Public Health Watch: Man With TB Detained, Isolated

Dr. William Schaffner, chairman of the Department of Preventive Medicine at Vanderbilt University Medical School, will be online Thursday, May 31, at 11 a.m. ET to discuss the case of a man who had spent nearly two weeks traveling in the U.S., Canada and Europe with "extremely drug-resistant" tuberculosis, a rare and often fatal form of the infection. The Centers for Disease Control and Prevention imposed an "order of isolation" after catching up with the man who is now in Atlanta undergoing treatment.

Is the public health in danger? What are the risks for the airline passengers who had prolonged contact with the man during the flights?

A transcript follows.

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Dr. William Schaffner: Good morning. Glad to be here to address some of your questions regarding the provocative TB case that is so much in the news.

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Los Angeles: Thank you for taking questions. Can you provide us with an overview of the TB patient's quarantine? What type of facility, limitations, environment, etc.?

Dr. William Schaffner: At present the patient with tuberculosis is being cared for at Grady Hospital in Atlanta, a large municipal institution. It, like all large general hospitals, has isolation facilities. These facilities consist of a private room, special air handling, such as the air moves from the corridor into the room and then is discharged into the atomosphere. Health care workers will wear special masks (really called respirators) that will protect them during close personal contact.

Interestingly, every general hospital is capable of caring for such patients safely, efficiently and appropriately and health care workers are trained in providing care with "respiratory protection."

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Chicago: Does everyone with XDR-TB in the United States need to be put into isolation under a legal order? If so, for how long?

Dr. William Schaffner: Short answer is no, they do not. Overwhelmingly, patients cooperate with their physicians in their treatment. Some are hospitalized, some can be treated at home. On rare occasions a patient with active TB who is deemed a threat to public health and who does not cooperate with therapy is confined to a treatment facility under a judge's order.

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Alexandria, Va.: Why is his identity being protected? Why do his fellow airline passengers advised to get tested, while the people who come into daily contact with him are kept in the dark?

Dr. William Schaffner: Public health and clinical medicine always protect the identity of the patient. Public health attention is focused on the passengers on the long airline trips because TB is transmitted through close personal contact usually over time in an enclosed space -- like an airplane. Casual contact (for example, in a restaurant, on a bus, etc.) confers little if any risk. Furthermore, this specific patient is thought to have a low-risk of transmission of his infection to others.

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Washington, D.C.: One thing puzzles me . . . I know tuberculosis is highly contagious and dangerous, but so are a lot of other diseases. Why the stepped-up level of concern for this particular disease? For example, I had to get tested for it before I could volunteer in my child's classroom. Why do people push the panic button over this disease but not as much for other highly contagious diseases? Thanks for answering.

Dr. William Schaffner: First, TB is not generally "highly contagious." It requires close personal contact over sustained time, usually in an enclosed space, to be transmitted to others.

There are two reasons that this particular case is of great public health interest: First, the specific TB strain is resistant to multiple drugs used in treatment. Thus, there is great concern that this hard to treat strain may spread. Second, it is known that this sort of multi-drug resistant strain may be more apt to cause serious disease. It is thought to be rapidly fatal, at least when it occurs in the developing world. This is another reason public health authorities have been particularly concerned.

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Washington, D.C.: If the government knew that the man had multi-drug resistant TB before he left the country, why did they stop at "we recommend that you not fly"? Why was he not put on a no-fly list at that point and not allowed to leave the country to begin with?

Dr. William Schaffner: This is a subtle issue. There are occasions when patients with highly infectious tuberculosis are not compliant with therapy. Public health authorities can approach a judge to issue an order to confine the patient to a treatment facility. This requires the judge be convinced that the patient is a public health hazard. In this particular instance (please recall that all details have not yet been publicly released) it appears that the patient was not a substantial infectious hazard. For example, there is no evidence he had transmitted his infection to his family or fiancee with whom he had extensive close contact. Furthermore, sputum smears from the patient were negative for the TB bacteria. Thus a judge might have been skeptical that he was a substantial public health hazard.

This, despite the fact that his TB strain was resistant.

Thus, it's an unsettle issue at present.

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Washington, D.C.: I find it peculiar that the man's wife hasn't been quarantined and isolated. Since the trip to Europe was their wedding and honeymoon, wasn't she with him the whole time? Isn't she the next most likely person to be infected? The May 30 Washington Post story said that she was with him in Atlanta this week, but there's no mention of any concern that she might have TB too.

washingtonpost.com: Man With Rare TB Easily Eluded Safeguards ( Post, May 31)

Dr. William Schaffner: She has been tested and been found negative for TB to date. Persons with TB are not uniformly infectious to others. Some are highly infectious. At the other end of the extreme others never infect anyone else. Fortunately at this moment the patient appears to be a the non-infectious end of the spectrum. Of course, we cannot assume that the risk to others is zero. That is why the investigation of his fellow passengers is being undertaken.

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Chicago: What can passengers do to protect themselves from contagious diseases during air travel? Should we be concerned?

Dr. William Schaffner: The risk of acquiring a serious infection during air travel is exceedingly low. However, it is well accepted that respiratory infections such as the common cold and influenza can be acquired during air travel in the winter months. Thus frequent hand washing is strongly recommended as well as avoiding those who cough and sneeze as much as possible. Despite this, I have acquired colds on air travel myself. Good luck.

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Arlington, Va.: Hi Dr. Schaffner,

I guess one can have TB that is "inactive" and not know it. Can you please explain the difference between inactive and active TB, and whether there could be people with multiple drug resistant TB that is currently inactive? Is this a danger?

Dr. William Schaffner: Infection with the TB bacteria does not always produce disease. Indeed, in the majority of instances it does not. This latent infection can be detected by a skin test or now a new blood test. When such latent TB is detected there are appropriate treatment regimens designed to prevent the disease becoming active in later years. Fortunately, very few of those are multi-drug resistant in the U.S.

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Central Virginia: The man in question describes himself as well-educated and intelligent, and doesn't think he's done a thing wrong in exposing a LOT of people to his extremely drug-resistant TB.

It reminds me of the HIV positive people who knowingly have unprotected sex.

Can you explain this criminally reckless behavior?

Dr. William Schaffner: The man's behavior certainly was reckless; however, it likely was not criminal. The circumstances are complex. He may not have been given clear, sufficient, strong instructions initially by the public health authorities. This remains to be determined. But there certainly is general agreement that when he finally was notified that he had a hazardous infection, his behavior was reckless.

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Austin, Tex.: Because the actions of the TB patient were deliberate and endangered others, losing any privacy rights, why shouldn't his identification and picture be broadcast in the media to alert possible contacts?

Dr. William Schaffner: First, public health and medicine respect the privacy of the individual. The persons at risk are those who were in the aircraft with him and these specific individuals are being traced and contacted. Casual encounters with this individual, such as at a restaurant or in a bus, etc., are not consequential.

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Washington, D.C.: How or where did the infected man acquire the drug-resistant TB?

Dr. William Schaffner: That is a fascinating question for which we do not have an answer yet. My public health colleagues and I are extremely interested in this question.

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Dayton, Ohio: Is this a "Typhoid Mary" kind of case? IE, the patient is infectious but does not himself exhibit any symptoms? What are the likelihood that there are other cases similar to this, but that no-one knows about?

Dr. William Schaffner: The analogy is not quite apt because this patient apparently had a few symptoms. Please recall that clinical details have not yet been made public. More generally, of course there may be the occasional patient with tuberculosis who is not yet diagnosed. This has always been a problem for public health and clinical medicine.

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Reston, Va.: TB isn't as easily transferred, yes, but it's still a very dangerous disease, especially if you are drug-resistant. What is the prognosis for the patient? Isn't drug resistant TB eventually lethal?

Dr. William Schaffner: TB remains a serious disease, particularly in its drug-resistant form. In the developing world where drug-resistant TB is more common, it is often rapidly fatal. It is estimated that almost half of such patients will have died after one year. However, this patient is being treated in a first-rate medical facility and there is every likelihood that his prognosis is substantially better than that -- although I cannot give you a numerical estimate.

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Carborro, N.C.: Why did the tests for TB take so long? He found out early this year that he had it, but it wasn't until May that they found out it was drug-restistant?

Dr. William Schaffner: You have put your finger on a problem that we struggle with every day. Unfortunately, the TB bacterium grows very, very slowly in the laboratory. Indeed, it had to be grown twice: first, the TB bacteria had to be isolated from his sputum and second, it had to grow again in the test for antibiotic susceptibility. Each of these growth cycles can take four to six weeks. Unfortunately, science has not been able to materially accelerate this process yet.

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Anonymous: Can person with latent TB (but is otherwise normal with no symptoms) transmit/spread the disease?

Dr. William Schaffner: A person with only modest symptoms might be able to spread the disease but this is unusual. "Spreaders" generally have symptoms from their tuberculosis.

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Once lived in the U.K.: Because I was a student in the UK, I was required to have a BCG (TB vaccination)--so now the TB skin test comes back positive. What sort of test would find TB in my case?

Dr. William Schaffner: In your case, two things would be important. Your clinical symptoms would be monitored and if indicated, a chest x-ray would be performed. Also, the new blood test might be employed if it were available in your health department. It is able to distinguish between BCG and real tuberculosis.

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Washington, D.C.: I read in today's Express that a possibly contaminated traveler did not want to identify himself because of the "stigma" that comes with a diagnosis of tuberculosis. Could you explain a bit more about such "stigma?" It seems that someone who contracts a disease through no fault of his own shouldn't be stigmatized.

Dr. William Schaffner: First, there is a social stigma that still may attach to tuberculosis. Fortunately, this has waned very substantially over the past 30 years. More importantly, this person may simply value his privacy and not wish to be bothered by both personal and media attention.

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Washington, D.C.: Can an entire plane full of people get infected with TB due to the air vent circulation during a flight? And can humans pass TB on to their pets?

Dr. William Schaffner: Humans cannot pass TB on to their pets with the possible exception of monkeys and elephants. They seem to be more susceptible to the human form of tuberculosis than other mammals.

Previous investigations of patients with tuberculosis on airplanes have indicated that passengers in the immediate vicinity of the patient were at some increased risk of acquiring the infection. This is particularly true of the person sitting two rows in front of and in back of the individual, along with his seat mates.

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Dr. William Schaffner: Thank you all for your thoughtful interest in this issue. I hope I've been able to be responsive to your questions. Best wishes, Dr. Bill Schaffner.

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