Extremely Drug Resistant Tuberculosis Infected Plane Passenger Data Dump

[mhatrw]

XDR-TB infected lawyer and his wife, who just happens to be the daughter of a doctor who works in the CDC's Tuberculosis Laboratory:



XDR-TB infected lawyer's father-in-law, a doctor who works in the CDC's Tuberculosis Laboratory in Atlanta:



http://www.azcentral.com/news/articles/0531tbscare0601.html

According to the CDC, there have only been 49 cases of the XDR reported in the United States since 1993, not including the two newest cases. Of those, just 17 were reported between 2000 and 2006.

http://www.nytimes.com/2007/05/31/us/31tb.html?ex=1181188800&en=c03bbae65e328c09&ei=5123&partner=BREITBART

The man told the Atlanta paper that tuberculosis was detected by accident when he had a chest X-ray in January for another undisclosed problem. ...

Dr. Cetron said that lesions showed up in the upper lobe of the man’s right lung, making doctors suspicious for tuberculosis because the infection often affects that area. Because the man had no symptoms and little cough, his doctors performed a procedure to obtain the secretions from which the tuberculosis bacteria were detected.

That process and additional testing to determine to which antibiotics might be effective can take weeks, even months. But some doctors not connected with the case questioned why four months passed between the X-rays and the letter from the health department.

A standard initial test for tuberculosis is to smear a sample of a patient’s sputum on a glass slide, stain it with a chemical and look for the microbes under a microscope. Doctors also try to grow the organism in a laboratory. It was from this test that doctors initially detected the man’s tuberculosis. At some point he began taking standard medication for the treatment of tuberculosis, but it was stopped because it was not effective, Dr. Cetron said.

http://www.11alive.com/news/article_news.aspx?storyid=97896&provider=top

Dr. Huitt said that Speaker has traveled extensively over the past few years. Just where he got a potentially lethal form of tuberculosis is a mystery. "He most likely acquired it from another person, somewhere, somehow," Huitt said. ...

11Alive News made an open records request regarding the letter that Fulton County health officials tried to deliver to Speaker on May 11. When they tried to deliver the letter, they found that the address they had been given was vacant. The letter said, in part, "It is strongly recommended that you postpone your travel and see a specialist in Denver, Colorado." ...

"We have a weakness and it's still there," said security expert Harold Copus. "We're vulnerable and it's scary, frightening."

Copus is a former FBI agent, who said Speaker may have unwittingly shown terrorists just how easy it is to bring a biological weapon into US airports and other countries, rewriting the book on walking time bombs. "I'm thinking I have just been given the keys one more time. I can now figure out a way to figure out how to exploit this great country we live in. That should not be happening. It shouldn't happen. Whoever's in charge of this watch has failed," Copus said.

http://www.ajc.com/news/content/health/stories/2007/05/30/0531meshcdctb.html

Fulton County and Georgia state health officials said they believe Speaker was clearly informed that he shouldn't travel. But they also acknowledge that despite their conversations, as of May 10 they knew he intended to leave the country for his wedding. They also discussed with CDC officials Speaker's intent to fly for at least two days prior to him boarding a May 12 Atlanta to Paris flight, according to CDC spokesman Tom Skinner and Georgia's state epidemiologist Susan Lance.

Skinner said Fulton County health officials contacted CDC on May 10 and said that Speaker, who at the time was diagnosed with multi-drug resistant tuberculosis, had told them he planned fly aboard airlines. The discussions continued on May 11, Skinner said. "We discussed with them several options to prohibit him from flying," Skinner said. All of those options involved actions that needed to be taken by state or local health authorities, he said.

Skinner said CDC never heard back from local health officials until May 18 -- after Speaker had already left the United States.

Lance said: "They gave us some options on how to proceed, but none of them were basically available," she said. She did not elaborate on what those options were.

http://www.wsbtv.com/news/13423399/detail.html

Speaker, a 31-year-old lawyer from Atlanta, learned he had TB in January. In May, doctors realized his strain, known as XDR-TB, was extensively drug-resistant. He then boarded a commercial flight to Paris May 12, and returned from Europe 12 days later on a flight from Prague, Czech Republic, to Canada.

"He talks at length about the decision first of all to go abroad, to hold his wedding abroad, and … there is a tape recording of the meeting that he had with health officials, and they say it confirms completely their view that it was all right for him to travel," Sawyer said.

http://www.ajc.com/health/content/health/stories/2007/05/31/0601meshtb.html

Speaker told the Journal-Constitution he has a tape recording of his meeting on May 10 with Fulton County health officials that will substantiate his contention that he was not told he could not travel. He did not immediately make the tape available to the newspaper. ...

Speaker told the Journal-Constitution this week that it is believed he contracted the disease while on a trip to Asia to do goodwill ambassador work and raise money for hospitals.

The bacteria that is in Speaker's lungs did not match any other DNA fingerprints of TB that CDC has catalogued, but during Wednesday's news conference, CDC officials said that database is so new that it is not unusual to find a sample that doesn't match any on file. ...

About two months ago, county health officials had him start taking a four-drug combination commonly used to treat TB cases. Meanwhile, government health officials tested his family members, his fiancee and other close contacts. "They all came up negative," he said.

http://online.wsj.com/public/article/SB118063766753120335-di2t902bH7ezLu7NVKAd3oCGs6s_20070630.html?mod=tff_main_tff_top

According to investigators, it appears that when Mr. Speaker arrived May 24 at the crossing at Champlain, N.Y., his passport was swiped, activating the flag on his records and the warning. Records show that he spent less than two minutes at the border post before being cleared to enter the country.

http://www.ajc.com/health/content/health/stories/2007/05/31/0601mettbside.html

Knocke said Speaker was stopped at the U.S. border at 6:17 p.m. on May 24 and cleared security at 6:18 p.m.

The CDC contacted Speaker by cellphone between Albany and New York City. He was isolated in New York, then flown to Atlanta, where he was kept in isolation under guard at Grady Memorial Hospital before leaving for Denver on Thursday. State and local officials said they told Speaker not to travel but didn't have the authority to block his plans.

State health director Dr. Stuart Brown said the incident points out that state and county officials need the power to forcibly quarantine someone. He wants the General Assembly to examine the issue of balancing personal rights and public health. ...

Brown asked, what if avian influenza — bird flu — were to become a bigger problem? Local authorities would need the power to restrain the travel of infected people, he said. "This is a decision that the legal minds need to grapple with," Brown said. "This is based on the common perception in America that individual rights have primacy, and in public health we are weighing that issue at the same time we are trying to protect the public."

http://www.washingtonpost.com/wp-dyn/content/article/2007/05/30/AR2007053001962.html

In early March he underwent a procedure to get a sample of sputum from his lungs, and by the end of the month, lab cultures revealed he had TB.

Further study of the bacterium showed on May 10 that it was "multidrug-resistant" -- it could not be killed by the two most commonly used drugs. TB patients are generally treated with at least three different antimicrobial medicines. ...

On May 22, while the man was still in Europe, tests in Atlanta revealed his TB bacterium was resistant to two classes of backup drugs, qualifying it as "extensively drug-resistant."

http://online.wsj.com/article/SB118058008642319672.html?mod=googlenews_wsj

Homeland Security officials say it wasn't clear when the man left Atlanta this month to go to his wedding and honeymoon in Europe that he presented a major risk. CDC officials only later contacted DHS and other federal agencies about the seriousness of man's condition after he was already abroad, according to a Homeland Security official.

CDC officials say they contacted him in Rome several times, asking him to go to a hospital in Italy, and telling him not to fly. U.S. Customs and Border Protection agents had been notified to be on the lookout for the man in case he ignored CDC warnings, officials said. They said that patient had a return ticket for June 4. Customs officials were told that if they encountered the man, they were to don protective clothing and quarantine him immediately.

CDC and DHS officals were considering options to restrict his travel, including using a CDC jet to fly him back home, as well as having him put on a "no fly" list so he would be flagged. But in the meantime, the man left Rome and flew to Montreal from Czechoslovakia on May 24.

"By the time we knew he was missing from Rome, the opportunity to intervene had passed," said Martin Cetron, CDC's head of global migration and quarantine.

http://foodconsumer.org/7777/8888/Non-f_ood_Things_27/053106292007_CDC_updates_investigation_on.shtml

Transcript of CDC Press Conference

The good news is about the patient. The patient continues to feel well and be asymptomatic. He is currently still in isolation at an Atlanta hospital, and he's under the care of infectious disease specialists at this hospital. ...

The outbound international Transatlantic flight that occurred on May 12th from Atlanta, arriving May 13th in Paris was an Air France flight number 385, and this was also, we learned, a Delta co-chair 8517. In total there approximately 433 passengers on board with 18 crew. This flight, although routinely scheduled for just over eight hours, we understand had some delays and potentially up to 30-13, excuse me, 13 hours in duration, and thus qualifies under the WHO guidelines. ...

On the return flight, which was much more recent, our Canadian partners have received the manifest and have much more information. The patient sat in seat 12C. This occurred on May 24th from Prague to Montreal on Czech Air Flight 0104. There were 191 passengers and nine crew on this flight. Approximately 30 persons were in that risk area, two rows in front, two rows behind, who are the highest priority for actively seeking and following up at this point. That flight, too, is reported to have left at greater than eight hours in duration.

The other flights which we can make available to you after this involved the routing from Paris to Athens from Athens to Thira (ph) Island in Greece on Olympic Air from Mykonos to Athens, Athens to Rome, Rome to Prague, and again, the other and the last return on Prague to Montreal, and as you're aware, the passenger, the patient and his spouse traveled by vehicle over land from Montreal into the United States, and we made contact with him on Friday afternoon between Albany and New York City, and then Dr. Gerberding informed you voluntarily and swiftly the patient was isolated in New York City on Friday through the weekend until we were able to arrange his transfer down here. ...

We can understand that that's their perspective and they have shared that perspective with us. We were told other things by those involved. Neither Dr. Castro nor myself were in that conference. CDC was not, you know, engaged in that discussion, but it is our understanding that a family conference was held with Fulton County Health Department and clinicians and the patient and his family, and that they were advised that he had multi drug resistant tuberculosis disease with an indication of pulmonary tuberculosis and advised against travel, and so that's where you have it. It has been clear that there wasn't a legal order issued to the patient, although in terms of not traveling, but it's a different understanding about what took place and what occurred in that conference. ...

Those are great questions. Thank you. When we reached him, finally caught up with this individual in Rome, one of my quarantine officers spoke to him to share the information about the progressive culture results, and to make clear under no uncertain terms should he use commercial aircraft. We also indicated that we were looking at a working option to safely arrange his transport back to the United States. ...

As Dr. Gerberding indicated yesterday, the patient had, from his own perspective, compelling reasons to travel. And there were no legal orders in place preventing his travel, and no laws were broken. Since we've issued our federal isolation order, he's been fully compliant. And, you know, I believe figuring out that aspect of the past is not nearly as important as taking the perspective and moving forward, aligning his interest and needs for care and treatment to get well and the public health interest and needs in the same place, right now is where our focus is. ...

OK. Richard, I think, you know, there's a difference of opinion about whether anybody condoned his travel, I think it's very clear from the conversations we've had with the health department, that they clearly told him not to travel. And they were aware, and he was aware that he had MDR TB, at least on the 10 of May, before he traveled on the 12. And he was clearly instructed not to. My understanding is that a written affirmation of that was being prepared to hand to him and arrived after he had all ready departed. And so that's where that gap occurred. ...

Yes, my way of contacting him in New York was via his cell phone number, which was provided to us by trying to reach out to family and figure out how to get a hold of him, and how to find him. We had asked family how to find him and that's the way we contacted him in Rome, as well.

So my understanding of the timeline and we're still verifying a lot of these dates, is that the meeting with the patient and his family and the health department occurred on the 10 of May, at which time his MDR TB was documented by laboratory results. And that we - in our program at CDC in headquarters learned about his multi drug resistant TB. That he had all ready traveled to Europe occurred on the 18, and of course, as you're aware he departed on the 12.

We reached him - the XDR results came on or around the 22 of May so this was an evolving situation. And one of my staff, Dr. Kim of the Atlanta quarantine station had been engaged in this, reached him on his cell phone on the 23 after multiple attempts. I think that's when he finally got through. ...

LARRY ALTMAN, NEW YORK TIMES: Yes, what isn't clear at all is what his initial symptoms were when he went for treatment, how he was first diagnosed, what the interval was. I've heard that it was back in January, we're talking about May here. There seems to be a huge gap there in terms of why he had a chest film, how the diagnosis was made, he was - it was done for other reasons, we're told in order to understand this, can you go right back to when the initial attempt to diagnose the pulmonary tuberculosis was made?

DR. CETRON: Well, what we understand is that the diagnosis was incidental. And again, we're valid - verifying all these facts. I'm going to ask Dr. Castro to speak to the timeline in terms of the laboratory results. But, he had an incidental chest x-ray either for orfall or for some unrelated reason and the lesion in the right upper lobe was determined on that incidental chest x-ray. He had no risk factors or reasons to believe that that was tuberculosis and underwent a procedure to diagnose that it was that procedure which identified the fact that the findings ultimately grew out MTB.

Now, culturing microbacterium tuberculosis, especially when the organism load is small can take many weeks. But, I'll defer to Dr. Castro to explain that so that time between the procedure to evaluate this right upper lobe lesion and the actual culture result of tuberculosis took some time, and then the drug susceptibility testing of that tuberculosis took some time. In the interval between the diagnosis and the culture result and the susceptibility results he was placed on treatment which ultimately was not effective treatment. So, that initial treatment was stopped.

DR. CASTRO: Larry, thank you for the question, this is Ken Castro. As you know, tuberculosis is a very slow growing organism and that adds to the - a layer complexity. It takes usually between 18 to 21 days for a culture to become positive under the best of circumstances. Then, if positive you add another couple weeks for drug resistance testing.

So you can see already a month interval easily going by before you have any results where you can hang your hat on. In a person with a load of baceli or bacteria that is not high, it'll take even longer. So that's what we're up against. And this point to an underlying weakness of the tools we have and the reason why for a long time many of us have been clamoring for the research and development to develop - to have new tools that are rapid and accurate and reliable for the diagnosis of tuberculosis, and similarly for the drugs that are going to be needed.

http://foodconsumer.org/7777/8888/L_etter_to_E_ditor_46/053104002007_CDC_update_2_extensively_drug-resistant_tuberculosis.shtml

Statement by Robert C. Cooksey
Research Microbiologist, Division of Tuberculosis Elimination, CDC

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

[sam sarrha]

1. maybe he got it flying on a PLANE..!!!!!

[kestrel91316]

2. Wouldn't THAT be the ultimate irony?!

[Kali]

3. wow thanks for putting all that together

this case is fascinating, the strange coincedences and misteps. A personal injury lawyer potentially injurring many people and a CDC germ researcher with a son-in-law infected with one of his "subjects" homeland security issues and all sorts of movie of the week drama.

[depakid]

5. Yep: I smell a book & movie of the week deal

:eyes:

[snagglepuss]

4. Thanks for putting this together. Its very infomative.

:kick:

[Celebration]

6. Hope there is an investigation

Of the father in law. I thought that I heard on the radio that there was going to be one, but I can't find a link and I was half asleep.

Most people that get married overseas without any family present do so against the family's wishes. Despite his protestations that he had little to do with the decision, I feel that there were a lot of reasons Cooksey did not want his son in law back in the country, not the least of which would be that it would be easier to link the TB back to the lab. That certainly is no smoking gun. But when you put everything together there is a large cloud of suspicion around the father in law.

Frankly, I can understand why the son in law came back to the U.S. His TB, while apparently extremely dangerous, was not really thought to be at the stage where he could give it to people. Had he not had the xray, he wouldn't even know he had it. Of course, I wouldn't have wanted to sit next to him on an airline flight, but I would be surprised if anyone contracted the disease.

This is speculation, but I would put my money on the father in law being a complete, irrational nut case.

Thanks for putting this all together, especially the pictures.

[Celebration]

7. Inquiry Into Role of Tuberculosis Patient’s Father-in-Law

http://www.nytimes.com/2007/06/05/health/05tb.html

The Centers for Disease Control and Prevention is investigating what role, if any, a staff scientist played in the international health scare set off by the odyssey of his son-in-law, who has extremely drug-resistant tuberculosis.
............snip

The C.D.C. said late Saturday that it was undertaking a number of reviews related to Mr. Speaker’s case, including how Dr. Cooksey “was involved in this matter.”

........snip............

Dr. Julie L. Gerberding, the director of the centers, said on Friday that Dr. Cooksey “may have been involved in preparing one of the lab tests to determine the type of bacteria” present in the specimen sent to the C.D.C. by Fulton County and Georgia State health officials..


Yesterday, the C.D.C. said it did not know whether Mr. Speaker’s name was on the specimens that Dr. Cooksey might have worked with or whether the labels were coded.

Dr. Gerberding also said that at several times “he helped us facilitate communication with his son-in-law and the wife,” Sarah. Dr. Cooksey’s “assistance was actually extremely helpful in getting us in cellphone” contact with Andrew Speaker in Europe, Dr. Gerberding said, “to help us determine how to help him get into a safer health care environment.”

[Celebration]

8. tape released

http://www.msnbc.msn.com/id/19095687/

ATLANTA - The family of a lawyer with a rare strain of tuberculosis released part of a tape recording Wednesday in which a health official is heard saying the man was not contagious and didn’t need to be isolated.

Andrew Speaker, the subject of the first federal quarantine order since 1963, has maintained that officials never ordered him not to fly before he left for his wedding and honeymoon in Europe. Officials say he flouted their orders, and Congress is investigating how officials handled the situation.

.............................

Just before a May 10 meeting at which the tape was made, he said, he had learned that the bacteria in his lung were resistant to at least two of the drugs and that he would need special treatment at the Denver hospital.

In the tape recording — made by Speaker’s father, Ted, also a lawyer — the patient asks about the hospital’s accommodations.

“Now, that I don’t know,” says Dr. Eric Benning, medical director of the Fulton County health department. “But because of the fact that you actually are not contagious, there’s no reason for you to be sequestered.”

At another point on the tape, Benning says: “As far as we can tell, you are not a threat to anybody right now.”