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Thursday, May 31st 2007

XDR TB Probably Shouldn't Equal Freakout

By now you’ve heard of the Atlanta attorney who, despite knowing he was positive for tuberculosis, hopped on a commercial flight to Europe. Then, after learning he had a particularly nasty form of the infection, hopped a commercial flight back to the U.S.; as the CDC says it, he took the flight against their instructions.

Dr. Martin S. Cetron, [a CDC official,] said he reached the man on his cellphone while he was in Italy to inform him that tests performed before he left for Europe showed that he had a form of tuberculosis that was extremely resistant to standard antibiotics. Dr. Cetron said that he advised the man not to take commercial flights home from Europe and that a United States Embassy would provide assistance, including examination by a tuberculosis expert.

While the agency began to explore ways to bring the man home, he flew to Montreal and drove into the United States. Then, after agency officials made contact with him, he followed their instructions to drive safely into New York without risk to the public.

The news story is understandable and necessary. Despite the “low” risk of him having infected others on the flight, public health officials are looking for those he was in contact with. They need to spread the word, and the media is the best way to do that. But the continual coverage afforded this story is an example of the oft criticized ‘state of fear’ reporting which drives a whole host of science stories (public health stories, global warming studies, etc.)

It is true extensive drug resistant tuberculosis can be a scary thing. Typical TB infection is treated with isonazide and rifampin (and pyrasinamide and ethambutol). Multidrug resistant tuberculosis doesn’t respond well to treatment with rifampin and isonazide. Second line drugs have to be used. They’re less effective, more toxic, and have more side effects. All happy things.

But it can get even better. Tuberculosis can mutate to be resistant to those second line drugs and, as in this case, you get extensive drug resistant (XDR) tuberculosis.

It is true, by some counts XDR – even in this country – has somewhere upwards of a 30% mortality. Between 1993 – 2002:

Cured Cases 20 828
Mortal Cases 21 375
Total Cases* 64 1513

*Total cases encompasses more than those “cured” or those leading to death.

It is a bad disease to get ahold of. But the coverage of it and the public…fear that such media coverage has promoted, belies a faulty belief of just how big a public health risk this disease poses. XDR TB isn’t easier to spread than typical tuberculosis. And, perhaps more importantly, in this particular case Andrew Speaker doesn’t appear to have been very infective (listen to the NPR story).

Dr. Gwen Hewitt, who is treating Speaker at National Jewish, says he expects Speaker to recover fully. Speaker has an active case of TB, but is healthy and not likely to be infectious.

“He would be considered of low infectivity at this point in time,” Hewitt says. “He’s not coughing, he’s healthy, he does not have a fever, so he is of low communicability at this point in time.”

Sure, there were some screw ups along the way in handling this case.

A U.S. border inspector who allowed an Atlanta lawyer infected with a dangerous strain of tuberculosis back into the country, disregarding a computer warning to stop the man and don protective gear, has been removed from border duty, officials said Thursday.

The unidentified inspector explained that he was no doctor but that the infected man seemed perfectly healthy and that he thought the warning was merely “discretionary,” officials briefed on the case told The Associated Press. They spoke on condition of anonymity because the matter is still under investigation.

The inspector ran Speaker’s passport through a computer, and a warning — including instructions to hold the traveler, don a protective mask in dealing with him, and telephone health authorities — popped up, officials said. About a minute later, Speaker was instead cleared to continue on his journey, according to officials familiar with the records.

The Homeland Security Department is investigating.

“The border agent who questioned that person is at present performing administrative duties,” said Homeland Security spokesman Russ Knocke, adding those duties do not include checking people at the land border crossing.

But those lapses don’t appear to poise a huge public health risk (and it is hard to argue they’re reflective of how the government would handle a true public health emergency). That being the case I’m not sure how anyone can think something like this Time article is more than a scare piece.

It might seem that after the threats of bioterrorism, and after the spread of HIV and SARS in recent decades, public health officials would be better prepared — and more coordinated — when it comes to dealing with nasty bugs that hitch rides from country to country in often unsuspecting plane travelers. But this latest TB scare illustrates that the system still has a long way to go to be able to deal effectively with such health crises.

Should the CDC have moved more quickly and issued a more unequivocal order for Speaker not to travel? “We try to balance individual freedoms with the public good, and that depends on a covenant of trust,” says Dr. Martin Cetron, CDC’s director of global migration and quarantine. “There were several communications between my staff and individuals in Rome, begging him to stay put and not travel while we worked on options for him.”

Weeks from now will anyone be worrying over this?

Years from now, does anyone think XDR TB will break the top 10 in terms of worldwide public health crises?

Should the public really be worrying about this over their morning coffee, especially when there are SO many more legitimate concerns? Even concerns that could be stuffed in the paper’s Health section if you need to fill column inches.

Oh…So That’s Why They Call It Acid Fast