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Free Andrew! Hysteria and the TB Case (from the New York Post)
By Elizabeth M. Whelan, Sc.D., M.P.H.
This piece first appeared in the June 2, 2007 New York Post:
Information is still coming in about the case of Andrew Speaker, the Atlanta-area attorney now quarantined because he carries an antibiotics-resistant strain of tuberculosis -- so perhaps our picture of the situation will change greatly. But at the moment, I find myself wondering: What's the big deal?
There is widespread outrage that Speaker, who was diagnosed with TB in January, elected to board commercial flights in mid-May to be married in Greece, to honeymoon in Italy and to return to North America. He's been called selfish, uncaring and irresponsible; yesterday, the label "terrorist" actually showed up in some media reports.
But consider these facts: He was completely asymptomatic -- no coughing or sneezing (the mode of transmission of TB) -- and he had no fever. Only an x-ray taken for unrelated reasons indicated that he had TB. Centers for Disease Control officials claim they ordered him not to fly to Europe -- but Speaker, who says he has tape recordings to back him up, claims the CDC only told him it "preferred" that he not fly.
The probability of having drug-resistant TB in the United States is extremely low -- from 1993 to 2006, there were only 49 cases reported. (Speaker had traveled worldwide, including to several Southeast Asian countries where TB is endemic, such as Vietnam -- where the exposure likely occurred.)
And when Speaker left for Greece, there was no evidence that his TB was the multiple-drug-resistant variety (called XDR TB). He was already in Italy when CDC officials finally contacted him to inform him that he had the rare XDR form of the disease.
Using its legal powers to prevent the spread of disease, CDC put Speaker on the U.S. "no fly" list -- and told him to enter an Italian hospital, where he would be put in isolation indefinitely. Speaker and his bride asked if the CDC could provide transportation -- even if it had to be a cargo ship -- so that he could get home for treatment. The agency denied the request.
The prospect of entering isolation in a foreign facility understandably terrified him. One would think that the newlyweds at this point had to be seeking advice from the TB expert closest to them - the bride's father, Dr. Robert C. Cooksey, a CDC microbiologist whose specialties include tuberculosis.
Did Dr. Cooksey advise them to leave Italy and get to the United States as soon as they could -- knowing that his new son-in-law was still asymptomatic and highly unlikely to infect anyone?
In any case, Speaker chose to avoid the CDC's ban by flying to Canada and driving across the border.
Surely we can sympathize with his dilemma: the shock of receiving the diagnosis of a disease that is terribly difficult to treat and associated with a significant mortality rate. Who wouldn't want to get home to access the best possible treatment?
Please note that CDC doctors -- and those from the Denver hospital where Speaker is now being treated -- have repeatedly stated that the chance that he infected others is extremely low -- near zero. Indeed, his bride is free of TB, even now -- after their honeymoon, which presumably saw considerable contact.
It thus seems overcautious to alert passengers on the manifest lists of the flights he was on that they might be infected. Alternately, if there is some unreported grounds for concern, and given that he had TB as far back as January -- and likely months before that -- one wonders why this precautionary testing was not ordered for others with whom he had close contact: his law colleagues, friends and relatives.
At this moment, Andrew Speaker is an otherwise healthy, strong, athletic, young man who is a prisoner -- isolated in a hospital ward in Colorado. President Bush signed an executive order to mandate the quarantine -- a power last invoked in 1963, when it was used to isolate a person suspected of having smallpox.
One can understand the confusion of observers who hear both that Speaker is in involuntary isolation and that the chances are near 100 percent that in his current state he poses no risk of infection to others. Do we have a bit of a medical over-reaction here?
Dr. Elizabeth M. Whelan is president of the American Council on Science and Health (ACSH.org, HealthFactsAndFears.com).
Lance (June 4, 2007)
You state (and I am confident that you are correct) that “in his current state he poses no risk of infection to others.” But you also state that coughing and sneezing are “the mode of transmission of TB.” Are you suggesting that Speaker be allowed to walk amongst us freely up until the very instant he sneezes? What if that first next sneeze were to occur in a crowded subway car? The chances of Speaker infecting others “in his current state” may be “near zero,” but the unacceptable risk is that Speaker’s “current state” could change at some unpredictable time in the future, and that Speaker could then infect others regardless of his best intentions, intentions that he has demonstrated can be selfish at times even if quite understandable.
Roberta Kowald BA LLB (June 4, 2007)
Thank you Dr for your excellent analysis and critique of the media frenzy surrounding this case. As you are aware - in 2005, the national US TB rate was the lowest since 1953 - 4.8 cases per 100,000 (which means that 3.8 statistical people other than Andrew Speaker are running around "loose"). Some of them traveled on planes - some of them may have even sneezed in a crowded theater.
But this current shark-fest isn't about health or information - or even about a rational discussion about what can be done about TB globally - it's about selling papers and getting people to tune into commercial news channels.
Even NPR led their story by insisting that Speaker has a "rare" and "exceptionally dangerous form" of TB - and
Newsweek led with the ludicrous statistic that drug resistant TB is "67% fatal".
What they both fail to mention is the reality - in fact, since 11% of cases worldwide are now multiple-drug resistant and the fatality statistic worlwide is almost exclusively linked to developing countries - most specifically India and China.
In fact - a far more disturbing disease trend worldwide is diarrhoeal diseases (TB is number three, globally).
Quickly now - Make sure that the Brangolina crew is banned from Africa again if they are carrying Kaopectate! Prevent the deadly spread of American tourists bringing deadly strains of the runs to our global neighbors by quarantining!
Janusz Z. Byczkowski (June 5, 2007)
I am afraid that Roberta's estimate is overly optimistic. Assuming that the incidence of TB in the US in 2007 is still as low as she said, it would make as many as 14,495 TB infected “statistical people” (in addition to Andrew) “running around loose” (the number she cited was per 100,000, while there is currently about 3,020 that many people in the USA). This number is closer to the 14,874 cases reported by CDC for the year 2003 < http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5412a1.htm >, than to the 3.8 suggested by Roberta. Even assuming that only 10 – 11% of multidrug resistant cases are “exceptionally dangerous” this makes about 1.5 thousand potential “Andrews“, walking around, traveling by planes, buses, etc.
Please do not tell that to journalists – I really do not want to read 1.5 thousand more scary stories (hopefully, only the first 3 stories would sell well ;-)
While all the hoopla around this case – including TV interviews - is in fact “no-news”, one aspect makes me a little uncomfortable: the border officer, the one who re-admitted Andrew to US, while showing good medical judgment did not do what he was paid for (to stop those placed on “no-go” list, for good or bad reason).
(July 1, 2008)
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