Rarely used public health powers have been invoked in the United States to forcibly isolate a man with extensively drug-resistant tuberculosis (XDR-TB) after he disregarded advice against flying. This type of tuberculosis has resistance to both first-line and many second-line tuberculosis drugs. It is associated with rapid disease progression and a poor prognosis, particularly in HIV-positive patients.
The individual has been identified as Andrew Speaker, a 31 year-old lawyer.
The Centers for Disease Control (CDC) used its isolation powers for the first time since 1963 after Speaker took two transatlantic flights, as well as numerous shorter flights around Europe, despite being initially told that he was infected with multi drug-resistant tuberculosis (MDR-TB) and, once further test results were available, XDR-TB. He was told on his diagnosis with MDR-TB that it was “preferred” that he didn’t fly. Once he was diagnosed with XDR-TB he was told in no uncertain terms that he must not fly.
Speaker initially flew from Atlanta to Paris on May 12th for his wedding and honeymoon in Europe. He was tracked down by US federal health authorities in Rome ten days later and told that he had XDR-TB, and as a result, had been placed on a no-fly list. But before plans could be finalised to admit him to a specialist TB isolation facility in Italy, the man flew to Prague, then to Montreal on May 24th. After arriving in Canada, he travelled in to the US and presented himself to health authorities in New York City. Speaker believed that the Italians would not have been able to treat his infection and that admission to an isolation facility in Italy would have “doomed” him.
Efforts are now being made to trace and screen for tuberculosis the passengers who sat near Speaker during his transatlantic flights. The flights concerned are Air France 385 (Delta code-share 8517) on May 12th and Czech Air 0104 on May 24th.
Immediate concern is focused on passengers who sat in the same row as Speaker, and in the two rows before and behind. Passengers sat in these rows will be screened for tuberculosis as soon as they are traced and have a further test two months later. It is believed that between 50 and 60 passengers on the Air France flight need to be traced, and in the region of 30 passengers on the Czech Air flight. All the crew on these flights will also be screened for tuberculosis.
Exposure to tuberculosis on flights lasting eight hours or longer is deemed by both the US CDC and World Health Organization to involve a risk of infection. However, the risk of infection for passengers who shared Speaker’s five shorter European flights is thought to be very low and no efforts are currently being made to contact them.
Speaker is said to be in a stable condition, to have no cough and to have smear-negative infection. Because of these clinical characteristics, health authorities in the US are confident that the risk of infection for passengers on the transatlantic flights was very low.
Although Speaker was advised that it was “preferred” that he did not to fly when he was informed that he had MDR-TB he is reported to have said that this was different to “must not fly.” In an interview with the Atlanta-Journal Constitution newspaper, the patient’s reaction to being told that he would have to receive treatment in an isolation facility in Italy due to the dangerous nature of his infection was “you’re nuts.” He has described his forcible isolation in the US, which involves the posting of an armed police officer outside his door, as “insane…I’ve cooperated with everything other than the whole solitary confinement in Italy thing.” He added, “I’m a very well educated, successful, intelligent person”.
Speaker added: “I didn’t want to put anybody at risk” by flying back to the US after being told that he had XDR-TB. He said his motivation was “to come home and get treatment.” Speaker was told that his passport had been flagged and he’d been placed on a no-fly list, but he correctly reasoned that attempts to fly to Canada would not be monitored.
He reportedly refused to be admitted to hospital in Italy because he feared for his life, as he didn’t believe that the Italians had the expertise to treat him and that he would have been “doomed” had he been admitted to an Italian isolation facility.
In a press conference on May 31st, Dr Martin Cetron of the CDC said that the decision had been taken to issue the rarely-used isolation order because of Speaker’s “international travel and the potential for interstate spread.”
Cetron added that it was hoped to lift the federal isolation order in the very near future, and CDC would then rely on a “covenant of trust” with the patient.