Tuberculosis (TB) is a disease caused by germs that are spread from person to person through the air. TB and XDR TB are spread the same way, but XDR TB is resistant to almost all of the drugs commonly used to treat TB disease. The general symptoms of TB disease include cough, weight loss, fever, and night sweats. When a person with TB disease of the lungs or throat coughs, sneezes, or speaks, TB germs may be expelled into the air and can remain airborne for several hours, depending on the environment. Persons who breathe the air containing these TB germs can become infected; this is called latent TB infection (LTBI).
This is the first investigation of a case of XDR TB during air travel. Due to the serious nature of this strain of TB disease, CDC is recommending that all U.S. residents and citizens on either of these flights receive evaluation and testing for TB infection. Passengers who were most at risk were those sitting two rows in front and two rows behind the patient.
If you were a passenger or flight crew member on either of the two flights listed above, we strongly recommend that you complete these steps at your earliest convenience:
Many persons born outside of the United States receive a vaccine called BCG (Bacille-Calmette Guerin) to prevent development of TB disease; however, we still recommend that persons who received BCG vaccination should be tested for TB.
For inquiries related to this investigation or questions regarding payment for TB testing, please go to State TB Control Offices.
For more information about XDR TB, please see these links:
We greatly appreciate your assistance on this important international XDR TB contact investigation.
Questions and Answers: XDR TB in Traveler
What is extensively drug resistant tuberculosis or XDR TB?
XDR TB is a rare type of tuberculosis that is resistant to nearly all drugs used to treat TB disease.
CDC is currently investigating a case of extensively drug resistant tuberculosis (XDR TB). The case involves a U.S. citizen with potentially infectious XDR TB who traveled to and from Europe on commercial flights between May 12 and May 24, and then re-entered the U.S. at the Canada-U.S. border via automobile. Since May 25, the patient has been hospitalized in respiratory isolation and is undergoing additional medical evaluation.
Why did the patient travel?
Normally, when a patient has tuberculosis, he or she is influenced through a covenant of trust to ensure that they don't put themselves in situations where they could potentially expose others. In this case, the patient had compelling personal reasons for traveling and made the decision to go ahead and meet those personal responsibilities.
How did the patient return to the United States and then Georgia?
On May 12, the patient departed Atlanta on and arrived in Paris on May 13 on Air France flight 385. The patient flew to Canada on Czech Air flight 0104 and then entered the United States by car on May 24.
It was not safe for the patient to fly on commercial aircraft, so government resources were used to bring the patient from New York back to Georgia in the safest and quickest possible way. In New York, the patient was put into isolation fairly soon after his arrival and was later flown to Georgia, his state of residence on the CDC aircraft, a step that we were not obligated to take under our quarantine authorities, but one that we felt was fair and appropriate given that he is a citizen of Georgia. His family members are here and his disease does require prolonged treatment.
Did the patient know he had TB before he got on these flights?
Our understanding from the county health officials, who were responsible for managing the patient when he initially presented with TB, is that he was aware of his diagnosis. When he departed, he may not have been aware of the fact that he had extensively drug resistant tuberculosis.
Where did the patient become infected with the extensively drug-resistant (XDR) TB?
The source of the patient's TB is still under investigation. CDC is conducting something called an Epi Aid, which means our epidemic intelligence service officers are actively participating and investigating not only opportunities for exposure to passengers, crew, family members, or others but also looking backward to try to determine where the original infection occurred that is an ongoing investigation.
Why was a federal order of isolation issued?
After the patient had left the jurisdiction, the TB organism was identified as extensively drug resistant. A federal order of isolation under the Public Health Service Act that gives CDC statutory responsibility for issuing quarantine orders was executed to protect the public.
This patient was ordered to be in isolation and is required to stay in isolation until the responsible public health official deems that he is no longer infectious to others. The patient currently is isolated and is undergoing medical evaluation.
Under what circumstances was the federal isolation order executed?
After speaking to CDC authorities, the patient voluntarily drove himself to the isolation hospital in New York City to be evaluated. He was given instructions on how to do that safely without putting public health at risk. He was admitted and served a provisional quarantine order that held for 72 hours while this assessment was going on. The patient was asked if he preferred to remain in New York City for his treatment or if he wanted to come home to Atlanta. He preferred to come home and we ensured the safe transport for that return to Atlanta on Monday via the CDC plane.
He was issued a federal isolation order on arrival in Atlanta to cover the period of time for us to hand over the jurisdiction and public health management of this case to the state and local authorities in Fulton County in the State of Georgia where he is a resident.
The order is in effect until it is either rescinded and the responsibility is transferred over to the local jurisdiction or until determined by the CDC Director that he is no longer a public health threat.
Has a federal order of isolation been issued at any other time?
Taking a measure such as issuing an order of isolation is unusual. The last order was issued in 1963.
What was the isolation order that was issued in 1963?
In 1963, the statute was used for quarantine, not isolation, of someone who had been exposed to smallpox. The decision was made to err on the side of caution and implement a federal quarantine requirement for the person until they were outside of their period of incubation.
What row numbers was the patient in?
We are still working with the airlines from the involved countries. On Air France flight 385, the patient was seated somewhere between rows 14 and 57, possibly on row 30. On Czech Air flight 0104, the passenger was seated in 12c.
How many people were on the planes?
The airlines involved in the investigation are large transcontinental airlines and they are generally full of passengers. Air France flight 385 had 433 passengers and 18 crew members and was approximately 13 hours in duration. Approximately 40-50 passengers and the 18 crew members are a priority. The Czech Air flight 0104 had 191 passengers and 9 crew members, and it was longer than 8 hours; around 30 people are a priority for evaluation.
Were public health officials aware that this man was leaving the country?
The local health officials have been involved in the care of this patient with TB from the moment that they were aware of the diagnosis and he was being seen in the clinic. Our understanding, from conversations with the health officials, is that the issue of travel was discussed. The patient was advised that it was not appropriate to travel when you have TB. This situation comes up often when people have TB or other communicable diseases. We have a high success record using voluntary means of information and advice. CDC was not aware that the patient had decided to leave the country.
How many countries are involved?
The number of countries affected by this is large, but the total is not known at this point in time.
For more information, visit www.cdc.gov/tb/, or call CDC at 800-CDC-INFO (English and Spanish) or 800-243-7889 (TTY).
What is CDC doing?
CDC is working with U.S. state and local health departments, International Ministries of Health, the airline industry, and the World Health Organization to notify and follow up passengers and crew who may be at risk for exposure to XDR TB. Each country involved in the investigation is determining guidance for its own residents.
Who should be tested?
The World Health Organization has guidelines for follow-up and care of persons who may have been exposed to someone with TB during air travel. In accordance with these guidelines, CDC recommends that U.S. citizens and residents who were passengers or crew on these flights be evaluated and tested for TB infection, with the following persons being at highest priority:
Passengers seated in rows 28-32 on Air France # 385/Delta # 8517, departing Atlanta May 12th; arriving in Paris May 13th
What is the risk of acquiring TB on an airplane?
The risk of acquiring any type of TB can depend on several factors, such as extent of disease in the patient with TB, duration of exposure, and ventilation. An important way to prevent the spread and transmission of TB is by limiting contact with a person with infectious TB disease..
Who should I contact for additional information?
If you were a passenger on the flights in question, please call CDC Info: 800 CDC-INFO (800-232-4636))
Media inquiries: 404 639-3286
For more information, visit www.cdc.gov/tb
Statement by Robert C. Cooksey
First and foremost, I am concerned about the health and well being of my son-in-law and family, as well as the passengers on the affected flights.
I am the father-in-law of Andrew Speaker, who was recently publicly identified as a person infected with extensively drug resistant tuberculosis. I do work at the Centers for Disease Control and Prevention. I have worked at the CDC for 32 years. I´m a research microbiologist in CDC´s Division of Tuberculosis (TB) Elimination, and my work does involve working with a wide range of organisms, including TB. As a research microbiologist, my laboratory work involves identifying the characteristics and features of bacteria.
As part of my job, I am regularly tested for TB. I do not have TB, nor have I ever had TB. My son-in-law´s TB did not originate from myself or the CDC´s labs, which operate under the highest levels of biosecurity.
I wasn´t involved in any decisions my son-in-law made regarding his travel, nor did I ever act as a CDC official or in an official CDC capacity with respect to any of the events of the past weeks.
As a parent, frequent traveler, and biologist, I well appreciate the potential harm that can be caused by diseases like TB. I would never knowingly put my daughter, friends or anyone else at risk from such a disease.
I would ask the media to respect my privacy and that of my family, and I will be respectfully declining all media requests. My thoughts and focus over the next few months will be with my family, and we are hopeful that Andrew will have a fast and successful recovery.
Robert C. Cooksey
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Content Source: Office of Enterprise Communication
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