I blogged earlier about the Georgia man who globe-trotted while infected with XDR-TB. I wrote that post late Tuesday evening, and since then, a number of other details about his case have come to light--and they're not encouraging. In fact, this serves as a nice example of a convergence of a number of areas I've written about before--obviously, the evolution of antibiotic resistance and the terrible position it leaves us in, the politics and policies of quarantine/isolation (and how they'd be enforced), and the global spread of infectious disease, so I figured this would warrant another post on the topic.
First, the "compelling personal reason" he had for traveling that was mentioned in early articles was this: that he he was getting married in Greece and then honeymooning in various stops around Europe. Now, I'm probably just unsentimental and maybe a bit too practical at times, but it seems to be a really poor idea to potentially expose not only your future wife (who apparently was tested in January and negative for TB) but also your relatives and other loved ones to a highly deadly bacterium on what's supposed to be one of the happiest days of your life. I mean, sure, you want people to remember your wedding, but not because they contracted tuberculosis there.
That's only the beginning of the dumbassery, unfortunately--it gets worse. More after the jump.
As the story broke, the unidentified man at the center of it wanted to defend himself, so he spoke with the Atlanta Journal-Constitution about his experience and his reasons behind what he's done. He claimed:
"I didn't want to put anybody at risk," the Fulton County man, who declined to be identified because of the stigma attached to his diagnosis, said in a telephone interview with The Atlanta Journal-Constitution. "We just wanted to come home and get treatment."
Of course, the problem is that he did put people at risk. What's worse is that, while he hadn't been given a diagnosis of XDR-TB specifically before embarking on his trip, 1) he still knew he had TB; and 2) he knew that the TB strain he had wasn't responsive to the treatments he'd been given:
The man at the center of the international health incident said his TB ordeal began in January. Because he has felt healthy, the disease was detected by accident, during a chest X-ray for something else. It uncovered a small mass in one lobe of his lung. A sputum test came back negative for TB, but a more sensitive culture test confirmed the diagnosis.
"So they started putting me on the standard four-drug treatment," he said. And they tested his fiancée and other close contacts for the disease: None of them had it.
But it turned out his TB was resistant to the first-line drugs -- and the second-line drugs. So county officials stopped treatment. The man said he and his private doctor -- with the agreement of government health officials -- made plans for him to undergo cutting-edge treatment with specialists at National Jewish Medical and Research Center in Denver after his honeymoon.
He knew his strain was **resistant to all the drugs they'd thrown at it thus far**. He knew that it was going to require "cutting-edge treatment" to get it under control. To make matters worse, the New York Times write-up notes that the man claimed "...He knew he had a form of tuberculosis and that it was resistant to first-line drugs, but he didn't realize it could be so dangerous." However, the article also states that "...The man told a newspaper he took the first flight from Atlanta to Europe for his wedding, then the second flight home because he feared he might die without treatment in the U.S."
So he didn't know how dangerous the bacterium could be, yet feared he'd die in Italy (where he refused to enter isolation after receiving the official XDR diagnosis). Fearing that, and finding out that his passport had been flagged and he was placed upon the "no-fly" list, he hopped a flight from Prague to Montreal (to circumvent U.S. airline travel) and then drove back across the border, turning himself in at a New York hospital.
This tidbit of information also brings up all kinds of public health and national security issues. Obviously, this guy shouldn't have been able to just get back into the country. I suppose it should be encouraging that at least he didn't fly in directly and make it through, but his backdoor route of entry again just exposes our weakness in keeping out potential "bad guys," even if they've been identified and flagged. It also highlights our lack of any kind of real policy with regard to quarantine or isolation. (Note that these are not the same things: quarantine is for those who have been potentially exposed to an agent but don't yet show symptoms, while isolation is for those who are certainly infected and may be shedding the pathogen). Now, the man claims that the public health officials he contacted told him that they "preferred" he not travel, but he informed them that he was going to anyway, and they didn't tell him to take any precautions. The health officials, however, give a slightly different version:
Dr. Steven Katkowsky, director of public health and wellness for Fulton County, said it's his understanding that the man was "advised not to travel."
"I didn't hear that conversation," Katkowsky said, "certainly the recommendation would be that if you have an active infection with tuberculosis, you ought not to be getting on a commercial airliner."
Katkowsky said after that conversation, the department attempted to hand-deliver a medical directive, dated May 11, to the man telling him not to travel, but his home address was vacant and he was not at his place of business.
When they finally located him, the patient and his new wife were already honeymooning in Rome. An official from the CDC told him to stay put initially, and then that he needed to turn himself in to Italian authorities so that he could be isolated and treated, and that he most certainly shouldn't fly on a commercial jet (and also that his passport had been flagged, so no goin' back in through the U.S. for him). This is when he bailed:
To evade the no-fly list, which they assumed only involved jets bound for the United States, the man and wife flew into Canada and drove a car into the U.S. At every check of their passports, he said they feared being caught, but weren't.
Why not just get treated in Italy?
The man said he wants people to understand he sneaked back into the United States because he feared for his life. An unsuccessful treatment in Italy would have doomed him, he said, because he said they lacked the expertise.
Now imagine this on a larger scale. Imagine dozens, or hundreds, of people infected with an organism that's either incurable or difficult to treat. Imagine knowing that you may be put into isolation or quarantine if you admit you're infected or exposed. It may be in an area you'd rather not be in; perhaps in a sub-standard medical facility, in an area many miles away from your loved ones, and you're (understandably) scared and worried. This current story involves one person, who potentially exposed many people on two continents, who's now locked away in isolation in Atlanta--and that wasn't easy to accomplish. What would happen if many more people were ordered into quarantine or isolation? Could the government handle it successfully? I don't think we know that. Or maybe we do, but it's just the wrong answer.
He continues,
"I'm a very well-educated, successful, intelligent person," he said. "This is insane to me that I have an armed guard outside my door when I've cooperated with everything other than the whole solitary confinement in Italy thing."
Mike notes that this guy acted bloody stupid. I agree that his actions were stupid, but it's pretty clear he's a smart guy. He was clever enough to get back in the country despite his flagged passport, after all, and the article mentions that he may have acquired the infection in the first place after work he carried out in Asia doing fund-raising for hospitals. He's no dummy. But he was a coward, and put many other lives at risk to save his own neck (and even worse, to have his wedding and honeymoon go off as scheduled). I don't think this escapade is a result of ignorance or scientific illiteracy as much as it is arrogance and self-centeredness (qualities that seem to shine through every step along the way of his ill-fated trip to Europe and back, and then continue when he called the paper to give his own side of the story). However, in addition to the intercontinental public health problems he caused, Tiffany notes he's also subjected himself (and potentially his new wife) to a host of legal issues:
If you gave no thought to the fact that if you get on a commercial airline and expose someone to a rare, deadly form of tuberculosis after you have been told not only not to fly, but to go into isolation, that you might have opened yourself (and if you die, your lovely, but apparently equally stupid new wife) to a giant chunk of legal liability--well, then, you are not well-educated or intelligent. If someone who was on the flight to Montreal gets or dies of this particular disease, guess who the wrong-doer is?
While she argues it's because he's lacking intelligence, I still feel it's more about arrogance--surely *he* couldn't infect others; he's intelligent! He's educated! He's important! Even having some understanding of the TB he's carrying wouldn't necessarily take away that feeling of personal exemption from the rules, of entitlement to go about his business that so many in society seem to feel. As Tiffany also writes, "Some people won't do as advised for the protection of the rest of us." That's the heart of the matter--he knew of his condition, he knew it was pretty bad (even if he didn't know the extent of just how nasty it was), he knew officials had advised him not to travel, he knew he could expose others, he knew he'd been ordered into isolation, he knew he wasn't supposed to fly on commercial jets. He did all that anyway--and in any kind of an epidemic situation, are we really going to be able to count on so many of us "doing as advised" for the protection of the rest? I highly doubt it.
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I read your first post first. This story just keeps getting worse and worse.
Maybe he thought that whilst TB might be fatal not turning up to a Greek wedding when you're the groom would be immediately fatal?
All jokes aside though- then going on the honeymoon reeks of denial. Sneaking back into the US despite the full warning he'd received plus his own work in the healthcare industry is reckless stupidity.
I suggest that you and some other "science" bloggers are putting too much focus on this individual's arrogance/stupidity/self-centeredness/whatever. My moderately-informed lay analysis of this situation is that his behaviour will come to be seen as reasonably typical.
My guess is that unless "the authorities" are willing to get police involved, this sort of thing will happen again and again. A long-distance warning call from CDC just isn't going to cut it.
If I were a couple of thousand kilometres from home and got a phone call requesting that I report for quarantine ... well, I like to think that I'd do the responsible thing, but I'm really not sure.
Well, that's rather my point--that if/when something really nasty hits, and if you're sick or exposed and told to either stay in your house, or asked to isolate yourself somewhere else (or even ordered into it), all hell is going to break loose upon attempted enforcement because we're going to be unprepared, and responses like this patient's *will* be typical.
However, I don't think that just because we may expect that this would be typical, that excuses his behavior. He's put a lot of other people at risk, and for what? If he needed to get married that badly, wear a mask and get a justice of the peace to tie the knot before heading off to treatment here in the U.S. There simply is no reason for him to have traveled like that.
And "science" blogger? Why the scare quotes?
As I said.
True, but irrelevant. That's part of my opinion - waxing indignant is pointless.
Unwarranted assumption on your part. Not every blog that comments on matters of science is a science blog. That's all...
I wouldn't be so sure that the average person would evade or ignore isolation and quarantine.
We saw this with SARS. No real treatment, 10% fatal, highly contagious respiratory disease. Once it was realized what it was and the danger, the main procedures were just isolation and quarantine.
It was a while ago but IIRC, there wasn't too much problem after the sturm and drang PR with getting patients and exposed to do the right thing.
Mr. TB denier sounds like a rather extreme personality problem. If someone exposed comes up with his strain of TB (fingerprint it if need be), he should be charged with assault or reckless endangerment. If someone dies of his XDR, he should be charged with manslaughter. Even without a conviction, this would make a point.
PS: His new wife must have been either desperate or clueless or both. Nothing most people would look for in a spouse.
I'm having some mixed reactions to this: on the one hand, I'm outraged at his behavior. On the other, I'm remembering with vivid clarity,an infectious disease specialist who barged into a patient's isolation room, refused to put on PPE, and then proceeded to use his bare hands (which he hadn't washed) to examine the patient, used his stethoscope on him - didn't disinfect it, nor did her use a disposable stethoscope, and broke every principle and rule of contact and respiratory isolation that was clearly in place and signed for the patient.
I think to the daily occurrence of nurses and physicians who refuse to wash their hands between patient contact. I think of all of the patients who take prescribed antibiotics until they feel better and then discontinue them. Or they take leftover medications from a family member. Or they come to work/school ill and symptomatic.
Overall, the US has a culture of stubborn independence and a culture that rewards nonconformity. We've done a terrible job in developing a culture of responsible personal/public health.
This fella acted in the extreme, but I'm not so sure that the norm doesn't tilt toward noncompliance.
The biggest problem is that he didn't understand how bad tuberculosis was -- most people don't. TB is something that their great-grandparents had, and the grandparents forgot to tell him. He doesn't / didn't realize that TB was the number one cause of mortality in 1900 -- not heart disease, not cancer, not accidents, but an infectious disease.
And it gets better -- if we don't get something to fight XDR with, we're right back to 1900, but worse -- we are more crowded and more interconnected, with much better chances of spreading this nastiness.
Heck, maybe he would have gotten the point if somebody had handed him a gun and told him to get to the airport and randomly shoot people -- he'd cause less suffering that way, and when the cops shot him, that would be the end of his spreading XDR TB. Think he'd get the point? Nah -- he's a cosseted young 'un, and only age teaches, just like always.
But his history and his own words don't support that. He'd been treated since January--that treatment failed. He was going in for an experimental treatment and surgery that would take 18 months and apparently he could only get in Denver. He knew he could die from it. How much worse could it get, beyond essentially untreatable and potentially fatal?
It is even worse. The CDC and Govt are lying through their teeth.
XDR TB has been in the US for many months - including an illegal alien who has it and who been in court ordered quarantine in Phoenix since last July.
Man With Drug-Resistant TB Locked Up
http://www.sfgate.com/cgi-bin/article.cgi?f=/n/a/2007/04/02/national/a1…
He didn't follow treatment directions either.
If you really want some unsettling information, see the DISEASES section THE DARK SIDE OF ILLEGAL IMMIGRATION posted at http://www.usillegalaliens.com/
BTW, a health screening is not part of the Bush-Kennedy amnesty plan. Who is handling your food in the restaurant where you eat?
MDR TB is all over the place:
In an article in the Journal of the American Medical Assn., Dr. Reuben Granich, a lead investigator for the CDC commented on MDR-TB:
"Evidence of it has surfaced in 38 of 61 California health jurisdictions, and it could 'threaten the efficacy of TB control efforts,' Granich said. The infected were said to be four times as likely to die from the disease and twice as likely to transmit the disease to others....Reluctant to label the infected as 'illegal' or even 'undocumented' aliens, the report notes that of the 407 known cases of MDR-TB, 84% were 'foreign-born' patients, mainly from Mexico and the Philippines who'd been in the U.S. less than five years. The percentage of TB cases among the 'foreign-born' jumped from 29% in 1993 to 53% as of last year."
As noted in an October 2006 article U.S. immigrants pose TB threat in World Net Daily:
WASHINGTON - The worst forms of a drug-resistant killer tuberculosis bug, rapidly spreading throughout the world, have been gaining ground in the United States along with record legal and illegal immigration levels, alarming public-health officials over a disease once thought vanquished.
Although the number of confirmed drug-resistant TB cases in the U.S. is relatively small - still measured in the dozens - health officials say visitors from other countries are bringing in the deadliest mutations.
The only visitors to the U.S. who are screened for tuberculosis and other medical conditions are immigrants who enter the country legally. There is no easy way to screen millions of tourists and illegal migrant workers.
....Over the last 30 days, TB has been discovered in dozens of states:
⢠Last month, six employees who work inside Detroit's AT&T building tested positive. Investigations into the outbreak are ongoing.
⢠In Oklahoma City, hundreds of patients and hospital workers may have been exposed to tuberculosis by a health-care worker, and at least 10 people caught it. A letter sent to 1,650 patients and 350 workers at Integris Southwest Medical Center in Oklahoma City warned of their potential exposure and urged them to get skin tests to determine whether they were infected.
⢠In Alabama, 22 LeFlore Preparatory Academy students and faculty members tested positive for tuberculosis infection and are undergoing further examination to determine if they have an active case of the disease, Mobile County Health Department officials said last Monday. The people who tested positive were among 909 who elected to be screened after a student was diagnosed with the disease.
⢠In Florida, public health and school officials said they had confirmed a case of tuberculosis at a Manatee County middle school. Seven months ago, it was announced that a school district employee whose job required visits to several campuses had active TB.
⢠In Cincinnati, a student and teacher visiting a high school became infected.
⢠In Connecticut, health officials are trying to figure out whether a University of Hartford student has tuberculosis.
⢠In South Texas, a second group of students and staff at McAllen's Zavala Elementary School were forced to undergo skin tests today after a student was discovered carrying the contagious airborne disease.
⢠In Pennsylvania, hundreds of Upper Moreland High School students had to be tested after the Montgomery County Health Department notified parents in the district that a male student had become infected over the summer.
⢠In Mississippi, more than 10 percent of the 102 Meridian firefighters have tested positive for the tuberculosis antibody, but state health officials say there is little cause for concern.
⢠In South Georgia, Mitchell County health officials are investigating a case of tuberculosis at a major chicken processing plant.
⢠In California, more than 6,000 inmates at California State Prison-Solano are being tested for tuberculosis after two inmates were discovered with the disease.
⢠In Wisconsin, nearly 100 students and staff may have come into contact with a West Allis day care employee infected with tuberculosis, health officials report. The employee, who had active TB, is being treated and is no longer at the center.
Just my opinion, but I would have to say that arrogance, stupidity (and fraternal twin, ignorance) and self-centeredness are all too typical of the human condition. Most people have at least one, and quite a few pull the whole trifecta. Look at any of hundreds of such things as refusal to wear seatbelts, just to pick one example. Or worse, refusing to buckle their toddlers into childseats because they look cute perched on the center console, ready to be catapaulted at any sudden stop.
Scott
I think that this individuals behaviour is in fact probably quite typical. That's what scares us (i won't say science blogger 'cause I'm not one) public health people. I'm fundamentally in agreement with you.
All the information in the world and he still followed about the silliest series of actions one can think of.
Possibly the difference between TB and SARS reactions is that TB has that comfortable old world disease feeling about it whereas SARS was mean and new and had a nasty sounding name.
SARS, say it again. New and nasty and scary sounding.
TB on the other hand, if you don't know any better, sounds like something poor people in the third world get. Until you read medical accounts from 100 years ago and you have some understanding of the evolution of resistance to antibiotics.
pfwag, what are they lying about? Even the articles note that there have been several cases of XDR-TB in the U.S. No one has denied that. What's different in this case is how he ran away from authorities when he was told to report to isolation, and then snuck back in the country. And I did blog about the Phoenix case previously here.
Regarding the info you give on immigration, that source is very poor. They cite the same (incorrect) leprosy numbers that just got Lou Dobbs in trouble, for example.
And yes, MDR-TB remains a problem in this country, but that differs from XDR-TB in that it remains treatable (though it's obviously more difficult to treat than TB that retains antibiotic sensitivity). Don't conflate the two. You must know that TB rates as a whole have gone down in recent years in the U.S., despite an increasing number of immigrants?
I find it somewhat believable that the patient may have made it to Italy without fully understanding the consequences of his disease and actions, especially since the "medical story" was certainly changing with time. While I've only made one TB diagnosis, I know I would intially say that this disease is *usually* very treatable, not life threatening, but requires the proper, monitored treatment for a substantial period of time. I would not recommend travel, but if pressed on the issue, I might not have prohibited it for a nonsymptomatic patient to attend his wedding (my future actions have probably changed from this incident). Granted, my actions would have changed with a MDR-TB diagnosis. I, however, would report the TB diagnosis as required by law, and others might prohibit travel.
So he is in Italy and gets a call from the CDC, who probably scared him (the CDC is known for this) to get him to do what they want (very, very bad medical practice). It is obvious that the CDC threated him (bad, bad, bad) by revoking his passport and putting him on the no-fly list. If the patient was so intent on getting home, send a jet for him. The CDC had an opportunity to end this, but they probably provoked the altercation. The patient, then, outsmarted the CDC. If I somehow made it to Italy and got a XDR-TB diagnosis, I cannot say that I would not do the same thing (and I should "know better").
But again, this wasn't his initial diagnosis--that was 5 months ago, and he already knew it was resistant to the antibiotic cocktail he'd been given, and that it needed a treatment available only at one place in the country, according to the patient himself! I agree with you had he been newly diagnosed, but I just don't buy it after going through all that treatment, and knowing how much more was to come, and then the fear he expressed over being treated in Italy, all signs point to him knowing.
There is a big "hole" in the information provided by the CDC for his whereabouts while he was in Greece... And this involves probably many American tourists...
If the Bush administration can lock up Osama's driver as a terrorist, they can certainly could and should prosecute this guy.
Reckless endangerment.
If I was invited to a wedding, and I found out the groom knew he had XDR-TB I would be absolutely rip-shit! WTF! Exposing everyone at the wedding to XDR-TB? If any of the relatives die, it will be deserving of a Darwin award.
I don't know what kind of congradulatory embracing and kissing is customary in a Greek wedding, but there is a real good case study here on how transmissible this XDR-TB is via those practices.
The individual in question has since been identified. At least three aspects seem especially alarming:
1. His father-in-law(?) is a microbiologist at the CDC specialising in the spread of TB, and apparently discussed the issues with the person before he flew. So it seems extremely unlikely he didn't know, before flying, what a stupid idea travelling with TB is.
2. Some people are accusing the microbiologist at the CDC as being the source of the TB. I find this disturbing since the accusation, currently sans any evidence, smells of the anti-reason which infests the USA these days.
3. The guy is apparently a lawyer. Since he is not a politician, this suggests it's quite reasonable to assume he's not stupid.
I myself would guess that, being a lawyer, he saw the issue in purely legalistic terms; i.e., since he was not prohibited from travelling, travelling was Ok. And had he been "legally" prohibited from travelling, my guess is the reaction would be to file (or at least threaten to file) a lawsuit (and get an "emergency"(?) suspension of the prohibition so he could travel).
Klearchos
"There is a big "hole" in the information provided by the CDC for his whereabouts while he was in Greece... And this involves probably many American tourists..."
Yeah! Who cares about all the other humans anyway?
Yes, but he's a *personal injury* lawyer. I can't believe he didn't see it as a thousand potential lawsuits against him everyday that he was out in public with this.
I think everyone seems to have overlooked the most obvious problem with this man's behaviour: he flew back to the US so he could get treatment that was only available in Denver, but was willing to expose people in Italy, who obviously had no hope of getting the latest treatment, and fellow travellers on the plane, not all of whom would be US residents. Remember, he chose this course of action *because* he knew he was carrying a potentially fatal communicable disease that could only be treated in Denver.
daedalus2u wrote:
I don't know what kind of congradulatory embracing and kissing is customary in a Greek wedding, but there is a real good case study here on how transmissible this XDR-TB is via those practices.
Well the worst kind,when the ceremony is over, all guests,relatives,friends present (counted in 10s or 100s) form a line and sequentially embrace and kiss the groom,the bride and the "close" family of the newly-weds.
I don't know how representative that guy's marriage was
-was there a typical greek-orthodox wedding? in this tread the National Jewish Hospital is mentioned,if this somehow means that he is a jew that sounds improbable
-
but without precise information who knows?
if it was close to an average ceremony well...
Klearchos wrote:
There is a big "hole" in the information provided by the CDC for his whereabouts while he was in Greece... And this involves probably many American tourists...
Klearche ,
setting aside the part in which you overly emphasised on American tourists forgeting the greek population,
well here the media,the news have been pretty reassuring,
quoting foreign media and local-national "CDC" personnel.
Though for some obscure reason I can't seem to trust either CDC,yours or ours.
And of course trusting the media (national or foreign) is out of the question.
thanks
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