It takes cases that had no clear explanation to the deaths and looks further into it.  It helps facilitate more testing to try to find answers and try to find any new diseases that might be emerging.  It also allowed us to look into the opioid epidemic from an infectious disease standpoint.  So we know that deaths involving infectious disease like pneumonia or endocarditis can be complicated if there’s opioids in the system.  So opioids at therapeutic or higher than therapeutic levels could impact our immune system. It actually makes your immune cells less effective at fighting off illness.  They are also sedatives, though, so they have side effects such as decrease in your breathing, making you less prone to cough, making your breathing more shallow, making it easier for something like a pneumonia to really set in.  So our project was looking at deaths detected through the unexplained program that had evidence of infectious disease as well as opioid use.  And what we found was a lot of suggestions of interactions between the two.  So opioids may make you more prone to get infectious diseases, but if you have a really severe infectious disease, you are more prone to opioid-related illness or deaths.  Especially true in pneumonia cases where even at normal prescribed and at overdosed levels, opioids seem to be playing a big role in illness.  Understanding how the opioid use and the infectious diseases like pneumonia interact with each other might better inform our future guidance for clinicians so we can handle these cases while people are still alive and not catching them through a system like ours.  Additionally, over half of the deaths that we captured through the unexplained death system were not captured in the statewide opioid surveillance data.  This happens because of how we do surveillance for opioid deaths.  It’s all dependent on death certificate coding.  So this is reliant on what actually gets written on the death certificates.  That then gets translated to a code and that’s how we do our surveillance system.  So there’s no national standardization for how to fill out a death certificate. And what we found was that if you have really profound infectious disease, like really bad pneumonia, that may be the only thing written on the death certificate and thus it’s not going to get picked up in opioid surveillance, which is quite concerning because it means that the epidemic, which is already quite severe could potentially be even worse.  91 Americans every day die from an opioid overdose and in 2015, there were over 33,000 deaths related to opioids, more than any year on record.  Opioids don’t discriminate against the young or the old, men, women, rural or urban areas.  We find it in all these areas.  And with the amount of opioids being prescribed, quadrupling in the last decade, it makes for a very complex public health threat that we really need to address from a lot of different angles to gain a deeper understanding of this epidemic.  Getting stronger scientific knowledge is just going to lead to better recommendations and interventions that can help us save lives during this epidemic.

DR. PATRICIA SIMONE: Thank you for your presentations. We heard about the problem of antimicrobial resistance and an example of the kinds of things we can learn from working with our global partners. We learned about a new syndrome with an unexplained cause, new causes of a previously known syndrome and using unexplained death surveillance to better characterize the opioid overdose epidemic. So we are now ready for questions.  We’ll start with those in the room and then we’ll go to those on the phone. Yes.  Do you have a question?

BETSY MCKAY: I have a couple.

DR. PATRICIA SIMONE: Please.

BETSY MCKAY: First of all, thank you for really fascinating — opioids. [ inaudible ].  And secondly, more importantly, what do you think the implications are to the rest of the– [ inaudible ].

DR. VICTORIA HALL: Yeah, so — and please correct me if I misrepresent, but the first question is what other illnesses besides pneumonia? So the unexplained deaths system, over half the cases were pneumonia cases. We did see a few cases of endocarditis, which is something with injection drug users who don’t use sterile techniques would be something we would see.  And the rest were just a variety.  We had a meningitis case.  But far and away, the best science out there is about the pneumonias with infectious diseases and opioids.  Especially because of how it modulates or it dampens your immune system and then also what it actually does to your breathing system.  The second question is so what? which is the motto of the EIS conference this year.  So what?  We looked into things.  Unfortunately, while I can’t speak to the magnitude of how much are we underestimating, it does seem like it is almost an iceberg of an epidemic, right?  We already know that it’s bad and while my research can’t speak to what percent we’re underestimating, we know we are missing some cases.  And that this is not just a Minnesota problem and this is an issue when we’re using death certificates for surveillance, that without having standardization across the nation of how to fill these out, not just the opioid epidemic, but other, you know, illness surveillance systems might be underestimating it based on how the certificates are filled out.  The second part of that, though, is guidance for providers.  So if there is the — we saw some evidence of pneumonias killing middle aged people that shouldn’t be killing middle age people and people that were taking opioids even at therapeutic level.  So while my research doesn’t speak to exactly what that guidance should be, it’s definitely an area as the epidemic goes on that we could be looking further into addressing.

BETSY MCKAY: Is the epidemic in Minnesota fairly representative of the rest of the country?

DR. VICTORIA HALL: Right. So we are pretty low on the list of severity in Minnesota. It seems like we always lag behind a few years from the rest of the country.  We just had our first Carfentanil case, which is a synthetic opioid that’s quite concerning.  So we have about 300 deaths per year due to opioids.

DR. PATRICIA SIMONE: Why don’t you ask another one and we’ll see if anyone else wants to come back.

BETSY MCKAY: My pleasure. What were the score — hospitals — and identify a piece of equipment or some sort of, you know, source infecting the patient or —

DR. PAIGE ARMSTRONG: So just to repeat the question for those on the phone, the question being primarily how is this (Candida auris) being introduced into the health care setting I think is the first part of that and then the second, from there, is there like a smoking gun so to speak within the health care setting? Is there one particular thing that we think might be the nidus? Yes, we’ve thought about all those questions. No, we do not have all the answers quite yet.  We have a laundry list of questions we want to answer about this particular organism and we’re working our way through based on what we think are the — of utmost priority and those that can impact the most are recommendations and save the most lives at first.  As far as whether or not or how it came into the health care system, that’s really a question of is this something that exists in the community?  And that’s a question that we’re still trying to answer.  Is this something like other multidrug-resistance organisms that does exist in the community and we’re just seeing it when people get sick from it in the health care setting?  We don’t have a good answer to that quite yet.  We’re looking into it more.  As for the second question, what do we think could be a nidus or a particular environmental reservoir within the health care setting?  We also thought about that when we were in Colombia and in subsequent investigations, there was one hospital where all four of the cases had been — had had surgery in one operating room and so, of course, that was of particular interest.  We sampled pretty much everything we could think of in that particular room.  One thing in the beginning of the investigation that was challenging was that we lagged a little bit behind.  By the time the outbreak was identified, we were about a month or so afterwards.  So while we didn’t find any positive in that particular operating room, we actually think that was a good thing because it meant that they probably cleaned it well afterwards.  So we’re still working on it.  I think there’s probably more than one reservoir within the health care setting.  And I think, you know, that just reinforces the importance of good disinfection because anything can really become colonized with it and through good disinfection and cleaning, you can prevent that from becoming the smoking gun as the thing that’s transmitting it.

DR. PATRICIA SIMONE: Let me just ask, operator, do we have any questions on the phone?

OPERATOR: We do have one question on the phone. Just a reminder for those on the phone, please press star 1 and record your name if you wish to ask a question.  It is from Dennis Thompson with HealthDay.  Your line is open, sir.

DENNIS THOMPSON: Thank you for taking my question. This is for Victoria Hall.  I wanted to ask, do you expect that the rest of the nation also is underestimating opioid related deaths based on what you’re seeing and what you saw in Minnesota?  If so, by how much do you think our estimates are off, by just a little or by a large amount?

VICTORIA HALL: Thank you. Having the only unexplained death system in the country, it really would be speculating to try and know what’s going on in other states. But what we know is the problem is with consistency of death certificates is something that is going across the whole country.  This is something that CDC and partners in all the states are working on trying to get better guidance on how to get medical examiners to have the same standards, so hopefully we can capture the same amount of data.  But it does show the importance of a system like an unexplained death in critical illness system at looking into emerging health threats to try to figure things out. While my data doesn’t support a percent that we’re underestimating, it puts out the question there of is there something that we need to look into further and can that better help with recommendations going forward to stop the epidemic and help save lives.

OPERATOR: We have another question from Mike Stobbe with the associated press. Your line is open, sir.

MIKE STOBBE: Hi. Thank you for taking my call.  Regarding the acute flaccid myelitis, I just wanted to make sure I heard correctly.  Did you say — how many organisms did you say that you tested for to explain this?  Was the number 250?

TRACY AYERS: Yeah. Over 250 types of different viruses. Most of them enteroviruses, rhino viruses, things that have been associated with this type of outcome before.

MIKE STOBBE: Are you continue to go test other things or have you gone through the list..?

TRACY AYERS: We’re continue to test more. We’re developing more assays to do this so we can get more sensitivity off certain specimens.  We’re also expanding to go look at non-infectious diseases.  We’re trying to increase awareness because we also would really like to have specimens as early as possible from the patients when they’re coming in.  So those are sort of some of the strategies that we’re taking now.

MIKE STOBBE:  Could you say that — so there are a lot in 2014, it went down in 2015, then it went up somewhat in 2016.  In 2016, can you forecast what’s going to happen or what’s the trend?

TRACY AYERS: No.  That’s one thing we certainly can’t do.  It’s hard to know what’s going to happen in the future.  But we do want to make sure we have this vigilant sort of awareness so that if it does occur in 2017 that we’re picking up these reports as early as possible and knowing about them.

MIKE STOBBE: Thank you.

OPERATOR: Another question, excuse me.

MODERATOR: Go ahead.

OPERATOR: This is from Maggie Fox with NBC News. Your line is open.

MAGGIE FOX: Thanks. Can I follow up on the acute flaccid myelitis, as well, please?  I found it hard to understand you in your initial speech, Dr. Ayers.  Can you say you looked at these viruses and you were unable to find any trend at all?  Can we specify that that includes EVD 68?

TRACY AYERS: EVD 68 specifically is one of the many enteroviruses that we tested for. so a portion of specimen do test positive for EVD 68, but we also have a portion of specimen that test positive for other enterovirus and a large portion that don’t testify positive for any of those.  So I think at this time its inconclusive what is the definitive cause.  But we will continue to look at EVD 68 as well as many other enteroviruses.

MAGGIE FOX: Is there a general problem with clinicians not testing people at first? This is a wider problem, you can’t figure out what anybody had because people don’t get tested early on?

TRACY AYERS: This is a really complicated condition that we’re just learning so much about it. We do have lots of — several specimen that are early on and some that are further out.  That’s not really the only problem.  It’s just that we need more information.  We need as much as possible.  We’re not getting like a clear definitive answer saying CSF [cerebrospinal fluid] or blood which would be sterile sites that would tell us where the infection is occurring, if we picked up something there it would be more conclusive.  But at this time, we really aren’t seeing that definitive cause.

MAGGIE FOX: And I’m sorry, if I could ask just one more question, what’s the difference between acute flaccid myelitis and Guillain barre?

TRACY AYERS: That’s a good question.  So Guillain barre, there’s different parts in the — without getting too technical — from your spinal cord to your nerve junction in your muscles that can cause paralysis.  And Guillain-Barré is one where at the nerves, the demyelination happens on its way to your muscle, you can get paralysis that way.  What we’re looking at for acute flaccid myelitis, very specifically, the infection is happening in the spinal cord.

MAGGIE FOX: Am I allowed to ask another question?  Can I ask about Minnesota?  Can you talk a little bit about how taking opioids worsens an infection?  You mentioned how it can make you more likely to be getting pneumonia, but can we have a little bit more detail on the mechanism?

VICTORIA HALL: Yeah. So it’s kind of this balance of opioids and infectious disease, which was what we were looking into.  It actually, in fact — impacts your macrophages, so that’s one of your main immune cells to help fight off infection.  And it kind of dampens it down and it dampens down your antibody response.  So you still have an immune system, certainly, but it just dampens it down.  Also, the mechanical motion of it. So our study found over half of our cases that were missed had pneumonia.  And when you take an opioid and it makes you breathe more shallow, breathe slower, less likely to cough, it’s a lot more likely things can settle in your lungs.  So while opioids won’t cause an infectious disease, the suggestion is there is an interaction between opioids and infectious disease.

MAGGIE FOX:  Thank you.

MODERATOR: More questions on the phone?

OPERATOR: We have our last question from Susan Scutti with CNN. Your line is open, ma’am.

SUSAN SCUTTI: Hi. This is for Victoria Hall.  You report that 59 or 3.5% of cases with evidence of opioid use.  The 22 deaths involving toxic levels of opioids, were they additional to the 59 cases?  Also, you found 53% were females.  Is this a higher number than expected?  Was any particular demographic represented in the additional cases of opioid deaths that you found?

VICTORIA HALL: yeah.  So I’m going to repeat your first question because it was a little quiet at the beginning.  You’re asking where the 22 number come from is my understanding.

Yes. So that 22 is out of that 59.  So what we did was we looked at any case with opioid use because we were also interested in even at therapeutic levels could opioids being playing some role in infectious disease.  But then, in order to compare it to the state system, we wanted only cases that we feel should have been caught in the state system.  So cases that in autopsy reports by a medical examiner, they mentioned lethal or toxic opioid levels.  Because once that determination was made, we felt that should have been captured in an overdose surveillance system.  So we had over half the cases that we found that were toxic or lethal not counted in the state system which leads us to wonder if there is underestimation of the total burden of opioid death disease.

SUSAN SCUTTI: And when you say toxic or lethal, you mean straight up overdose?

VICTORIA HALL: Right. And that gets to a huge complication of the opioid epidemic is there is no clear cut line on what an overdose is.  So a chronic user or long-term user might be able to take a much higher dose than a first-time person who just got prescribed an opioid.  So we really had to rely on the medical examiner’s judgment. They had to look at the death, look at how long a person has been on a medication to decide whether they think that level is toxic or not.  So just another complication of the opioid epidemic.  When you ask about demographics, we found the demographics of the cases that we caught through the unexplained death system were very similar to what was captured in the entire state overdose system.  So nothing significantly different in our demographics versus what was captured in the entire state overdose system.

SUSAN SCUTTI: Okay. Thank you very much.

MODERATOR: Any further questions on the phone?

OPERATOR: We have no further questions, ma’am.

MODERATOR In the room?

BETSY MCKAY: [Inaudible question].

TRACY AYERS: So the question was what do we need that would tell us what is happening. so if we had 100% of cases that we were able to isolate one specific organism from something like the cerebral spinal fluid, which is where the infection is happening in the spine that would maybe help give us very strong evidence that it’s that cause, but I think this is so complicated that I think there’s lots of information we would have to think about, as well.

BETSY MCKAY: [Inaudible question].

TRACY AYERS: Right. It’s really hard when you have a very — something that’s a newly recognized condition and you’re capturing data on it. So at this point, we have three years’ worth of information in which as you noted 2015 there weren’t that many cases.  So it’s really hard to know, based on the limited amount of data what that means going forward or if that’s really all the cases.  And, in fact, we’re very open to making sure that case reports consider not just children, but adults, as well.  We just want to learn as much as possible and make sure that we’re capturing all the information that we should be considering.

MODERATOR: Anything else? Okay.

DR. CHORBA: A quick question for Emilio. The cases that you identified Zika, your systems were capturing your Gullain-Barré cases, do you think you got all the cases in Puerto Rico, not necessarily just Zika related cases, or were you capturing just Zika related cases? If so, did you capture all, some? Do you think there are some you are not capturing?

DR. EMILIO DIRLOKOV: Right. Thank you so much for your question, Dr. Chorba. The question was about if — in our surveillance system for Guillain-Barré Syndrome, if we were limited to Zika associated GBS patients or if we were capturing all patients and, if so, how many were we expecting possibly were not captured by our surveillance system. It’s important to remember that Guillain-Barré is a post infectious autoimmune disorder.  It can be caused by Zika attributed to Zika virus, but there’s many other triggers, including bacteria and viruses.  So for our surveillance system, under the Zika virus response, we asked providers to report any case that had a suspicion of GBS.  So even prior to them being confirmed as GBS patients, we wanted to know about those cases to make sure that we were capturing those trends and monitoring them. Moreover, having earlier samples allows us to confirm those arboviral disease infections, so dengue, Zika or chikungunya viruses which all affect the island.  So throughout last year, we identified 120 cases of which 102 were reported to us directly through — by providers.  But then at the beginning of this year, what we’ve been doing is an investigation.  So going back to every single hospital on the island and asking them to report cases from their medical records that have an ICD 10 code for Guillain-Barré. So after they report those, we go back and we do chart review to see if those people were actually Guillain-Barré patients that presented in the last year.  So certainly we might have missed some people, but we hope that that is a small proportion of the people.  To put this in context, we expect in Puerto Rico every year about 60 GBS patients per year.  So having 120 is a doubling of our baseline incidents for year.

MODERATOR: Okay. So barring other questions, we will close. I want to first thank the officers for their presentations and for their work showing up the breadth and depth of what CDC does in investigating different diseases and conditions so that we can learn everything we can to improve the public’s health.  These officers really are our public health heroes.  I want to thank all of you for joining us in person and on the phone.  If you have additional questions about today’s topics, please feel free to ask question of the press officers here in the room or call the CDC press office at 404-639-3286 or send an e-mail to media@cdc.gov. A transcription of this media available will be available at CDC.gov/media later today.  Thank you all for coming.

OPERATOR: You may now disconnect and have a great rest of your day.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES