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Atlanta Lawyer's Drug-Resistant TB Triggers Global Watch
Debra Anscombe Wood, RN
Tuesday June 26, 2007

Andrew Speaker was a man reportedly so determined to marry his betrothed that his actions set off an international health alert that has had public health officials on two continents scrambling to locate people in contact with him.

It all began May 12 in Atlanta when Speaker, infected with extensively drug-resistant tuberculosis (XDR TB), departed for Paris aboard a commercial airliner, according to the Centers for Disease Control and Prevention. He visited several European cities as part of a wedding-honeymoon package before CDC officers caught up with him in Rome following his marriage in Santorini, Greece.

"One of my quarantine officers spoke to him to share the information about the progressive culture results," said Martin Cetron, MD, director of the CDC's division of global migration and quarantine, during a telephonic press briefing. Cetron said it was made clear "[in] no uncertain terms" that Speaker mustn't use commercial aircraft.

After Speaker and his bride returned to the U.S., authorities directed him to a New York hospital and issued a federal order of isolation under the Public Health Service Act. CDC officials say Speaker broke no law.

Julie Gerberding, MD, MPH, director of the CDC, said during a telephonic press briefing that it's unusual for the agency to place a citizen under a formal isolation order. In 1963, the agency quarantined someone exposed to smallpox. With XDR-TB, it considered the organism so potentially serious that it felt compelled to act.

"We have no suspicion [Speaker] was highly infectious," Gerberding told reporters. "In fact, medical evidence would suggest his potential for transmission would be on the low side."

However, according to the health alert, Speaker has radiographic evidence of pulmonary TB and is culture-positive for XDR TB. He has had three sputum smears, all of which have tested negative.

"A negative smear may not mean you are not infectious," Gayle Schack, RN, a nurse consultant at the Colorado State Tuberculosis Program, told Nursing Spectrum by phone. "It probably means you are not as infectious, but it's a real gray area."
Why so dangerous?

The World Health Organization (WHO) defines XDR TB as a subtype of multidrug-resistant tuberculosis (MDR TB). In addition to resistance to the two most important first-line drugs, isoniazid and rifampin -- which serves as the definition for MDR TB -- XDR TB has resistance to any fluoroquinolone and at least one of the injectable agents: amikacin, kanamycin, or capreomycin.

"XDR means we do not have drugs to cure you, so it has a high mortality rate," said Kim Field, RN, MSN, director of Tuberculosis Program Services at the Washington State Department of Health, in a phone interview. "And we have no drugs to give to people exposed to you to prevent further disease."

Carol Pozsik, RN, MPH, executive director of the National Tuberculosis Controllers Association, told Nursing Spectrum treatment for XDR TB with second-line drugs typically begins as an inpatient and once stabilized continues as an outpatient, which may last about two years.

"Second-line drugs are not as tolerable for patients as first-line drugs," she said.

A patient with XDR TB also may require surgical resection and debulking of the lung, according to Noreen Nicol, RN, MS, FNP, chief clinical officer and CNO at National Jewish Medical and Research Center in Denver, where Speaker is now receiving treatment.

"We will use all conventional treatments first," Nicol said by phone. "With drug resistance, the question is: Will it respond to a combination of antibiotics? People are only surgical candidates if the TB is localized to a small, specific portion of the lung -- hopefully, a lobe of the lung."

A patient's length of stay varies, Nicol said. Imaging diagnostics to monitor lesion response to medication typically take place at four- to six-week intervals after treatment begins. Surgical recovery lasts four to eight weeks, at which time additional cultures and sensitivities are done.

WHO reports with good TB control programs, cure is possible for up to 30% of people with XDR TB. Thirty-seven countries have notified WHO about cases of XDR TB. Ken Castro, MD, director of the division of tuberculosis elimination, said during a telephonic press briefing that a cure may be possible in as many as half of patients.

From 1993 through 2006, the CDC has reports of 49 persons who have met the definition for XDR TB. The organism from Speaker does not match any of those that the agency has in its fingerprint pack, but Gerberding told reporters that that's not unusual since health officials are just beginning to develop an international collection of XDR TB strains.

Field said determining a patient has XDR TB takes time -- 28 days or more to obtain initial susceptibility. Once the bacterium shows resistance to front-line drugs, state officials send a specimen to the CDC for second-line drug testing, which takes another three to four weeks. During that time, Field said, the patient is not receiving drugs to treat the infection and is therefore getting sicker and potentially exposing others to the disease.

According to CDC documents, public health officials believe regular TB and XDR TB are spread the same way when the bacilli become aerosolized and then are inhaled by another person. Aerosolization occurs when an infected person coughs, sneezes, speaks, or sings. The bacilli can float in the air for several hours, and people who become infected usually have been exposed for hours or days in poorly ventilated or crowded environments.

"It depends on the person being exposed," said Nancy White, RN, BSN, CIC, director of epidemiology at Grady Memorial Hospital in Atlanta, where Speaker was transferred May 28 by CDC air transport. "If they are immunosuppressed due to medication or illnesses, they could become infected more quickly than someone with a strong, intact immune system."

An X-ray taken in January after an injury indicated Speaker possibly had TB, Cetron told reporters. Respiratory secretion samples showed growth of tuberculosis organisms, and subsequent sensitivity testing indicated drug resistance. The CDC has not indicated how Speaker contracted TB; press reports have suggested he could have become infected while in Southeast Asia, but the source is still under investigation. His wife initially tested negative, Cetron said.

On May 31, Speaker left Grady for treatment at National Jewish, where he is being evaluated and treated. Gerberding said the bacterium infecting Speaker is susceptible to two of the second-line drugs.

Nicol said Speaker will receive medication first and possibly surgery. Clinicians at National Jewish believe he's a good candidate for treatment because he's a healthy 31-year-old who is nutritionally sound and whose disease appears to have been caught in the early stages. His stay may last from two to four months, followed by two years of additional medication, Nicol said.
Reaching out

CDC officials are working to reach people who were seated near Speaker on the two transatlantic flights he took, as they lasted eight hours or longer, Cetron said. As of June 8, the CDC had reportedly contacted 255 of the 274 U.S. passengers on the May 12 Air France flight from Atlanta to Paris. Speaker and his wife were the only Americans on the May 24 Prague-to-Montreal flight. Passengers will be tested and, if negative, rechecked in eight to 10 weeks.

While some say the CDC has overreacted, many public health nurses support the efforts. Field said that this case has gotten more public attention than most, but contact tracing routinely takes place with TB patients.

"In every case," Schack said, "you need to care for the patient, the contacts, and the community."

Debra Anscombe Wood, RN, is a Nursing Spectrum contributing writer.

Editor's Note: Read CE module 86e, "TB or Not TB?" It's available online at www.nurse.com/ce/syllabus.html?CCID=2937.

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Isolation vs. Quarantine

The CDC had Atlanta lawyer Andrew Speaker isolated under federal public health law, instead of quarantining him. That's because, according to the agency's website, isolation applies to people known to be sick, while quarantine is used for those individuals who have been exposed to an infectious agent but who might not yet have fallen ill.

As the site explains, isolation protects the healthy while allowing for the "focused delivery of specialized health care" to the sick. It's a standard procedure used in hospitals today for patients with TB and certain other infectious diseases.

For more, visit www.cdc.gov/ncidod/dq/ isolationquarantine.htm.