Man With Rare TB Detained, Isolated

By David Brown
Washington Post Staff Writer
Wednesday, May 30, 2007

The federal government last week detained and quarantined an Atlanta man who had spent nearly two weeks traveling in the United States, Canada and Europe with "extensively drug-resistant" tuberculosis, a rare and often fatal form of the infection, officials said yesterday.

The Centers for Disease Control and Prevention imposed an "order of isolation" on Friday after catching up with the man, who had flown into Montreal the day before and then driven to New York City. He was flown in a government plane on Memorial Day to Atlanta, where he is now undergoing treatment.

Although states occasionally use their authority to forcibly detain and treat patients with infections, this was the first time since 1963 the federal government has done so. The last case involved suspected importation of smallpox, a disease eradicated in the 1970s.

The CDC and the two airlines that transported the man twice across the Atlantic are laboriously trying to learn who had close, prolonged contact with him during the trip. Those people will then be contacted by local health departments -- potentially dozens of them on two continents.

"We don't think, from past scientific investigation, that their risk is high. But we want to offer them the chance to be tested," CDC Director Julie L. Gerberding said yesterday afternoon in a news briefing.

Although many details of the patient's recent activities were unknown or were not being disclosed yesterday, officials said the man had recently been diagnosed with TB and knew he should not travel when he left the United States on May 12.

After testing revealed his tuberculosis was extensively drug-resistant, he was contacted in Europe by health authorities and told not to take a commercial flight home -- advice he ignored.

Martin Cetron, a physician who directs the CDC's division of global migration and quarantine, said he spoke to the man by phone Friday and told him to go to a New York hospital. The man went willingly.

While the man had broken the "covenant of trust" that is usually sufficient to keep infectious TB patients from willfully exposing others, "from our perspective no laws were broken here," Gerberding said.

TB cases that are resistant to the two first-line classes of drugs and to at least two second-line classes have been detected in 37 countries and are increasing worldwide.

It is especially a problem in places such as South Africa and the former Soviet Union where TB treatment is inadequate, or prevalence of HIV infection is high. An outbreak killed 52 of 53 people it infected in a rural hospital in South Africa in 2005 and 2006, according to reports last summer. XDR-TB, as it is known, is rare in the United States, with only 49 cases detected since 1993, of which at least 12 were fatal, according to a CDC report in March.

Earlier this month, public health officials in Arizona obtained a court order allowing them to confine and treat a 27-year-old dual Russian-U.S. citizen who had undergone months of TB treatment in Russia, where he had often been homeless. He is undergoing treatment for XDR-TB in a Phoenix hospital.

In most people, the body's immune system controls the TB bacterium on its own, forcing it to become "latent," or inactive. Drug resistance does not make that less likely, nor does it make the microbe inherently more virulent or contagious.

Instead, XDR-TB's danger stems from the fact that when it does cause active illness, the infection is very hard to cure. That, in turn, increases the risk it will be passed on to someone else and that patients ill from it will die.

XDR-TB often occurs in prison populations and in people infected with HIV, but officials yesterday would not say whether the quarantined patient had either of those risk factors. He was described as a resident of the Atlanta area; his name, age and race were withheld.

Officials at the CDC and the Public Health Agency of Canada sketched this account of the case yesterday: The man was diagnosed with tuberculosis when he had an abnormal chest X-ray, which was done for another reason. A laboratory culture revealed TB bacteria in his phlegm. But he had no symptoms from the illness, and in particular no fever or cough.

He flew from Atlanta to Paris on May 12 on Air France Flight 385, arriving the next day. He flew back from Europe on May 24 aboard Czech Airlines Flight 0104, which departed from Prague. That flight arrived the same day in Montreal. He left Montreal in a rented car and drove to the United States, entering at Champlain, N.Y. The man's wife was with him in New York and accompanied him in the CDC plane to Atlanta. Where she met him -- or whether she traveled to Europe with him -- was unclear yesterday.

Officials did not say how many other countries he visited in Europe.

Brief or long-distance exposure to people with infectious TB rarely results in transmission of the microbe. Health authorities want to trace the people who sat in his row and two rows in front of and behind him on the transatlantic flights. Studies have shown that risk of infection is very unlikely outside that zone of exposure, or even within it for short periods of time.

Those passengers will be skin-tested to see if they have recently been exposed to the TB bacterium. If they have been exposed, they will be treated with anti-TB drugs.

Gerberding said the man had relatively little TB bacteria in his phlegm, a finding that makes it less likely -- although far from impossible -- that he would transmit the infection to someone else.


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