CDC quarantines man who has lethal TB strain

WASHINGTON -- The US Centers for Disease Control and Prevention, underscoring the threat of an emerging, lethal form of tuberculosis, issued a rare federal public health order on Monday that placed an infected Georgia man into quarantine and announced yesterday that it is searching for airline passengers he may have exposed to the disease on two trans-Atlantic flights earlier this month.

It was believed to be the first federal order of quarantine in 44 years, when public health officials ordered the isolation of a person infected with smallpox.

The patient, whose identity is being withheld by the CDC, was diagnosed with extensively drug-resistant tuberculosis -- a particularly virulent strain of the disease that can be transmitted through sneezing or coughing. The potentially deadly strain, known as XDR-TB, was first identified about 18 months ago in a South African province, where it killed 52 of 53 infected people.

Though health officials said the risk of widespread infection within the US public is low, "we felt it was our responsibility to err on the side of abundant caution" and keep the Georgia man in isolation, said Dr. Julie Gerberding, the CDC's director .

CDC officials said they were scrambling to locate the airline crews and dozens of passengers from the two flights the patient boarded: Air France Flight 385 from Atlanta to Paris on May 12, and Czech Air Flight 0104 from Prague to Montreal on May 24. Health officials said the crews and any passengers who were seated near the patient are at highest risk and should be immediately tested for TB infection.

Gerberding said that US officials were working with governments around the world in trying to find the passengers.

The man, who knew before his trip that he was infected with a form of TB that was difficult to treat but was not aware he had the deadlier strain, drove from Montreal back into the United States in a private car on May 24. By then, tests confirmed the man had extensively drug-resistant tuberculosis; when the CDC received word of the diagnosis it caught up with the man in New York City on May 25 and urged him to report to a hospital, said Martin Cetron , director of CDC's Division of Global Migration and Quarantine.

Cetron said the man was immediately hospitalized but was given the option of being treated in Atlanta near his family, and he chose to go home. Officials said they did not want to risk exposing the public to the disease again, so they dispatched a CDC plane on Monday to fly him to Atlanta.

"We didn't feel it was safe for him to fly on a commercial aircraft," Gerberding said. ". . . Anybody who comes into contact with XDR-TB could become infected."

When the man arrived in Atlanta on Monday, officials handed him the quarantine order. "We want to balance personal liberties with public health and, because this organism is so potentially serious, especially to those who have reduced immunity, our responsibility is to err on the side of caution," Gerberding said.

Fulton County health officials in Georgia knew the man had a form of drug-resistant TB and asked him not to fly because all forms of the disease are contagious, a CDC spokesperson said last night. But CDC officials said they did not know he was infected with the deadlier strain until he had already departed. It was unclear whether additional lab results had confirmed the diagnosis after he headed to Europe.

"We were surprised that the patient had left the country," Gerberding said. "He felt he had compelling personal reasons for traveling, and then he went ahead and met those needs," she said, declining to reveal the reasons for his trip, citing privacy concerns.

Authorities do not consider his travel to be a criminal matter.

Public health specialists said yesterday that the CDC handled the matter responsibly .

"It's a really rapid response, and I think what they did was appropriate," said Allan Rosenfield , dean of Columbia's Mailman School of Public Health . "There is a threat of passing the disease in the really enclosed space of an airplane, so they were absolutely right" to dispatch the CDC jet to New York.

Around the world, XDR-TB is most dangerous in poor countries with underfunded public health systems, limited access to drugs and medical diagnostic tools, and high HIV infection rates. A person infected with the acquired immune deficiency syndrome virus with a weakened immune system has difficulty fighting off all diseases.

But specialists also say that in an age of increased global air travel, no country is completely safe from tuberculosis. An infected person in an enclosed jetliner can easily transmit the airborne virus to flight attendants and nearby passengers.

"We're all connected with air travel and other types of travel. It's inevitable there will be more cases in the United States," said Gerald Friedland , director of the AIDS program at the Yale School of Medicine. Friedland was lead investigator of the South Africa outbreak that killed 52 people in late 2005 and early 2006.

After the South Africa outbreak, a World Health Organization panel defined XDR-TB as a strain of the virus that is resistant to the two primary TB-fighting drugs, as well as at least three older, less effective classes of tuberculosis medication.

Using that definition, US health officials in the last year reviewed old cases that had been identified as multiple-drug resistant TB, and determined that 49 Americans have been diagnosed with XDR-TB since 1993.

An estimated 2 million people die from tuberculosis each year, but specific information about mortality rates in developing nations is "very incomplete," Friedland said. Even in industrialized countries like India and China, there is very little testing for drug-resistant tuberculosis, much less the XDR-TB strains.

In places where large numbers of HIV and TB cases intersect -- mostly in sub-Saharan Africa -- only a handful of laboratories can successfully identify XDR-TB cases, specialists said.

Officials in South Africa, which has intensified efforts to identify the drug-resistant organism, acknowledge they do not know the full extent of the problem. The country's health department says that about 68 percent of all XDR-TB patients have died in their latest figures; in KwaZulu-Natal Province, the site of the Yale study, the mortality rate is now at 89 percent.

"We don't have the luxury of single-isolation rooms that industrialized countries will have," said Dr. Karin Weyer , director of TB research for the South African Medical Research Council. "We at least treat them in wards set aside just with TB patients and don't try to mix them with confirmed HIV-positive cases."

Weyer said that even the best health systems in the world will have a hard time fighting cases of XDR-TB because of the poor selection of drugs. "For many patients, it becomes a virtually untreatable form of TB, and eventually the outcome will be death," she said.

John Donnelly can be reached at donnelly@globe.com.