TB

TB INFO
90% latent, 3 weeks before contagious, not very contagious, two main antibiotics treat it and takes a long time to kill it; only human host
WHO fact sheet: http://www.who.int/mediacentre/factsheets/fs104/en/index.html 1/3 of world infected!
MDRTB is not very contagious, but can be lethal (in reference to resistant to specific drugs)
XDRTB is resistant to most effective drugs, can spread from one to another when TB is active (from low immune system)
leading killer of women of reproductive age globally
http://www.cdc.gov/tb/faqs/default.htm
U.S. info
http://jama.ama-assn.org/cgi/content/full/297/16/1765
In 2006, a total of 13,767 tuberculosis (TB) cases (4.6 per 100,000 population) were reported in the United States, representing a 3.2% decline from the 2005 rate. This report summarizes provisional 2006 TB incidence data from the National TB Surveillance System and describes trends since 1993. The TB rate in 2006 was the lowest recorded since national reporting began in 1953, but the rate of decline has slowed since 2000. The average annual percentage decline in the TB incidence rate decreased from 7.3% per year during 1993-2000 (95% confidence interval [CI] = 6.9%-7.8%) to 3.8% during 2000-2006 (CI = 3.1%-4.5%). Foreign-born persons and racial/ethnic minority populations continue to be affected disproportionately by TB in the United States. In 2006, the TB rate among foreign-born persons in the United States was 9.5 times that of U.S.-born persons.* The TB rates among blacks, Asians, and Hispanics were 8.4, 21.2, and 7.6 times higher than rates among whites, respectively.

http://jama.ama-assn.org/cgi/content/full/298/1/83?maxtoshow=&HITS=&hits=&RESULTFORMAT=1&andorexacttitle=and&fulltext=%22pandemic+influenza%22+%22national+strategy+%22&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=date&resourcetype=HWCIT
Media coverage of Speaker's situation provided many people with an introduction to XDR-TB, which is the latest chapter in humanity's battle with the "white plague." Once thought under control in developed countries, TB cases increased in the 1980s after funding cuts for TB prevention and treatment programs and the emergence of the AIDS pandemic. The reemergence of TB had the harshest consequences in the developing world, particularly with the impact of HIV/AIDS on susceptibility to TB infection. The increase in TB cases led to an increase in inadequate or incomplete antibiotic treatments, which produced resistant TB strains.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5511a3.htm
For 2005, a total of 14,093 tuberculosis (TB) cases (4.8 cases per 100,000 population) were reported in the United States, representing a 3.8% decline in the rate from 2004. This report summarizes provisional 2005 data from the national TB surveillance system and describes trends since 1993. The findings indicate that although the 2005 TB rate was the lowest recorded since national reporting began in 1953, the decline has slowed from an average of 7.1% per year (1993--2000) to an average of 3.8% per year (2001--2005). In 2005, the TB rate in foreign-born persons in the United States was 8.7 times that of U.S.-born persons.* In addition, Hispanics,^† blacks, and Asians had TB rates 7.3, 8.3, and 19.6 times higher than whites, respectively. Moreover, the number of multidrug-resistant (MDR) TB^§ cases in the United States increased 13.3%, with 128 cases (up from 113 in 2003) of MDR TB in 2004, the most recent year for which complete drug-susceptibility data are available. The deceleration of the decline in the overall national TB rate, the persistent disparities in TB rates between U.S.-born and foreign-born persons and between whites and racial/ethnic minorities, and the increase in MDR TB cases all threaten progress toward the goal of TB elimination in the United States. Effective TB control and prevention in the United States require sufficient resources, continued collaborative measures with other countries to reduce TB globally, and interventions targeted to U.S. populations with the highest TB rates.

Mayo Clinic Proceedings July 07: http://www.mayoclinicproceedings.com/inside.asp?AID=4425&UID=#bib1
"This case has focused attention on important public health issues: the global TB epidemic and the risk of spread of infectious agents either knowingly or unknowingly via air travel."
"Among infectious diseases, TB is second only to the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome as the greatest contributor to adult mortality, causing approximately 2 million deaths per year worldwide. The World Health Organization (WHO) estimates that one third of the world’s population is infected with Mycobacterium tuberculosis and that 1 in 8 deaths in the world today is due to tuberculosis."

CDC site: http://74.125.45.132/search?q=cache:-fDaIzycrLEJ:cdc.gov/tb/pubs/iom/Ending%2520Neglect%2520Slides%2520Compressed.ppt+u.s.+federal+funding+for+tb&hl=en&ct=clnk&cd=7&gl=us
increase 1988-1992
IOM site: http://books.nap.edu/openbook.php?record_id=9837&page=2
1994 abated

MDRTB as man-made in sense of origin in treatment applications, which need to use multiple drugs
http://www.prnewswire.co.uk/cgi/news/release?id=95088
antibiotic resistance
APHA http://www.apha.org/publications/tnh/archives/2007/August07/Globe/TBGlobe.htm "The case of (drug-resistance) is just one example of a problem we’ve been dealing with for decades, and it’s the basic public health system that really needs to be strengthened. (XDR-TB) is a problem that we made and we’re really the only ones that can undo it."

http://www.ucsusa.org/food_and_agriculture/science_and_impacts/impacts_industrial_agriculture/prescription-for-trouble.html
"Why are these drugs losing their power? Because they're being overused. Bacteria become resistant to antibiotics through overexposure to them. Hardy strains of the bacteria survive the exposure and pass on that resistance trait to successive generations. And they also pass the trait across to other bacteria that are unrelated, including some that cause human disease. Eventually the antibiotic wipes out all the vulnerable bacteria, and only resistant bacteria remain. Then the drug is no longer effective."
http://www.scq.ubc.ca/attack-of-the-superbugs-antibiotic-resistance/
However, the bacteria in particular have proven to be much more innovative and adaptive than scientists had imagined. Bad practices and mismanagement have only exacerbated the situation. The rate of resistance acquisition is accelerated by the widespread misuse of antibiotics.
http://74.125.45.132/custom?q=cache:g7MDN7vPGdgJ:www.nwc.cc.wy.us/dotAsset/111689.pdf+antibiotic+resistance+modern+medicine+inevitable&hl=en&ct=clnk&cd=4&gl=us

http://www.cdc.gov/tb/xdrtb/ XDR TB is described as TB that is resistant to the two most important first-line TB drugs (isoniazid and rifampin) and the two most important second-line drugs (a fluoroquinolone and an injectable agent—amikacin, kanamycin, or capreomycin), according to the CDC. The agency says 49 cases of XDR TB occurred in the United States between 1993 and 2006.

WHO TB fact sheet, 2007 http://www.who.int/mediacentre/factsheets/fs104/en/index.html

Until 50 years ago, there were no medicines to cure TB. Now, strains that are resistant to a single drug have been documented in every country surveyed; what is more, strains of TB resistant to all major anti-TB drugs have emerged. Drug-resistant TB is caused by inconsistent or partial treatment, when patients do not take all their medicines regularly for the required period because they start to feel better, because doctors and health workers prescribe the wrong treatment regimens, or because the drug supply is unreliable. A particularly dangerous form of drug-resistant TB is multidrug-resistant TB (MDR-TB), which is defined as the disease caused by TB bacilli resistant to at least isoniazid and rifampicin, the two most powerful anti-TB drugs. Rates of MDR-TB are high in some countries, especially in the former Soviet Union, and threaten TB control efforts.

STOP TB Strategy http://www.who.int/tb/strategy/en/

CASE INFO
CDC ditched 'em http://www.denverpost.com/sportscolumnists/ci_6037621, http://abcnews.go.com/GMA/OnCall/story?id=3231184&page=1, http://www.cnn.com/2007/HEALTH/07/03/tb.speaker/index.html Misdiagnosis of XDRTB, which is highly drug resistant and may require lung tissue removal

NEJM 8/2/07: Legal Power and Legal Rights--Isolation and Quarantine in the Case of Drug-Resistant Tuberculosis http://content.nejm.org/cgi/content/full/357/5/433?maxtoshow=&HITS=&hits=&RESULTFORMAT=&fulltext=andrew+speaker&andorexactfulltext=phrase&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT
"Speaker's case provoked a flurry of media attention and public outrage. During hearings, Representative Bennie Thompson (D-MS), chair of the House Homeland Security Committee, exclaimed, "We've dodged a bullet. When are we going to stop dodging bullets and start protecting Americans?"¹ The implication was clear: tuberculosis carriers threaten the nation. Like terrorists, they must be thwarted by enhanced security measures, including the vigorous application of isolation and quarantine. Lost in the debate was the recognition of legal checks on the use of compulsory isolation and quarantine as well as the importance of such checks to protect the public health."

nobody got: http://www.usatoday.com/news/nation/2007-11-28-tuberculosis-lawyer_N.htm

air travel risk
WHO 2006 http://whqlibdoc.who.int/hq/2006/WHO_HTM_TB_2006.363_eng.pdf
"To date, no case of active TB has been identifi ed as a result of exposure on a commercial aircraft. Furthermore, no evidence of TB disease has been reported among those known to have been infected with M. tuberculosis during air travel. From 1992 to 1994, the United States Centers for Disease Control and Prevention (CDC), together with state and local health departments, conducted seven contact investigations, one centred on a cabin crew member and six on passengers with infectious TB who had fl own during this period...All index cases were highly infectious...In only two of the investigations was there evidence to suggest transmission of M. tuberculosis infection: one from a cabin crew member to other crew members, and another from a passenger to other passengers (6, 10). In the fi rst report, evidence of transmission was limited to cabin crew with at least 12 hours' exposure to the infectious source. In the other, transmission of infection occurred to only a few passengers seated in the same section as and in close proximity to the passenger with infectious TB, and only on one fl ight lasting more than eight hours.
These results suggest that the risk of infection with M. tuberculosis during air travel is similar to that associated with other activities in which contact with potentially infectious individuals may occur (e.g. train travel, bus travel, any gathering in enclosed spaces). No case of TB disease has been reported among the infected people in the seven studies carried out by CDC. No other instances of possible TB transmission on aircraft have been published since then."

Timeline http://www.cdc.gov/tb/xdrtb/

Washington Post, 6/10/07 http://infoweb.newsbank.com/iw-search/we/InfoWeb?p_product=AWNB&p_theme=aggregated5&p_action=doc&p_docid=119B4BFDA75D7420&p_docnum=12&p_queryname=1
Return of the White Plague: "Aside from the disagreements over which health officer said what, arguments about the loopholes between federal, state and local health regulations, or the media ruckus over whether Speaker was just a guy trying to have a nice wedding or a modern-day Typhoid Mary with a law degree, one obvious point demands our attention. Tuberculosis is a bad disease, and it's contagious. International air travel poses real risks in the spread of tuberculosis. Coughing, sneezing, singing, yelling and even laughing can spread TB germs. People contract tuberculosis after prolonged exposure (eight hours or more) to someone with the illness. This is the same length of time as most transoceanic flights, where passengers breathe re-circulated air for hours on end."

Washington Post 6/7/07 http://infoweb.newsbank.com/iw-search/we/InfoWeb?p_product=AWNB&p_theme=aggregated5&p_action=doc&p_docid=1199F8EF304C8468&p_docnum=15&p_queryname=1
Officials Detail Errors in TB Case - Travel Followed Lack of Cooperation, Late Reaction, Weak Safeguards
" The hearings provided the fullest accounting to date of an episode that has embarrassed the agencies at a time when immigration is dominating the political debate and the threat of pandemic flu or bioterror attack remains a concern. "

Border control insufficiency, public health understanding and civil liberties, global threat governance and quarantine authority re export; China assumption; suicide terrorist again! DHS role
Senate Appropriations June 07 http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=110_senate_hearings&docid=f:41837.wais

"Frankly, as long as the tide of global infectious diseases
broadly and MDR and XDR TB in particular continue to rise,
quarantine and border controls will never adequately protect
Americans. So I think it's very important to recognize that we
need to look outside our borders as well as at our border
protections if we're going to be fully addressing these issues."

"Obviously, this case raises grave questions on how prepared
we are as a Nation to prevent the spread of a dangerous
infectious disease. This subcommittee, under the leadership of
Senator Specter and myself, has made it one of its top
priorities, if not the top priority, to make sure that our
public health infrastructure is adequately funded to respond to
natural or man-made biological threats.
We did this because we know that public health, both on the
Federal and local levels, is our first line of defense against
new and existing infectious diseases. We did this because we
knew the threats we face from both bioterrorism and emerging
infectious diseases, for example SARS or pandemic flu. In the
case of pandemic flu, we know that we have to count on public
health because with an outbreak we will have to wait perhaps
months before we have an adequate vaccine after an outbreak.
That's why I'm dismayed and concerned that so many things
went wrong in this case of a drug-resistant tuberculosis. This
is not the first and will not be the last time that we count on
our public health system to keep us safe.
Some things went right. The doctor who first diagnosed the
TB in the Atlanta man did indeed report the case to the local
health department. The local health department did respond and
either suggested or directed--I don't know which--that the
patient not travel overseas."

"First of all, up front before the patient
left the United States, we believe that we could strengthen our
States' ability to restrict the movement of patients before
they demonstrate noncompliance with a medical order. If we
believe the patient has a strong intent to put others at risk,
we need to have confidence we can take action absent
documentation of intent to cause harm.
I want to emphasize this because the whole history of
quarantine has been devoted to keeping people out and
containing them, and it is the first time that we've really had
to address keeping people in our country. So our statutes
weren't really designed with this modern age of global travel
and the vast multiple dimensions of international travel that
we experience."

what the screen said on the alert was: ``If you see this individual''--and then
subsequently, the next day we put an alert on Sarah Cooksey,
his fiancee at the time--and it said: ``Place mask on
subject.'' It said: ``Refer to secondary. Place mask on
subject. Place in isolation, well-ventilated room if possible.
Subject has multiple resistant TB, public health risk.'' Then
it gave the name of the Public Health Service doctor and
contact him 24 hours, and it gave two telephone numbers for
him. So the instructions were very clear.

"do you have the capacity
to pick up a phone and talk to somebody in Italy or China or
Japan or other reasonably--or developed nations generally, and
maybe even undeveloped nations, and get an agreement and an
immediate action event when you have somebody who you think is
a risk to their, obviously, their society and to people that
they're traveling with?"

"Senator Gregg. I think the almost bigger issue, although
this issue is obviously significant, especially for people who
were traveling with him on those airplanes, but the bigger
issue is the potential threat this represents to world travel
and to commercial activity and to different countries. I mean,
this individual chose consciously to move with an infectious
disease. It's potential that a terrorist might choose to infect
themselves and move with an infectious disease.
Is there any capacity at all to deal with that type of a
situation?
Dr. Gerberding. Well, certainly there is and in a situation
of a suspected terrorist we would be able to immediately engage
law enforcement without anybody questioning the validity of
that. I think we have to acknowledge that with infectious
diseases we cannot hermetically seal our borders. We can have
people moving across borders with infections who are
asymptomatic. We can have people moving across our borders with
diseases that don't manifest symptoms that would be picked up
at our quarantine stations or by our Customs and Border Patrol,
no matter how well trained they were. Right now we only have
quarantine officers in 20 airports around the United States and
we have I think more than 240 crossing areas where people can
come across our borders."

"In one of the notes that was given
us, at 3:35 on May 24 CDC gave DHS Mr. Speaker's information,
and according to this note the Terrorist Screening Center,
which administers the no-fly list, determined that Mr. Speaker
did not qualify for the list because he was not suspected of a
crime.
I hope that's not what the decision was. I hope that's not
the position, because dealing with terrorists you just can't
wait for the crime. The whole theory that we've supposedly been
functioning under relative to responding to terrorists is that
you've got to find them before they commit the crime. This is
not a post-crime event. It's the big problem we've had with
changing the culture at some of our law enforcement
communities, because they're always crime-related, to get them
to anticipate."
"This is certainly a national security issue and I'm glad
that this committee has raised that as a concern. But it's not
about terrorists or the idea of people voluntarily infecting
themselves. We have literally millions of people around the
world crossing borders every day. Many of them are infected,
whether it's with TB in one of these variants or other
infectious diseases. What we need to do is to recognize that
unless we address the problems of these diseases, particularly
TB but others as well, at their source, which is in the world's
poor communities around the world, that no walls that we can
build can possibly be high enough to protect the American
population."

And Justify harsher legal measures re travel and ph threats; Timeline; TB info; no-fly list issues with DHS terrorist detention vs. public health isolation
Committee on Homeland Security Sept 2007 http://hsc.house.gov/SiteDocuments/tbreport.pdf

ACLU Jan 2008 http://www.aclu.org/pdfs/privacy/pemic_report.pdf
While Speaker was in Europe, a CDC laboratory diagnosed Speaker’s TB as the more dangerous, extensively resistant TB (XDR-TB). At that point, instead of treating him like a client or a patient, the CDC began to treat Speaker like a dangerous public enemy. Rather than helping him and offering him a safe way to get home, the CDC contacted him in Italy and told him to stay there—leaving him sick and stranded in a foreign country, cut off from his family and other support networks. The agency also asked the Department of Homeland Security to add Speaker to the no-fly list, which is used to try to keep suspected terrorists out of the United States.

NYT 6-5-07, The TB Patient and the What-Ifs http://proquest.umi.com/pqdlink?index=13&did=1282420331&SrchMode=1&sid=1&Fmt=7&retrieveGroup=0&VType=PQD&VInst=PROD&RQT=309&VName=PQD&TS=1231607849&clientId=1564

"To the Editor:

As a physician and a woman of ethnic origin, I am disturbed that Andrew Speaker, the man with a dangerous form of tuberculosis, feels that an apology is acceptable. But that is a decision that he and his family will obviously have to live with.

I pose the following scenario and wonder how different the response would be if the patient in question were a young male of Islamic origin?

Kavita K. Patel, M.D.Santa Monica, Calif., June 1, 2007

To the Editor:

The border agent let Andrew Speaker pass, despite knowing that he was being sought by health authorities, on the grounds that he did not look sick.

Does that mean that in a parallel case, someone who does not look like a terrorist will also be allowed entry?

Margaret SmythCharlestown, Mass., June 1, 2007"

Touch off xenophobia: American Conservative, 7/2/07: http://proquest.umi.com/pqdlink?index=4&did=1299553381&SrchMode=1&sid=1&Fmt=7&retrieveGroup=0&VType=PQD&VInst=PROD&RQT=309&VName=PQD&TS=1231608348&clientId=1564 "The story of Andrew Speaker, the now infamous trans-Atlantic traveler and tuberculosis case, may have faded from the headlines, but the bureaucratic incompetence he inadvertently revealed persists. One week after Speaker delivered his televised apology, Kalpana Dangol, a student at Colorado State University and native of Nepal, went to a Colorado Springs hospital complaining of abdominal pain. A few hours later she died. Her body had been ravaged by TB. Officials speculate that she contracted the disease in her native country, where according to the WHO, about 23 of every 100,000 people die of TB.

Dangol's story is tragic: a life cut short at 19. It is also disconcerting. Without knowledge of who enters the country, our homeland security system invites an epidemic."

ScienceNOW: Don't Blame Immigrants for Tuberculosis, 11/1/07 http://sciencenow.sciencemag.org/cgi/content/full/2007/1101/1?maxtoshow=&HITS=&hits=&RESULTFORMAT=&fulltext=andrew+speaker&andorexactfulltext=phrase&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

"The national debate over illegal immigrants in the United States has sparked fears among health authorities about the spread of diseases, such as tuberculosis, but a new study indicates that those concerns are overblown. Researchers in Norway analyzed more than a decade's worth of tuberculosis cases and found that infected immigrants pose little risk of spreading the disease to the general population."

Alternet: How to Confront the Dangers of Tuberculosis, 6/14/07 http://www.alternet.org/healthwellness/54217/how_to_confront_the_dangers_of_tuberculosis/

"T.B. Harry"
blog, selfish http://www.thekidalog.com/seejanemom/2007/06/tb_patient_need.html
Typhoid Mary culpability http://www.huffingtonpost.com/michael-seitzman/hey-tb-guy-the-rest-of-_b_50239.html, http://outeasy.wordpress.com/2007/06/01/tuberculosis-andy/

Comparison Cases
ACLU report 1/08: In another case, a 27-year-old TB patient named Robert Daniels was involuntarily quarantined in Phoenix, Arizona in July 2006 for disobeying an order by Maricopa County health officials to wear a face mask in public at all times.
AZCentral TB patient indicted as risk to public health Mar 25, 2008
Daniels was confined in a locked room at Maricopa Medical Center in August 2006 and treated as a convicted prisoner with no phone, windows, shower, television or other amenities. The controversy prompted court hearings in which physicians testified that Daniels ignored treatment instructions and caused a health hazard by going out in public without a mask. (AZCentral -- News)

Francisco Santos, teen arrested and jailed for having TB: Teen With TB Agress to Take Medicine, 11.com 8/28/07
http://www.11alive.com/news/article_news.aspx?storyid=102321

Washington Times 10/07: Man Criscrossed Border With TB
Amado Isidro
A Mexican national infected with a highly contagious form of tuberculosis crossed the U.S. border 76 times and took multiple domestic flights in the past year, according to Customs and Border Protection interviews and documents obtained by The Washington Times.
http://hsgac.senate.gov/public/index.cfm?FuseAction=PressReleases.Detail&Affiliation=R&PressRelease_id=8a309777-f508-454f-a1dc-795dc22d68f1&Month=10&Year=2007
Houston Chronicle 10/31/07 TB case frustrates senators - Committee poses 31 questions on why the U.S. failed to block traveler http://infoweb.newsbank.com/iw-search/we/InfoWeb?p_product=AWNB&p_theme=aggregated5&p_action=doc&p_docid=11CA48A8226A9F88&p_docnum=5&p_queryname=3
El Paso Times 10/19/07, Juárez man with drug-resistant TB not contagious http://infoweb.newsbank.com/iw-search/we/InfoWeb?p_product=AWNB&p_theme=aggregated5&p_action=doc&p_docid=11C66F99A0EF6198&p_docnum=10&p_queryname=4
Washington Times 1/26/08, Senate panel seeks reply in TB flier case http://infoweb.newsbank.com/iw-search/we/InfoWeb?p_product=AWNB&p_theme=aggregated5&p_action=doc&p_docid=11E6FB1E6134BB80&p_docnum=2&p_queryname=7

New Scientist, 12/19/07: Extreme TB patient slips through aircraft surveillance nethttp://www.newscientist.com/article/mg19626343.400-extreme-tb-patient-slips-through-aircraft-surveillance-net.html
However, back in October 2006, another man who genuinely was a threat flew unnoticed from Beirut, Lebanon, to Paris, France. Unlike Speaker, he was coughing up bacteria-laden sputum, and died 10 days later of XDR-TB that had resisted nine drugs - possibly due to poorly managed treatment in Chechnya, the Russian republic where he had been living.

Money grab
Atlanta Journal-Constitution 1/13/08: Did CDC hype TB case as a fund-raising ploy? Agency denies it, but critics say Andrew Speaker was pawn in publicity grab
http://infoweb.newsbank.com/iw-search/we/InfoWeb?p_product=AWNB&p_theme=aggregated5&p_action=doc&p_docid=11E274D82016B8C0&p_docnum=1&p_queryname=5
After years of flat funding, the 2008 federal budget includes $140.4 million -- a 4 percent increase -- to combat TB in the U.S. It would have been a 9 percent increase if President Bush hadn't vetoed the Labor/HHS funding bill and required cuts.
The actions were in stark contrast to the private way the agency dealt with 100 other TB cases involving airline travelers, both before Speaker and after, including an incident last month when a severely ill drug-resistant TB patient flew from India to Chicago.

Reuters 6/5/07 Senators seek jump in TB control spending
http://www.reuters.com/article/healthNews/idUSN3123541420070605

The Hill 6/6/07: TB scare breathes new life into public health legislation
http://thehill.com/business--lobby/tb-scare-breathes-new-life-into-public-health-legislation-2007-06-06.html

The Stop TB Partnership welcomed the approval of US$153 million in spending for global TB control programmes for 2008--up US$72 million from 2007 spending. An additional $150 million was dedicated by the US President's Emergency Plan for AIDS Relief to address the TB-HIV co-epidemic in 2008.
http://www.stoptb.org/assets/documents/end%20of%20year08.pdf