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BMJ. 2007 June 9; 334(7605): 1187.
PMCID: PMC1889983

Tuberculosis case exposes flaws in international public health systems

The ease with which a man infected with extensively drug resistant tuberculosis (XDR TB) flew on several international flights exposes flaws in international public health systems. The asymptomatic US lawyer flew on two transatlantic flights and several European flights for his wedding and honeymoon.

It also led to an international search for passengers who may have been exposed to this almost incurable disease.

Local public health officials in the United States could not prevent him from travelling; the US Centers for Disease Control and Prevention (CDC) failed to contact him; a “no fly alert” did not prevent him from flying; and a border alert to detain him was ignored.

The good news, said Julie Gerberding, head of the CDC, was that the risk of transmission was low. The man was “smear negative,” with no detectable bacteria in his sputum.

Mario Raviglione, director of the Stop TB programme at the World Health Organization, told the BMJ that “if the International Health Regulations, 2006, had been in place, the relevant procedures outlined would have been followed correctly. [The regulations] will come into effect on 15 June worldwide and 17 July in the US [United States].

“The US did inform international authorities and partners, although WHO was notified as the individual was already returning to the US. The [regulations] . . . will provide further support for international surveillance and coordination to ensure effective response to similar cases in the future. The challenge will [be] to ensure that [they] are put into practice, which heavily depends on the health authorities of each . . . country.”

Dr Raviglione agreed that the risk of transmission was low. “Under normal conditions the quality of the air on board commercial airliners is higher than it is in most buildings. Passengers travelling on flights longer than eight hours may be at higher risk of becoming infected with tuberculosis if they sit near someone with active tuberculosis, but the risk should be similar to what it is in other circumstances where people are together in a confined indoor space. Brief contact with an infectious individual poses little to no risk of becoming infected with tuberculosis.”

The US man, Andrew Speaker, a 31 year old lawyer from Atlanta, Georgia, is now in isolation at the National Jewish Medical and Research Center in Denver, a tuberculosis centre, under a detention order from Denver health officials. He will probably stay for at least two months to receive antibiotic treatment and may need surgery to remove the tuberculosis infiltrate.

The CDC is investigating a possible link to his father in law, Robert Cooksey, a microbiologist at CDC who works on multidrug resistant tuberculosis. Dr Cooksey said that he has always tested negative for tuberculosis.

The problem began when Mr Speaker had a chest x ray in January for a rib injury. It showed an infiltrate that indicated tuberculosis. A sputum test for tuberculosis was negative, but a more sensitive culture test was positive. Test results indicated that he had multidrug resistant tuberculosis, defined as tuberculosis that is resistant to isoniazid and rifampicin.

Further tests were under way when Mr Speaker planned to leave for his wedding. He said that he felt well. Local officials and the Centers for Disease Control and Protection knew that he had drug resistant tuberculosis. He and his father, also a lawyer, say local health authorities told him they “preferred” that he did not travel but did not forbid it.

He and his fiancée flew from Atlanta to Paris, and then to Athens, Mykonos, and Rome. He told Alison Young of the Atlanta Journal-Constitution that CDC telephoned him in Rome and had said that tests showed he had extensively drug resistant tuberculosis (www.ajc.com, 30 May, “Atlantan quarantined with deadly TB strain, CDC issues rare isolation order; air passengers warned.”)

Extensively drug resistant tuberculosis is multidrug resistant tuberculosis that is also resistant to more than three of the six classes of second line drugs. Kenneth Castro, CDC's tuberculosis chief, said that extensively drug resistant tuberculosis has been found in every region or country where scientists have looked for it.

There have been 49 cases in the United States between 1993 and 2003. Extensively drug resistant tuberculosis killed 52 out of 53 people within 16 days of diagnosis in a hospital in KwaZulu-Natal, according to N R Gandhi and colleagues at the 16th international AIDS conference in Toronto in 2006.

Mr Speaker was told to turn himself in to Italian health officials, be isolated, and receive treatment there for an indefinite time. He worried that treatment in Italy might be a death sentence because they lacked the expertise. “I thought to myself, ‘You're nuts.' I wasn't going to do that. They told me I had been put on a ‘no fly list,' and my passport was flagged,” he told the newspaper. He and his wife assumed that the ban applied only to flights to the United States. They left their Rome hotel before a CDC representative arrived, flew to Prague, and then to Montreal.

Mr Speaker appeared on Good Morning America, a leading morning television show, and said he had felt abandoned by the US and feared for his life.

In Montreal they rented a car and drove south into the US. A border guard scanned Mr Speaker's passport, saw the notice to detain him, but allowed him and his wife into the US because, according to news reports, he looked healthy. Contacted by telephone on his way south to New York, Mr Speaker voluntarily went first to a respiratory isolation unit at Bellevue Hospital in New York; then by CDC plane to Atlanta, where he was in an isolation unit at Grady Memorial Hospital; and then by CDC jet to Denver.

Notes

See www.cdc.gov/tb/xdrtb for further information.


Articles from The BMJ are provided here courtesy of BMJ Publishing Group