Airline trips by resistant-TB patient trigger alert

May 29, 2007 (CIDRAP News) – In a rare action, federal health authorities have ordered an Atlanta man who has extensively drug-resistant tuberculosis (XDR TB) into isolation and are looking for people who recently flew with him so they can be tested for the disease.

The Centers for Disease Control and Prevention (CDC) said the man, who was not named, flew from Atlanta to Paris on May 13 and from Prague, Czechoslavakia, to Montreal, on May 24. After he reentered the United States by car, he was contacted by the CDC and voluntarily reported to an isolation facility in New York City, officials said. Later, the CDC sent its own airplane to fly him back to Atlanta, where he is hospitalized in isolation, the agency said.

"We felt it was important at this point in time to take our responsibility to protect the public to the ultimate limit and issue an order of isolation," CDC Director Dr. Julie Gerberding said at a telephone news conference today. She said the last time CDC staff could recall issuing a similar order was in 1963, when a person who had been exposed to smallpox was quarantined.

Because of the risk of infection and in line with World Health Organization (WHO) guidelines, the CDC is recommending TB testing for passengers who sat within two rows of the infected man, for cabin crew members, and for all US residents who were on either of the two flights. The flights were Air France 385 (Atlanta to Paris, May 13) and Czech Air 0104 (Prague to Montreal, May 24). The CDC did not list the affected row numbers today, saying further checking was needed.

"Other passengers [who didn't sit near the man] might be worried, so we're requesting that they be notified, but we don't think from past scientific investigation that their risk is high," Gerberding said.

XDR TB is defined as TB that is resistant to the two most important first-line TB drugs (isoniazied and rifampin) and the two most important second-line drugs (a fluoroquinolone and an injectable agent—amikacin, kanamycin, or capreomycin), according to the CDC.

Both regular TB and XDR TB are believed to spread when TB bacilli from a person with the disease become aerosolized as a result of coughing, sneezing, speaking, or singing, the agency said. The bacilli can float in the air for several hours, and those who breathe them in can become infected.

The man's TB case was known before he flew to Paris, and local health officials were involved in his care, Gerberding said. However, the evidence about the extent of drug resistance emerged gradually over several weeks, and "it didn't become known to CDC till after the patient left the US that his infection was resistant to both first- and second-line drugs," she explained.

Gerberding said it was her understanding that local health officials had advised the man not to travel. But the patient "had compelling reasons for traveling" and decided to go ahead with the trip, she said.

"If we'd been aware that travel was imminent, we might have been able to act" with the help of local officials, she said.

She also observed, "From our perspective no laws were broken here."

Gerberding said she didn't know yet how many passengers are affected by the alert or how many countries they represent. "We don't get this information with the push of a button; it represents many hours of work by the airlines" and by public health officials from many countries, she commented.

The TB patient is "smear negative," meaning the TB bacteria don't show up in microscopic examination of his sputum, Gerberding said. That finding "is correlated with a low risk, but certainly not a zero risk" of TB transmission, because about 17% of TB cases are caused by exposure to people who are smear negative, she explained.

However, there is no evidence that XDR TB is more infective than drug-susceptible TB, she noted.

Dr. Martin Cetron, director of the CDC's Division of Global Migration and Quarantine, said the CDC contacted the patient after learning that he had reentered the country. Cetron said he talked with him personally, asking him to go to an isolation facility in New York City, and he agreed.

After the man was assessed in the New York facility, he was offered the choice of staying there or returning to Atlanta, Cetron said. He chose to return to Atlanta, so the CDC sent a plane to pick him up. On arrival, he was served with a federal isolation order.

"We did not feel it was safe for him to fly on commercial aircraft, so we took the unusual step of using government resources to bring him back to Georgia as quickly as we could," said Gerberding.

She said she couldn't comment on the man's current condition. The prognosis for XDR TB patients depends on the treatment; patients in the United States, with excellent treatment, can recover, but in some countries the disease is often fatal, she indicated.

The CDC said the United States had 49 known cases of XDR TB between 1993 and 2006.

See also:

Transcript of CDC news conference

CDC fact sheet on XDR TB

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