Health Officials' Reaction to TB Scare Gets Much Support

Jul 06, 11:29 AM

Current Headlines: By Lawrence K. Altman

Last May, after Andrew Speaker, the Atlanta lawyer with active tuberculosis, flew to Europe, federal officials held a news conference to urge his fellow passengers to get tested for tuberculosis because they said he had the most dangerous form of the disease. The news set off a barrage of publicity, much of which blamed Speaker for potentially exposing others to such a dangerous disease. Speaker became a worldwide pariah.

On Tuesday, federal health officials and doctors at National Jewish Medical and Research Center in Denver, where Speaker, 31, is being treated, said tests showed his form of tuberculosis was less severe than thought, although still life-threatening.

So, was the hysteria necessary?

In interviews Wednesday, infectious-disease experts in Canada, Europe and the United States who are not connected with Speaker's case generally supported actions by the Centers for Disease Control.

Some questioned the need for a news conference, saying it might have been possible to alert those who were involved in a quiet manner. But many they said that neither Speaker nor the CDC have disclosed the full facts in his case.

Others said that there had been a need for publicity to track down the passengers. Erring on the side of caution, they said, made sensible public practice for the agency charged with protecting the nation's health, even if it became embarrassing.

"I can understand the arguments and all the emotions," said Mario Raviglione, director of the World Health Organization's tuberculosis department in Geneva.

"If I sat next to a passenger with drug resistant tuberculosis, I would not be happy if I caught it, because I'd be getting a serious disease and need to take toxic drugs for two years and still face death," Raviglione said. "They did the right thing."

In an e-mail to other county officials in May, Steven Katkowsky, director of Fulton County Health Department in Atlanta, which oversaw Speaker's case, defended the idea of making the issue public. At the time, he wrote that "if we don't say anything as a preemptive strike, the questions of what did you know, when, and what did you do are bound to come up."

The new tests show that Speaker is one of an estimated 400,000 people in the world who have multiple-drug-resistant tuberculosis, or MDR-TB. Earlier, it was believed that he had XDR-TB, an extremely drug-resistant form of the disease. The MDR and XDR forms affect only a few hundred people in the United States, for example.

While Speaker's case was unusual in many aspects, it followed the standard ways doctors detect and treat tuberculosis. Doctors detect TB largely through skin tests, X-rays and laboratory tests. After taking sputum and lung secretions from a suspect, doctors smear a portion of the specimen on a glass slide. They add chemical stains to help detect TB bacteria (often nicknamed red snappers) when they look through a microscope.

If bacteria are seen, a patient is said to be smear positive and is considered infectious to others. If no bacteria are seen, the smear is said to be negative. But about 17 percent of patients who are smear negative can still transmit the bacteria.

A portion of the sputum specimen is put on culture media to grow the bacteria. If bacteria turn up, technicians perform additional tests to determine the bacteria's susceptibility and resistance to antibiotics.

Treatment depends on the patterns found. The smears and cultures are repeated in a few weeks.

If a smear turns negative for a hospitalized tuberculosis patient, some doctors allow patients to be discharged provided that social workers find that home care is adequate and that the patient has money to buy food and prescription drugs, among other criteria.

"Every case is a careful judgment call" and there is a need to protect confidentiality, said Lee Reichman of the New Jersey Medical School Global TB Institute.

Speaker's smears have been repeatedly negative but his cultures have been positive.

Doctors initially treated him for regular TB until later tests showed he was MDR positive. After meeting with Fulton County health officials, he flew to Europe to get married and honeymoon before doctors switched him to a new drug regimen.

A key point in Speaker's case is that although he was smear negative, he was not treated for MDR-TB.

The CDC caught up with Speaker by telephone in Rome in May, telling him that he had extremely drug-resistant tuberculosis and advising him to seek care there. But Speaker then flew back through Canada. When CDC officials reached him again by telephone in upstate New York, they issued a federal isolation order, the first such order in four decades.

Speaker voluntarily drove to Bellevue Hospital in Manhattan, where he stayed a few days until the CDC flew him to Grady Memorial Hospital in Atlanta. He then flew to Denver in a medevac plane.

Repeating culture tests is standard medical practice. But health officials often have to act before findings from repeat tests are available.

"It's a call you make at the time, doing what you have to do with what you have on hand," said Frank Plummer, chief science adviser for the Public Health Agency of Canada.

Plummer said his agency would have made a similar decision and would have exercised "abundance of caution."

Laboratory testing is not a precise science. Discordant TB test findings from different laboratories often occur and have to be resolved.

But Plummer, who also directs the National Microbiology Laboratory in Winnipeg, said the discordance between the two laboratories in this case "doesn't make sense" and that he hoped a review would "solve the mystery."

Speaker's TB strain resembles one known as the Haarlem strain originally isolated in the Netherlands. But scientists at the CDC and the WHO said they had been unable to find an exact match between the genetic fingerprints of his strain and those found in tens of thousands of other drug-resistant tuberculosis cases.

Reflecting on the case, Kent Sepkowitz, director of infection control at Memorial Sloan-Kettering Cancer Center in Manhattan, said: "Everyone is a genius in retrospect. But if events had broken the other way and Speaker had XDR-TB, CDC would look like schmucks."

(c) 2007 International Herald Tribune. Provided by ProQuest Information and Learning. All rights Reserved.