Tuesday, June 05, 2007

Problem-Response-Solution: Raise the fear, then CDC presses for expanded powers to quarantine in XDR-DR hype

Specialists say TB case a sign of things to come

The unexpected turns in the case of Andrew Speaker, the Atlanta lawyer with extensively drug-resistant tuberculosis, have riveted the country.

By John Donnelly, Globe Staff

Alerts Speaker made two trans-Atlantic flights against the counsel of public health officials. A border guard let him into the United States apparently because he appeared healthy. His father-in-law works in the field of tuberculosis research. And Monday, his doctors in Denver reported that two tests of his sputum show no presence of the TB bacteria.

But TB specialists said Monday that the real importance of the case is that it is a warning to all Americans: The United States should brace itself for many more cases of the drug-resistant airborne germ in the months and years ahead.

"This is the tiniest tip of the iceberg," said Dr. Paul Farmer, a Harvard professor who has treated drug-resistant TB in Haiti, Peru, and Siberia. "We need to take excellent care of our own but also acknowledge that we're lucky as a nation: We have little TB, drug resistant or otherwise. We need to think about this much more globally."

Farmer said poor countries need laboratory diagnostic tools, more drugs, better trained doctors who could perform surgery if necessary, and a cadre of community health workers. Those workers visit patients in their homes, which ensures they are taking their drugs properly and protects them from hospital-acquired infections or illnesses.

Senior World Health Organization officials met privately Monday in Geneva to review the lessons of Speaker's case. Dr. Mario Raviglione, director of WHO's Stop TB Department, said in an interview that the TB specialists "found a number of things that failed in the system" that allowed Speaker to travel from country to country in Europe and eventually to the United States.

Speaker, who is under a federal quarantine order while being treated at a Denver hospital, flew to Greece last month for his wedding and honeymoon.

While in Europe, he learned he had an extensively drug-resistant strain TB, known as XDR-TB, and the Centers for Disease Control and Prevention told him not to fly and turn himself into a clinic. Instead, Speaker took a series of steps to avoid the no-fly order, eventually taking a plane from Prague to Canada and then driving into the United States.

Raviglione said Speaker's evasive actions exploited poor communication abilities among international health authorities, airline carriers, and border patrol posts that allowed him to travel from Rome to Prague, and then from Prague to Montreal, before crossing into the United States in a private car.

But most critically, he said, the US case revealed the lack of urgency in fighting drug-resistant tuberculosis, including the most dangerous type, XDR-TB. Since XDR-TB was identified a year ago in South Africa, when 52 of 53 patients died from the disease, health authorities have identified cases in 37 countries, including the United States.

"TB is not just a disease of the poorest people," Raviglione said. "This is a disease that can hit everyone, even reach a lawyer in the United States. It spreads through the air and respects no border. No one should feel safe in this world."

An estimated 424,000 new cases of multiple-drug resistant TB were contracted in 2004 -- the latest available statistics -- up from roughly 273,000 in 2000. Because many patients survive for years after diagnosis, specialists estimate that as many as 2 million people around the world are infected with a form of drug-resistant TB. Of the cases in 2004, an estimated 62 percent were in China, India, and Russia.

While funding for AIDS and malaria have greatly increased in recent years -- the Bush administration last week proposed $30 billion in additional money to fight AIDS starting in 2009 -- the amount for fighting tuberculosis has lagged well behind. Raviglione said WHO will publish a report in the coming weeks estimating that the cost of controlling XDR-TB alone will be an extra $1 billion annually. Now, he said, the TB fight needs an additional $1.5 billion to $2 billion a year, including funding for XDR-TB.

Senator Edward M. Kennedy, a Massachusetts Democrat, along with two other US senators -- Sherrod Brown, an Ohio Democrat, and Kay Bailey Hutchinson, a Texas Republican -- will introduce legislation Tuesday calling for giving US public health officials the "resources needed to eliminate TB in the US," including funding for new research on anti-TB drugs and vaccines.

Mycobacterium tuberculosis, which has been found in 4,000-year-old Egyptian mummies, has been treated with antibiotics since 1944. But the TB bacteria has developed mutant strains when patients didn't use the drugs properly.

Some of those strains eventually developed multiple resistances, and much of the medical world, including the WHO, believed for years that drug-resistant TB was virtually incurable in poor countries.

But successful treatment of patients by Farmer, Dr. Jim Yong Kim, and others at the Boston-based Partners in Health in the late 1990s in the Carabayllo slum outside Lima, Peru, showed that belief was false.

Drug-resistant TB is no longer a death sentence in many poor countries, but the discovery of XDR-TB in South Africa more than a year ago raised new difficulties about treating strains of a disease that respond to fewer and fewer drugs.

"We need to wake up and pay attention to what's happening with TB in other parts of the world," said Dr. Mark L. Rosenberg, the Harvard-educated executive director of the Task Force for Child Development and Survival in Atlanta. "We need to start treating XDR-TB where it is, not just respond to one case of one American who will get the finest treatment."

John Donnelly can be reached at donnelly@globe.com.

Original article posted here.

TB Quarantine Raises Legal Questions


ATLANTA (AP) -- The case of a jet-setting tuberculosis patient might soon shift from the hospital wards to the courts. The patient, Andrew Speaker, an Atlanta personal injury attorney, could sue the federal government for being quarantined on the basis of federal regulations that some scholars see as unconstitutional.

Or Speaker could be sued by fellow airline passengers, especially if any caught the disease from him - which some legal scholars say is much more likely.

"He may be personally liable if someone contracts TB" from being near him on his recent flights to and from Europe, said Peter Jacobson, a University of Michigan professor of public health law. "I can see a jury coming down very hard on someone like that who willfully ignored advice not to travel."

Speaker flew to Europe for his wedding and honeymoon after being advised by health officials not to make the trip because he had TB. Then, while he was in Rome, U.S. health officials told him to stay put because further tests showed he had an even more dangerous, drug-resistant type of TB than previously thought.

The 31-year-old newlywed disregarded those instructions, taking commercial jets to Prague and then Montreal in an attempt to sneak back into the United States.

In an interview earlier this week with The Atlanta Journal-Constitution, Speaker said he declined to report to Italian health officials because he believed the only lifesaving care for his condition was available in the U.S.

"I'm a very well-educated, successful, intelligent person," he told the newspaper. "This is insane to me that I have an armed guard outside my door when I've cooperated with everything other than the whole solitary-confinement-in-Italy thing."

A barrage of criticism was posted Thursday on the Web site of a Georgia newspaper that carried Speaker's engagement announcement and allows outsiders to post comments.

Under a picture of the smiling couple on the Appen Newspapers Web page, a person signed as 'Concerned Citizen' wrote: "Warned not to fly but just put your personal pleasure above the safety of other passengers. I hope you get sued by potential victims for your actions."

Lawrence Gostin, a public health law expert at Georgetown University, agreed with those who feel Speaker has exposed himself to possible litigation.

"There are a number of cases that say a person who negligently transmits an infectious disease could be held liable," he said.

Perhaps the most significant legal issues in Speaker's case concern the federal quarantine law, and the difficulty federal health officials had trying to learn the identities of those who were exposed to Speaker, Gostin said.

The quarantine order was the first issued by the federal government since a patient with smallpox was isolated in 1963, according to the Centers for Disease Control and Prevention.

CDC officials have been requesting changes in the nation's antiquated quarantine laws to gain easier access to airline and ship passenger lists, provide patients a clearer appeals process when subjected to quarantines and give health officials explicit authority to offer vaccinations and medical treatment to quarantined people.

In the past week, Speaker was quarantined in New York City and then again - under guard - at an Atlanta hospital. The quarantine order was not approved by a judge, but rather issued under the CDC's administrative powers.

There's a reason for that, Jacobson said: In certain rare instances, such action is deemed necessary to avoid legal delays in rapidly protecting the public from a disease-carrying person.

While Speaker was still in Atlanta on Wednesday, a CDC official said Speaker had the right to request an administrative hearing to appeal the quarantine order but had not. (On Thursday, Speaker was flown to a Denver hospital, where he is no longer under guard.)

The legal rights of a quarantined person, including the right to request a hearing, are not clear under current law, Gostin said. Some legal scholars said the absence of clear guidelines could lead to a legal tangle that might stall government quarantine actions during an outbreak of pandemic flu or other contagious diseases.

Speaker can challenge the constitutionality of the quarantine order, and might even be able to seek a federal payment for damages, Gostin said.

Airlines can be slow to hand over passenger information because of concerns of violating customer privacy. It was not until late Wednesday that the CDC got full information from Air France about U.S. passengers on Speaker's May 12 flight from Atlanta to Paris.

One proposed change in the law would require airlines and cruise lines to electronically submit passenger and crew lists to the CDC upon request.

Original article posted here.

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