I'm not a lawyer and I don't play one on TV. But I think I know the difference between quarantine and isolation, and the widespread media reports that the Georgia resident with XDR-TB was the first person "quarantined" by the US government since 1963 didn't make sense. Quarantine means to segregate and possibly confine people who have been exposed to a contagious disease and therefore may become infectious themselves and spread it to others. But they are not sick. People who are segregated from the public and whose movement is restricted are under isolation, not quarantine. The Georgia resident has clearly been isolated, first in an isolation ward in a New York hospital and currently at Grady Memorial in Atlanta. Both isolation and quarantine are meant to stop the spread of contagious disease and are authorized under federal law: 42 U.S.C. Section 264.
As I understand it (and I would be glad to have any clarifications or corrections from a real lawyer), the law authorizes the government to isolate or quarantine a person or persons, the diseases and other details to be further set out in regulations or Executive Orders. The regulations are in the Code of Federal Regulations at 42 C.F.R., Parts 70 and 71. (cites and links courtesy CDC Public Health Law News).
Infectious tuberculosis is designated one of the diseases for which federal isolation and quarantine are authorized through Executive Order 13295. The other diseases are SARS, Cholera; Diphtheria; Plague; Smallpox; Yellow Fever; and Viral Hemorrhagic Fevers (Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet isolated or named). The stipulation of infectious tuberculosis stems from the fact that most people infected with the tubercle bacillus never become sick or contagious. When I was in medical training it was more the rule than the exception for health care workers to convert from negative to positive skin test early on. I, myself, have been a positive reactor for more than 50 years. It is also very common to see scars from old TB lesions in the lungs of people who never knew they were infected and were never sick (latent TB). You are infectious if the TB organism can be found in your sputum, but often people are treated if they have a recent positive skin or blood test and a history suggestive of recent infection, e.g., they have been in contact with an infectious case. Thus positive reactors amongst the passengers in this case would likely be considered for immediate treatment, although the treatment regimen would have to be carefully considered as this is said to be an XDR organism.
According to CDC, this is the first time any of the regulations or Executive Order have been used for TB. The realization this was XDR-TB and the patient was traveling came to a head on a holiday weekend, compounding the matter. There is still a lot to learn about this episode and it is likely new procedures will be put in place as a result. We will learn in time if outright blunders were made, but we already know much needs to be done to make this system work in a timely way. We also want it to work in a way that doesn't make the protections themselves a problem.
An immediate reaction was that this individual should have been locked up -- forcibly detained, as a matter of policy. Let's assume he was highly infectious (possible, but not likely, in this case) and that you might have crossed paths with him on his travels. Maybe a bus, the same plane, the same airplane concourse. Of course if you are a good citizen, once you realized it you would turn yourself in (you would, wouldn't you?). At that point, should you be forcibly detained and tested? If not, why not? If you test positive -- which many people do, as I noted above -- should you then be locked up? After all, we now have a good argument that if he infected you, you have XDR TB. Of course it will take about six to eight weeks to find out, so we'll have to lock you up for a couple of months. Then if you are infected, treatment is a couple of years. Keep you locked up? If not, what makes you different?
More generally, what about anyone diagnosed with tuberculosis? Last year there were almost 14,000 TB diagnoses in the US. Since we don't know if one of those diagnosed might be drug resistant (although we know some will be), and by the time we find out, they will have infected others, should we lock them up too? All 14,000? If someone who has XDR TB is so dangerous they must be locked up, then isn't this what we must do? Or should we only lock up people who have been diagnosed with XDR TB -- something that happens only after they have been around and possibly infected others for months.
I don't know what the answer is. But "lock 'em up" isn't likely to be any better for TB than for HIV.
Update: Other posts here.
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That is how they explained it on NPR this morning.
Turns out the lawyers new father-in-law works at the(drum roll please) CDC and has done work on (drum roll again please) tuberculosis!!!
Welcome to the family, Son
Another good one. . . He was allowed back into the U.S. by a border inspector who disregarded a computer warning to stop him and don protective gear, officials said Thursday. The inspector has been removed from border duty.
He's probably going demoted to a job inspecting poultry imports from Asia
Another good one. . . He was allowed back into the U.S. by a border inspector who disregarded a computer warning to stop him and don protective gear, officials said Thursday. The inspector has been removed from border duty.
Hm. Wonder how many terrorists came in on this guy's watch...
Ahem: Having taken care of patients with active TB - they are placed on respiratory isolation precautions which include using tissues when coughing, sneezing or expectorating, disposing of tissues in a sealed paper bag for incineration, and having THE PATIENT use a mask to contain droplets and aerosolized secretions when traveling outside the negative pressure and HEPA filtered isolation room. When in direct contact and providing care, the caregiver also dons a mask.
It is safe to assume that if you routinely travel in public places that you have been exposed to people with active TB. What you haven't had is long term exposure to their secretions.
In the irony department, though, this story is a winner.
Oh come on now, he apologized didnt he for endangering everyone without their permission?
I pause here Revere and its for the reality check. He did it fully knowing that the disease was there. He created a diplomatic incident in doing so. With the information initially given out it was rightfully but wrongfully assumed that he was a foreigner. How convenient that he was a US citizen with a Daddy in law at the CDC and now we get to foot the bill for him. Okay, so we are dealing with someone who could have just as well been an American Taliban with smallpox. The problem? Trying to deal with under the law someone who knowingly and willfully endangered the public. I underline that. This means that if he told someone, they knew it they were guilty of criminal conspiracy.
That is a crime in all 50 states and possessions and under Federal laws. Did it rise to the level of Executive Order? Now theres the rub now isnt it. Does it mean we will be locking people up? Thats a term. I would indict him right here and now for reckless endangerment, get a conviction and then lock him up. But they wont. They aint going to a camp in Wisconsin either. Too expensive. Put them into the house with a leg bracelet or something but hauling them off should only be done when they dont comply with public health officials instructions. Like before he left, and now. Dumbass!
This guy is a fucking idiot and he tooled on out of here with TB and crossed international borders. Remember that act of war thing under the UN Charter? Who is to say that if he arrived in Russia say to pick up the wifey to be if she were a mail order one that they wouldnt perceive it as such? They arent too happy right now. Some countries only need an excuse. I wouldnt call him locked up either. I would call him a possible terrorist and detain him and that puke that let him back in should be arrested himself.
As for the terrorist possibilities he is detained and thats the reason for the Executive Order. There is no E.O. for being stupid. His detainment is lawful and it has been prosecuted as such. This guy is about a tenth of an inch from being the only newlywed in jail and not for having TB. Its for a crime. We worry too much about the rights of the person who has affected us. Screw him. This aint second hand smoke we are talking about. You are medical type and you cant say that he hasnt infected anyone can you, definitively? Obviously someone cruised into your life from the above post that had it. Right or wrong? I am sure you have yourself checked periodically? FWIW I too test positive and I bug down every year to get the test done because it was on the DoD watch that it happened. One quick Xray and the test and I am outta there. No lesions and no problems. Central America has more than their share of it. Another reason for immigration control.
If this is determined not to be a public health hazard then good, I agree with you that this guy has all the rights in the world. If not, then the E.O. was fully within the bounds of the governments rights to quarantine/isolate. Tennessee State Law gives the local health departments the right to detain anyone that in their sole opinion is a health risk. They are afforded the right to an attorney if they want but up to the isolation wards in Nashville, Memphis, Knoxville or Chattanooga they go and a judge decides if they can get out ....later. Pretty much the same in every state.
I just hope that BF doesnt come in because if and when it does and any state declares a state of emergency or martial law, or the federal government themselves declares it then all bets are off. You will have the right to do what you are told, when you are told to do it. They cant kill you unless you commit an illegal act as defined by the then president or governor. But thats their current definition. If you get down into each states or federal constitution there is no limit to what a President, EMA or governor can to do maintain order and order is also what they interpret it as.
I mean what you are seeing here is fully lawful and maintaining order is in their eyes only. You cant protest under a declaration of martial law.
Who does this guy think he is kidding? Surgery to take out the infection in his lung? Seems to me that they already got his brain. None of this sits too well with me either Revere. Who has the rights here? The guy with every deleted expletive for being an idiot who might also be a terrorist under the current definition, or the people of the US and EU where he was tooling around and feeling really comfortable about possibly infecting. Dilemma? Not really. I know whose side I am on.
One quick also note. This was a secondary promulgation from an E.O. from the 1960's and 1983. Seems they were wondering about it then too.
So he has an "active infection" because they were able to culture, whereas you could be latent or just exposed if you have a positive test or in addition they see scarring/shadow on a chest X-ray?
Yeah but... when a rich young personal-injury lawyer decides he'll ignore the isolation directives because it would be too complicated to reschedule his Santorini wedding and thereby miss involving his new father-in-law who does TB work for the CDC... at least you can say that if there *is* a god, S/He is a lousy novelist!
I'm sure there are a dozen miniseries already being prepped, waiting on production only to see if Andrew Speaker (and does that sound like a bad-novel pseudonym or what?) dies, gets arrested, or get sued by his former co-workers acting on behalf of one of the airline passengers who's going to spend the next 18 months taking potentially life-threatening antibiotic prophylaxis. Or maybe it'll be the fired border guard suing Young Andrew, on the grounds that Speaker threatened him and besides who doesn't hate rich young connected lawyers?
Pinko: Yes, that's correct. Technically, since I (and a gizillion others from my era) had a positive skin test, we "have" latent TB, although 95% of people infected "just" have latent TB, i.e., don't have any clinical illness.
Anne Laurie: He didn't know he had XDR until the last leg of his trip (when he was in Rome). Try putting yourself in his place for a moment. You had probably been told (truthfully) you weren't infective or at least very infective and you had a treatable disease. All of a sudden you are told you have a life altering disease, you are away from home, you are told you have to check in to a hospital in a foreign country where you don't know the language and stay there, under confinement, for an indefinite period, possibly a year or two, and possibly never, because the disease can't be treated. You aren't sure if they know how to treat your disease, but you know there is a hospital in the US that might be able to. So you panic and try to get home. When you get to the US you turn yourself in, so you aren't a fugitive. Then your life is ruined by media exposure. Meanwhile it is highly unlikely anyone was infected.
Maybe you would have stayed put in an Italian hospital and waited to see what would happen. If it were me, I'd like to think I would have done that, too. Truthfully, I don't know. I don't know this guy from a hole in the wall, never heard of him, don't know anyone in his family. I know he is a lawyer but I don't know if he's rich and really that's not very material. If he were poor, would it have been better behavior? I still feel sorry for him and can't bring myself to condemn him.
Dear Revere(s):
I honestly don't know whether or not I would have hopped on the plane in the first place, given the ambiguities, but I am 100 percent sure, without the slightest doubt, that I would have gotten myself home, by whatever means, the fastest way possible. Facing a possibility of never getting out of that Italian hospital?...uh, no.
It's great to be "holier than thou" in hindsight, but fear is a wonderfully effective motivator, and not necessarily to do the most honorable thing. Click those heels, Dorothy. We're outa here.
If anything good is to come out of this, let the CDC and Border Patrol consider it a test of how crappy their communication and intercept systems are. I feel so much more secure knowing they are all on duty.
He, so "successful" could have shook down relatives to charter a private flight;
being in Rome 48 more hours wasn't going to kill him. He said himself the second line drugs didn't work either and treatments had stopped- he said he knew the next thing was the big last intervention. Knew -for how long?- he had TB had didn't read up on it nor DR-TB, or, did he really read all the ambiguous terms in his favor?
Nature doesn't let you win on semantics. Low risks are ok to expose others, but risk to him to stay put in Italy
- where they could have been advised from Denver, and the CDC, right?
How do you think his interview would have gone if he was just some guy flying over for his honeymoon and some fugitive jerk with XDR-TB sat next to him on a flight
and now it spoiled him trip and took the fun out of his wedding?
Think Mr.Lawyer would be screaming lawsuit and asking FIL at the CDC to
say why this is so dangerous and crimnal lawsuit time?
CRF-You danged skippy. The USGovt would have repatriated him as part of the requirements of the State Dept. The military has a portable isolation box that slides very nicely into a C-130 and for them it would have been a practice exercise. Until then Speaker could have sat his butt in a room or hospital room. Santorini? Please... I wonder how many people on Santorini now are wondering if they have TB? How many could develop it later on.
Revere this is a classic case of Bird Flu. Not the disease itself but how we will react to it. The CDC is soft pedaling it...again. I sent all of the stuff to my drinking buddy last night and this morngin he told me that there is a "small risk" but its no where near zero and any doctor seeing this would have told him to report himself into the nearest facility for treatment and alerted the equivalent of their CDC.
He also said that the treatment could be severe and that there is no guarantee that the removal of the mass will yield an outcome that he wants to see. In fact, he said while its not his direct field, as a rule this guy is likely a dead man walking.
Typhoid Mary was his description and he also said in that statement that while unfortunate his disease is a evolving one and that in that mutation to XDR it could turn deadly to others "at any time." He also said the guy was the six million dollar man and that he could have called any drug manufacturer and THEY would have chartered the jet to pick him up. Why? Guinea Pig. Everything to gain and nothing to lose. Surgeons also he said would be drooling to get their hands on him. Successful cure of a XDR-human using surgery and drugs? One does the cutting the other does the back up as an MD and the drugs post and they both get to write the paper. He asked if I had a contact.
The run towards XDR-TB he said has been about 40 years. They come up with a better drug, it gets better at what it does. Constant battle. But he also went on to say that NO ONE has the right to put anyone in jeopardy without their consent.
If it had been Ebola I wonder what he would have done then, gone to a party on the way to the hospital?
Revere wrote: [i]Let's assume he was highly infectious (possible, but not likely, in this case) and that you might have crossed paths with him on his travels. Maybe a bus, the same plane, the same airplane concourse. [/i]
Maybe a guest at his wedding going through the receiving line hugging, shaking hands with, and kissing the bride and groom?
I would be so pissed.
OTOH, Revere, you make a really compelling case for his mindset in Rome. I think I would probably have tried to make it home as well. It would be a horrible dilemma.
One thing is sure: This whole notion of isolating these patients is a friggin' scary, scary prospect for everyone. It's like TB Guantanamo. I think the precedent is chilling, but I certainly don't have any pat answers. I doubt anyone does.
The thing that I find oh so interesting about all of this is how it is illustrating the gaping holes in our public health monitoring and enforcement in the U.S.
Dear Revere(s):
I don't think I've seen any info on where the CDC thinks Speaker got it. Are they back-tracking, too? Why no mention?
Galen, my sieve memory tells me I saw something yesterday that said he probably picked it up in Central America where he had been doing some sort of charity related work. I'll try to find a cite.
Galen, speedwell: I've read he has done a lot of international travel in the last six weeks, including SE Asia (Vietnam was mentioned). CDC says the strain is different than used in the father in law's lab and the father in law is negative on repreated and periodic testing (it is possible he is anergic, but that is stretching it a bit). So the mystery of how he was infected remains as does how his bugs were cultured, since his sputum smear is negative for AFB. Presumably an induced sputum sample (he doesn't have a fever or cough) grew the stuff out.
BTW, this may be a dry run for bird flu, but it isn't bird flu. It is very hard to find documented cases of TB transmission on an airplane (I could only fiind two, one was cabin crew to cabin crew, the other immediate passengers on very long flights, but in both cases it was said the index case was highly infectious which this person is not). And even as a metaphor for bird flu it fails, because there is no hope -- none -- of keeping bird flu out by shutting down air travel or travelers once it becomes easily transmissible.
I can't find any documentation that anyone told him he was a risk to others PRIOR to his leaving the U.S.
The Fulton County Health Department is working in overdrive to try to persuade the world that they warned him. But FoxTV 5 in Atlanta got a redacted copy of the letter Fulton County tried to deliver to Speaker, and the parts of the letter read by the Fox5 reporter said nothing about him being a risk to others.
Here are the two quotes read by the reporter:
"As a precaution it is strongly recommended that you postpone your travel and see a specialist in Denver Colorado."
"It imperative that you are aware that you are traveling against medical advice."
I hope the TV Station will post the entire letter, so we can see for ourselves whether Fulton County grounded its medical advice to him in terms of risk to others or not.
Path Forward: Tomorrow's post will cover some of this. He apparenty told ABC News that he was told he was not a risk to others and has it on tape.
Hi revere, just wondering about all the big deal made about this guy from Atlanta with the drug-resistant TB and wonder why they do not worry about people from (for example) South Africa, with possibly the same strain traveling. Thanks.
Bee: The XDR cases from South Africa were rural and poor and HIV positive or AIDS patients. They aren't very likely to travel. On the other hand, as I'll note in a post one of these days, there is very little evidence people get active TB on an airplane (there isn't a single documented case, actually), With a third of the globe TB infected, worrying about airplanes is probably fruitless. You'd have to worry about every public place.
Tuber Lung Dis. 1996 Oct;77(5):414-9.Related Articles, Links
Tuberculosis risk after exposure on airplanes.
Miller MA, Valway S, Onorato IM.
National Immunization Program, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
SETTING: Domestic and international air-flights. OBJECTIVE: To estimate the risk of tuberculosis (TB) transmission aboard aircraft. DESIGN: A contact investigation of passengers and crew from two flights was conducted following identification of a fellow passenger with pulmonary TB. Immediate post-exposure and follow-up tuberculin skin tests (TSTs) were obtained. RESULTS: Of 120 contacts, 86 (72%) had a negative TST (< 5 mm); 29 (24%) a positive TST (> or = 5 mm), and 5 (4%) a TST conversion. Of the 29 persons with a positive TST, 27 had other identified risk factors for TB. Risk factors for positive TST included non-US birth (Relative Risk (RR) 9.7 P < 0.01) or history of Bacille Calmette-Guérin (BCG) vaccination (RR undefined; P < 0.01). Risk was not associated with specific aircraft or seat relative to the index case for US-born contacts. All five TST converters were born in countries where BCG vaccine is routinely given. CONCLUSION: The positive TST reactions and conversions suggest boosting from BCG vaccination or prior exposure in TB-endemic countries. Since two positive contacts had no other identified risk factor, TB transmission on board the aircraft could not be excluded. Contact investigation of exposed aircraft passengers should be considered on a case-by-case basis, with consideration of the infectiousness of the ill passenger and the flight circumstances.
This is from the Aussie Health Service and states that the traveler should have two weeks of intense meds and then two? negative sputum tests before traveling via air. My problem with all of this is as my drinking buddy the doc said that the risk while not high was/is not zero and he had the same response and it was that "informed consent" wasnt followed. Nor did the putz as best I can tell even wear a mask or inform anyone. I believe the no fly list protocols were not followed and the agent who let him in should be prosecuted. The protocol was to don protective gear and call the CDC AND DETAIN! Someone also felt that was needed and needed enough to put that information in there. Why in Hell wasnt it followed?
http://www.health.vic.gov.au/ideas/diseases/tb_airtravel
Hm. Last I recall, the protocol for active TB was to isolate in the hospital for two weeks on antibiotics, then if you get three good-quality sputum samples on three occasions that are negative, you can consider them to be non-contagious and let them out as long as they continue on meds.
Presumably someone with XDT who was on drugs to which their brand of XDT was immune, would not be able to produce those clean sputum samples. Someone whose XDT was responding to the drugs he was given would be released, but only because he's not shedding bacteria at a rate capable of infecting others.
I don't see how the protocol for confining or not confining someone differs for ordinary TB vs. XDT. In this case I'm angry because I am under the impression that this guy was not on meds and had not been cleared on the sputum-count issue.
If he's not shedding bug then it shouldn't be a problem, whether it carries resistance genes or not, 'cause its not going anywhere.
Lisa-My drinking buddy said that this particular type of TB is very strange and it goes thru some sort of phases. Infectious, non, then back to infectious in the later stages and aparently when the thing starts to grow bigger to take the patient out. Everyone forgive my outburst but shit, this is a grown man. Educated and had been in the care of a doctor who told him it wasnt a good idea. Bad idea to the point that he was tagged up in the anti-terrorism network computers. He was let in anyway. He is an attorney and a cognizant person. Screw me, but its not for him to decide whether he goes to Santorini with a communicable disease, its for the Greeks, Italians, Czechs, and anyone elses turf he crossed. Revere wont condemn him. Okay thats where lefties compassion is overruled by the rightist protection of the peoples laws. All the jerk had to do was make a phone call to the State Dept from anywhere in the world and they would have come to get him. That too is the law. He would have expatriated so fast that it would have made your head spin. PLEASE COME GET THIS GUY would have been the message from whatever country. I made an initial assumption that was wrong that only an idiot from another country could or would do this and I was flat wrong. Speaker if I read the stuff from FEMA may only pose a slight risk, but that everyone is to be aware and get the tests.
Revere and Lisa-I know you dont dole out med advice, so whats the gig on the GCB? Is this something we should trot down and get if we are concerned or is it dangerous too? I dont understand the processes or the mechanism for the use.
Maybe you would have stayed put in an Italian hospital and waited to see what would happen. If it were me, I'd like to think I would have done that, too. Truthfully, I don't know. I don't know this guy from a hole in the wall, never heard of him, don't know anyone in his family. I know he is a lawyer but I don't know if he's rich and really that's not very material. If he were poor, would it have been better behavior? I still feel sorry for him and can't bring myself to condemn him.
Revere, if it had been me, I wouldn't have been getting married in Santorini, even if could afford it, because most of the people we wanted at our wedding couldn't afford it either. I don't particularly "condemn" Speaker myself, but from the stuff he's said on the news that I've seen, yes he was advised against travelling *before* he left the country. The fact that he didn't take the CDC warning seriously feeds into the public perception that young white Americans who can afford to stage their weddings on romantic Greek islands are spoiled narcissists who don't care how many other people are inconvenienced as long as they can go where they want, when they want, doing whatever they want and screw the rest of the world. He's become a perfect synecdoche of the modern Ugly American -- a one-man symbol of our ugly little Iraq adventure, or a representation of Bush's new anti-Kyoto emissions-non-controlled proposals. Speaker may be a genuinely nice man who just happened to be in the wrong place at the right time, but the best he can hope for right now is to end up as the punchline in a nine-days-wonder joke.
Randy: This bug isn't different than other TB bugs in virulence or infectiousness, only in drug sensitivity. TB of any strain can lie dormant and then suddenly jump up (that's how Eleanor Roosevelt died after steroid treatment activated her TB).
Anne Laurie: I have more to say about it in today's post. That this guy is taking the rap for Iraq may be true but not relevant to the underlying question. I'm an American, too, and opposed the war from before it started and don't want to be blamed for it. How I would act in his position is indpendent of that issue.
Annie-Revere, just in from back channels is that this guy had started to feel bad (from the TB, blood discharge is what it said) and thats the reason he was so intent on getting back into the states. Dont know if this is confirmed just yet.
What I heard from Nat'l Jewish is that he was asymptomatic and smear negative. Since his medical information is confidential I don't know if we will actually be told the details unless he wishes to release them.