By Julie E. Fischer – The wild ride of Andrew Speaker, clean-cut bearer of drug-resistant tuberculosis, finally careened to a relatively subdued close in a Denver hospital after splashing the acronym XDR-TB across headlines and hearing rooms. Questions raised by his ability to thwart Federal public health intentions, not to mention US border security measures, continue to simmer.
Mr. Speaker is certainly not the first person to travel with tuberculosis, or TB – the World Health Organization estimates that about one-third of the world’s population currently harbors the TB pathogen, most in a non-contagious latent form. For 2005, WHO estimates that 8.8 million new TB cases occurred, and that 1.6 million people died of TB. What made this particular case so notable? The US Centers for Disease Control and Prevention learned that the Atlanta lawyer had boarded a trans-Atlantic flight infected with a type of TB that cannot be treated easily, and decided that the potential consequences for other passengers merited extraordinary measures.
The discovery of effective antibiotics halfway through the 20th century finally dethroned TB as one of the top killers in the US Drug resistant TB arises from inappropriate or incomplete antibiotic treatment, a common problem where laboratory testing, adequate drug supplies, and healthcare workers trained to manage treatment effectively are in short supply. Multi-drug resistant TB strains are resistant to the two most powerful anti-TB drugs; XDR-TB, first reported in 2006, is also resistant to at least two second-line drugs. Although XDR-TB is no more contagious than other strains and still constitutes a relatively small percentage of cases globally, the severely limited treatment options and low cure rate hearken back to an earlier age.
The bare facts have been well publicized: the patient received a preliminary diagnosis of multi-drug resistant TB, departed anyway for a planned wedding and honeymoon in Greece and Italy, found himself the target of something less than a manhunt but more than a casual inquiry, and evaded authorities by changing his travel plans and arriving via Canada. A U.S. Customs and Border Protection officer ignored a notice that would have prevented Mr. Speaker from driving into New York, where CDC invoked its isolation authorities to confine an individual for the first time since 1963.
Although CDC Director Julie Gerberding’s assertion that “our system works very well” appears overly rosy, CDC did act pragmatically when confronted with an international disease carrier posing uncertain risk to others who had broken no laws. The fact that Speaker either honestly or willfully misinterpreted medical advice against international travel suggests that CDC experts might have communicated both the risks and the possible options more clearly. Mr. Speaker’s case highlighted several other major issues: some key lessons learned from SARS remain relevant, interagency communication at the intersection of health and security remains problematic, and the “diseases of poverty” can be neglected only at our own risk.
Do risks to the public’s health truly constitute security issues, and if so, have we given the front-line agencies charged with protecting public health the appropriate legal, logistical, and technical tools? Current Federal laws and regulations give CDC isolation and quarantine authorities to limit the movement of people infected with specific diseases (including infectious TB) into the country or between states. The Federal regulatory framework primarily focuses on public health emergencies, leaving most authority over individual patients at the state and local level. Legal precedent has mostly allowed public health authorities to act in what they believe is the public’s best interest when balancing civil liberties against potential outbreaks. Whether the Speaker case shows a need for extensively greater Federal quarantine authorities should be an issue for careful debate rather than a knee-jerk reaction. Common sense does suggest that Federal health authorities should be able to detain people with certain contagious diseases traveling out of the country, as well as coming in – after all, the airplane is the same confined space regardless of route. Laws based on the assumption that all infected persons would defy authority and require confinement without any indication of intent would need to be highly specific to avoid infringing upon fundamental rights.
During the 2003 SARS outbreak, privacy and legal concerns frequently delayed the release of airline passenger manifests to the CDC for longer than the 10-day incubation period of the disease, thus preventing CDC from notifying exposed passengers of their risks and options in a timely fashion. In this case, airline responses appear to have been shortened from weeks to days, still too long in a disease with a shorter incubation time than TB. CDC proposed new regulations to address this problem in November 2005, but implementation has been slow following a controversial interim agreement between CDC and the Department of Homeland Security to share passenger lists and other tools designed to prevent terrorism rather than protect public health. These same concerns apparently consumed hours during Andrew Speaker’s flight, as CDC and DHS legal teams again pondered the right to constrain individuals who pose a risk to others by virtue of contagion rather than intended violence.
The decision of an individual border official to dismiss a “flag” on Mr. Speaker’s passport requesting that he be held because of health concerns illustrates the difference in sensitivities to disease versus terrorist threats. This event also highlighted problematic interagency communication and cooperation issues. County health officials incorrectly assumed that a CDC technical expert on TB consulted about the case would initiate appropriate quarantine steps. For some reason, CDC appears to have initially requested Customs and Border Protection’s assistance via a field office rather than an interagency channel.
Although biodefense strategies clearly bear examination, flawless border security and the most draconian quarantine measures imaginable would not solve the underlying problem. Multi-drug resistant TB arises from poorly managed treatment, a problem fostered by resource constraints, governance failures, and historically sporadic humanitarian aid for treatment programs in the developing world. Research has also been sorely neglected; diagnostic and treatment tools for TB depend on decades-old technology, and laboratory confirmation of drug susceptibility can take weeks. WHO recently announced specific strategies as well as a $2.5 billion dollar budget to tackle the emergence of drug-resistant TB this year as a supplement to its 10-year “STOP TB Global Plan,” which already boasts an anticipated $31 billion shortfall in full funding of the program through 2015. Donor nations have pledged additional funding through other mechanisms, including the public-private partnership called the Global Fund to Fight AIDS, TB, and Malaria, but the honoring of those commitments as the disease disappears from the headlines remains a perennial problem.
What lessons will we draw from this wake-up call? If the question is, “What more can the U.S. do to protect its citizens from exposure to TB?” then we will fight a brave (but probably futile) battle to build bigger walls against outside disease threats. If, instead, the current concerns can be harnessed to ask, “What more can the U.S. do to improve diagnosis, treatment, and prevention of TB worldwide as well as at home, averting the rise of more drug-resistant disease and potentially saving more than a million lives each year?” then Andrew Speaker may someday be hailed not as the Typhoid Mary of the jet age, but as the spark igniting real political will for a global approach to health security.
Image: Estimated worldwide tuberculosis incidence rates in 2000, WHO.
 WHO Global Tuberculosis Control 2007, http://www.who.int/tb/publications/global_report/2007/en/index.html
Dr. Julie E. Fischer leads the Stimson Center’s Global Health Security program which explores the growing demands on the world’s public health infrastructure, from policies intended to contain transnational disease threats to a new role for international health interventions in defense and diplomacy.