Effect Measure

Walking TB blues

The walking TB problem is in the news again. This time it’s not a well to do lawyer from Atlanta but a Mexican born resident of Norcross, Georgia, a healthy appearing teen ager told last Friday he had tuberculosis and would have to undergo treatment. We don’t know exactly what he was said to him about the nature of the treatment or his disease, but whatever it was, he wasn’t having any of it. He refused treatment and wanted to go home to Mexico. The lawyer was told not to travel while in Europe and he headed home to the US. In both cases a bewildered and scared patient wanted to go home. Only one of them made it (see our coverage here). The teen never got out of Georgia. Gwinnett County Georgia health officials put him in jail:

They put Santos in jail Friday evening, in a rare act of a government agency confining a sick person. Santos is the only inmate in a special medical isolation cell designed for inmates with contagious conditions. The cell, which measures about 15 feet by 20 feet, has a special ventilation system that keeps the air from reaching other inmates.

The 5-foot-5 teenager has a toilet, sink, bed and a mirror made of polished metal. Two deputies guard him and the other medical inmates.

Will, the county health attorney, said Santos was detained because he is a public health threat.

“He has active, contagious TB,” Will said Saturday. “He is at risk of communicating that with anybody he comes in contact with.”

Will said Santos is being held under a court order for confinement. He’ll stay in that cell until either he starts cooperating and accepting treatment, or a judge makes some other decision at a Sept. 5 hearing. At that commitment hearing, the judge could decide to place him in a hospital with security. (Atlanta Journal Constitution)

We don’t know the grounds for the statement he has active TB and is contagious. Most people infected with this organism have neither active disease nor are contagious. But let’s assume it has a solid basis. Let’s also leave aside this young man’s immigration status, (unknown at present) since it is not germane. Authorities don’t want to send a contagious person to another country whatever the status of their paperwork. This still leaves some fairly sticky issues.

How long do you confine someone, and if and when they agree to treatment, what do you do at that point? Release them to the community? Require supervised treatment and surveillance? Release them to a hospital while being treated but still involuntarily confined? At what point do you let them free completely? What safeguards are there for unnecessarily depriving someone of their liberty under the claim they are a public health threat? How is that established? Will everyone be treated the same, or will some people (e.g., those with less resources) be more likely confined than others?

I don’t have answers to these questions. They all present dilemmas. I know from comments left here during the earlier TB discussion that many readers take a pretty hard line. If you are one, here’s what I think you ought to do if you are not to be hypocritical: make an immediate appointment with your health care provider for a TB test. You should be more than willing to face the possible consequences of having it come up positive even though you feel fine: mandatory treatment with drugs with often unpleasant side effects for two years and maybe restriction on travel, movement or employment. In other words, the real possibility your life will be turned upside down. Failure to do this means you are possibly putting the public at risk.

Watching what happens to others with this diagnosis isn’t much incentive to do your duty, is it?

Comments

  1. #1 peggy
    August 30, 2007

    Revere, You already know this, but for those that don’t, what I remember about TB treatment: Treatment for TB is mandatory only for active disease, not a positive test. Anyone with active disease is required to be confined for the first weeks of treatment (at home or hospital or other places like the teenager you discuss) and to have directly observed therapy (DOT) where a nurse dispenses the medication and observes the person taking it. I have seen homeless people put up in motels for the duration of their DOT. For those that don’t comply, they can be picked up by police with a warrant. Public health nurses who work with TB go out into the community to provide DOT, and sometimes have to search for their patients among the homeless and on street corners.

    For those without active disease but a positive test, there are guidelines for helping to decide whether the benefit of prophylactic treatment outweighs the side effects.

  2. #2 revere
    August 30, 2007

    peggy: What you say is true. That’s why I inserted “potential” and “possible” in the post. There is a point, however, when you get a positive test you didn’t expect that all possibilities are open, and that’s the point I was referencing from the perspective of an individual. If you feel fine, there is little incentive to go get a test because it will either mean nothing of some anxiety for a period or it will mean something bad in terms of how they live. But ifyou are really hard nosed about this then you should go get a test to see ifyou are putting others in danger. Somehow I suspect that “hard nosed” is more hard nosed for others and few will do this just because I point it out. It was a “look at this from the other guy’s point of view” post.

  3. #3 Susan Och
    August 30, 2007

    Could you give a little more background on walking TB vs. treated TB? My husband tests positive on a tine test and was hospitalized in isolation when he was not much more than a baby, but he never knew if he actually had TB.

  4. #4 ssal
    August 30, 2007

    Previously, you pointed out that on commercial airplanes, the air that the passengers breathe flows not from the front of the passenger compartment to the rear but from side to side, i.e., from the center line toward the windows. Elsewhere (maybe you also pointed it out), I’ve read that passenger air is HEPA filtered. My main question is: On a typical passenger airplane, say, a 737, do you know how many individual HVAC units there are? (I assume there would not one for each row of seats) In other words, how many HEPA filters are in place? How adviaable and difficult would it be to install ultraviolet C units somewhere on the downstream side of each of the HEPA filters?

    Also, my understanding is that as opposed to flu, there is little dispute that TB is spread in large part by microdroplets and droplet nuclei. I think I recall seeing ads for disposable N95 masks for about a dollar or less. What thoughts do you have about airline passengers wearing N95 masks. If Mrs. Revere (or any chiidren or grandchildren or great-great=great grandchildren you might have) were flying commercially, say, from New York to Los Angeles, would you feel better if they were wearing an N95 mask? And even better if all the passengers were wearing them?

  5. #5 ssal
    August 30, 2007

    In the above entry “adviaable” should be “advisable.”

  6. #6 revere
    August 30, 2007

    ssal: I don’t know how many HVAC units there are but I ‘m guessing the answer is one (Randy?). Yes, N95s are probably effective for TB but your chance of getting TB on a plane are so small I wouldn’t bother. I fly a lot and I wouldn’t consider it. I don’t know the cost or safety issues with UVGI units on planes but again, I wouldn’t think it cost effective.

  7. #7 M. Randolph Kruger
    August 30, 2007

    http://www.donaldson.com/en/aircraft/support/datalibrary/001210.pdf

    http://content.nejm.org/cgi/content/abstract/349/25/2416?ck=nck

    Here is my best understanding of the deal SSAL. If someone is in the plane and honking virus, then your chances are moderate that you might be contaminated on your clothing or infected via an airway or eyes. It has a lot to do with the viral nature of the bug. You aim the fresh air vent at your head then its going to kill a lot of virus from general air friction but its also going to collect it on the backside of the filter and aim it right at you. HEPA filters collect the particles on the front and some portion always escape either through or around the sides of it.

    Most airliners fly about 300-400 hours per month, so at a 6000 hour C check TBM (Time Between Maintenance) thats a lot of funk on a filter after about four years. Want to hear something crazy? The procedure for removal almost 100% ensures infection if the guy removing isnt wearing gear and it recontaminates the air ducts when you are removing it. They treat it like you are changing the filter on the furnace in the attic. Not as a biohazard.

    During the first days of SARS I would put my people into a plane ONLY if they were wearing a full face plate mask to download shipments from the Far East or Canada. We almost got it here and the “there is no cause for alarm” standard line was being pumped. The Canadians were furious at the Chinese as was the US. Kind of like they patted us on the head and said we have so many people here so whats a couple of thousand over there? That enraged me, but like all lawsuits its borne in the assumption and I had to assume the worst because no one would or could tell me anything. My people in my estimation were in danger so I took action. But the big question is do the filters work?

    I can tell you that the airplane HEPA filters do not give you BSL quality air because some always slips by. The filter quality means that the “filtered air” as it exits will be clean in relation to the air presented that is contaminated to the level it prescribes for 6000 hours by parts per million or particles per inch detected on the backside. But that is the assumption that the air is going to directly to the intakes in a straight and linear way. Thats wrong, it will contaminate said intakes as well. Anything that exits the filter that is either unfiltered by nature of the filter media or bypasses then it will also contaminate. Its not as a rule going to grow though as there is nothing it likes in that filter. Its in the airlines interests though to filter it and remove it as often as possible because it accounts for about 400 lbs of weight that has to be lifted each and every day of the year that the aircraft flies. Used to be the ducting was just tossed after two or three years because it was so crapped up. Tape up the tubes, remove and replace.

    As for that “filtered air”, it doesnt take into account the time you are sitting on the ground with the doors open and with the guy two rows up blowing funk into the air. If that turbo air system either via the APU or bleed air system off the engines isnt running then you are a sitting duck target. Keep that in mind. HEPA filters helps out is all. But after all you are tuna in a can for several hours regardless if you are going from Memphis to Atlanta, or many hours if you are going from Hong Kong to Chicago. What are your chances? I dont think anyone could say. As for the mask, its designed to keep bugs in you rather than out and it doesnt account for your eyes either.

    Revere wisely doubts the efficacies of masks and I agree. Put a mask on, fit it well and make sure its a full N95 and go out side and have kids throw dust into the air and just walk around, bend over and do the things you would do when gardening. Do it for 30 minutes. Then take it off and tell me how much dust got past the seal. Its a lot I can tell you and way more than enough for an infection. Oh, and the mask when you take it off will have lots and lots of nasties that will flick off when you remove it right at mouth, nose and eye level. All points of infection.

    To prevent an infection you would need a mask such as a N95 or 99 full face plate (you can email me for a commercial site at memphisservices@bellsouth.net) and then you STILL would have to properly decon to get out of the thing. And you still might become infected. Not very feasible. I am set up and trained for it and the min time we can do a decon is about 15 minutes for the removal of masks and suits. Then about another 15 for the shower in phenolic and rinse off. Does wonders for your hair too.

    TB, SAR, BF dont be surprised if one day you get a knock at the door having ridden a plane or a public transport of some kind. Buses dont have HEPA filters, especially school buses.

  8. #8 Paul Todd
    September 2, 2007

    I do not understand how someone with TB who is not coughing and is sputim negative can be considered contagious, as they claimed with Speaker and probably this case as well.

    Frankly, the best way to avoid TB or other infection via air travel or any other travel is for there to be a requirement that anyone coughing be made to wear a mask provided by the airline.

    I also do not understand why we treat people with TB that is not contagious and who are not sick. It may be technically active, based on X-Ray and bronchoscopy (as in the Speaker case), but doesn’t giving drugs to someone with TB who is feeling well, and if it would more likely than not resolve on it’s own, increase the risk of drug resistance as they are the people less likely to take it as prescribed?. If the drugs can kill all the TB and if this means the TB will not remain in the persons body in it’s latent form I guess this would make sense. But does it?

    Those cases of otherwise healthy adults with TB will normally resolve and become latent w/o drugs. If I remember correctly, only 5% of those who are initially infected with TB get sick and require treatment. The others simply carry the disease in it’s latent form, and 5% of them will later go on to develop an active case requiring treatment as they get older or sick with other diseases that weaken them.

    But we are a fearful society, always quick to ask government to take draconian actions to “protect” us.
    And they are happy to do so as long as it does not affect the gun lobby or other corporate interests, especially when it gives government more power over the people.

  9. #9 M. Randolph Kruger
    September 15, 2007

    http://www.winnipegfreepress.com/breakingnews/local/story/4038307p-4647487c.html

    Revere/Tom DVM… Is bovine TB the same virus as human type. Is it contagious?

  10. #10 revere
    September 15, 2007

    Randy: Bovine TB is not a virus. It is a tuberculosis bacterium (M. bovis) and in the past was mainly infected humans through raw milk. There are reported cases of person to person transmission, although it is not very contagious and this is uncommon.

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