This was the kind of fallout from the TB case I was most concerned about:
States should have the power to restrict the movement of patients with contagious diseases even before they have the chance to disobey doctors' orders, federal health officials say.The need for such authority to order someone quarantined emerged as lesson No. 1 from the case of the Atlanta lawyer who went to Europe despite having a dangerous form of tuberculosis.
[snip]
"First of all, up front, before the patient left the United States, we believe that we could strengthen our states' ability to restrict the movement of patients before they demonstrate noncompliance with the medical order," Gerberding told lawmakers. (Fox News)
We've discussed this here quite a bit. I don't want to rehash the case of Andrew Speaker further. At this point we need more information than we have (or may get) about his specific case. More important is the policy fallout from a case where all sorts of people were quick to jump on their horses and ride madly off in all directions. Even people who should know better are drawing parallels between an apparent failure to restrict this person's air travel and a supposed weakness in our defenses against pandemic influenza. We do have weaknesses, but failure to detain the TB isn't evidence of one of them. Everyone who has looked at the question, including the Department of Homeland Security, CDC and its parent agency, the Department of Health and Human Services, not to mention independent experts, has concluded that trying to control the spread of influenza by controlling air travel is futile. This is not to say that a restriction in air travel won't have a slowing effect. But it won't be the result of intentional policies. The system will start to slow on its own as travelers stay home and air crews suffer absenteeism sufficient to cancel flights. The system is already very brittle and the shock of a pandemic will seriously affect it.
So forget about implications for pandemic influenza. The TB situation is more complicated. While there is no documented evidence anyone has contracted active TB from an exposure on an airplane, it is plausible it could happen. We rub shoulders with infectious TB all the time, unfortunately. Multiply drug resistant TB (MDR) is now common in the former Soviet Union and eastern Europe and there is a great deal of traffic between many places where MDR TB is endemic and North America. Andrew Speaker is an example, having reportedly traveled in such areas for the six years prior to his diagnosis. And that diagnosis was quite accidental, the result of a chest x-ray done to look at a rib he had injured. The moral of the story is there is a frightful amount of TB in the world, much of it infectious and undiagnosed, and we are riding the buses, subways and airplanes with these cases on a daily basis. There is nothing unusual about Andrew Speaker except that we know about him. We won't make a dent by giving extraordinary police powers to a government that seems to have an unlimited appetite for police power.
I believe in the power of government to make people's lives better. I am proudly a person of the Left. I am for universal health care (single payer) and effective regulation of industries who don't care about the health and safety of their workers and the general public. I am not opposed to effective and robust public health powers. But I am also a libertarian when it comes to government interference with personal liberties. This is a case where the candle isn't worth the game, and I am not the only one disturbed by the direction this is being taken:
Peter Jacobson, a health law professor, had concerns about Gerberding's statement on two fronts.
"That's not the federal government's role and it's far, far too broad a statement. There has to be a credible threat, a direct threat of harm before you restrict someone's freedom to move, before you intrude on their individual liberties," said Jacobson, director of the Center for Law and Ethics and Health at the University of Michigan.
"For her to say in such a broad manner that a state should restrict people before they're noncompliant is extremely intrusive in my view," he said.
Also, the District of Columbia-based association representing state health officials noted that it is now up to the states, not the federal government, to determine when to issue an isolation order.
The Bush administration never loses an opportunity to extend its coercive reach over the citizens of this country and Gerberding rarely loses an opportunity to ingratiate herself with her masters. But this isn't just the right wing. Liberal Senator Tom Harkin from Iowa is solidly onboard:
Harkin, the chairman of the Senate Appropriations subcommittee that questioned Gerberding, said the agency was notified May 18 that Speaker had multiple drug resistant tuberculosis, but the Homeland Security Department was not told until four days later. Speaker was not placed on a no-fly list until May 24.
"Again, with the rapidity of world travel today, it seems to me that this time frame should have been collapsed to just a few hours," Harkin said.
Said Gerberding: "I think we should have done it faster, and I think we'll be able to accelerate this next time. In retrospect, that was a mistake and I wish we had done it differently."
Twenty years ago we might have gone this route with HIV/AIDS. After all, is it so different to say we need to lock up HIV positive people because they might have unprotected sex and spread the disease? In fact some HIV positive people did just that. The next logical step, of course, would have been to lock up those at high risk of getting infected with HIV. You know where that would have gone. We didn't do it. But that was before September 11.
TB? Lock 'em up. Let's start with the immigrants.
Update: Other posts here.
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I'm going to be a stinker, and raise the counter position by focusing on a particular problem: infection control. Currently, most of the actual regulatory power (i.e., shutting down wards and hospitals, closing public use facilities) resides at the state level; the CDC essentially issues guidelines (if that) and leaves execution up to the states. Given that a lot of outbreaks aren't confined to one states (e.g., the MDR-Shigella outbreaks in the Missouri tri-state area), this leads to many holes. Some states didn't have the authority to act in this case, while others did.
In the case of nascent threats like KPC and VRSA, the absence of national guidelines, coordination, and enforcement, which could include mandatory isolation of patients and temporary removal of 'carrier' employees from the workplace, is a serious problem. Having said that, I don't really feel confident leaving the response to this particular federal administration...
Mike: I don't think we disagree too much. My main concern is at least two-fold: this case will produce ill-considered and overbraod responses with consequences for civil liberties; and the one you voiced, that this is another tool and weapon in the hands of a very controlling and anti-liberty administration, political party and tendency -- the Giuliani-Lieberman-Bush mindset.
Revere, excellent post my man. I agree the limitations on civil liberties should absolutely never, ever reach the level that Gerberdinator/Harkins suggested. Mike, I dont want ANY administration to have the reach and control that have been set into us post 9/11. We are a much safer but much more controlled nation now. Talk about a bomb on a plane and you are on the ground and on the way downtown.
Post 9/11 laws put in may have been a little rough, but we did it as a knee-jerk and most of it was necessary. Some of it wasnt. Some of it was axe grinding. But it was a good post Revere until you brought up the immigrants. I assume you are speaking of the illegal immigrants. First, it would cost a fortune just to pick them all up and treat their current diseases as they continue to bomb the current public health system with fake ID's and birth certificates. Second they are illegal now arent they? But its not about immigration. Its about sick people wandering in with the magic bullet disease either by air or leaving here with it. Either could carry the equivalent of a 50 megaton strike in any country. Speaker caused a major ruckus on the other side of the planet and to be polite, he would be in a ward right now and locked up if he was in Italy or the Czech Republic. Thats their law. Do we need to do the same? I really dont know. We have laws, but were they followed by either party?
Credible evidence exists for the case that this was a pre-planned program. When he started changing flights and things it was an overt act. Its not a rehash, but establishing the facts. He was one of ours. Cognizant, educated, a member of the bar and he knew very well what he was doing. If I were his attorney I would have told him NOT to testify via phone to the Congress. His story has changed four discernable times that I can see. Its debatable if a crime was committed.
Your point about HIV/AIDS is taken and how they by the same token could be rounded up as public health hazards. Okay, thats a given and they could do it right now under existing law both federal and many states. A positive test means round them up and send them to sanatorium camps. Right? No way! Do we need more laws? That seems to be what the Dems were suggesting to CDC and Gerberding-Harkins included. IMO we dont need any more laws just a little more common sense and maybe a little fine tuning of federal law and/or states laws. Speaker is currently in the box not charged with a crime. To charge him would likely be costly to try and interfere with his treatment which if I read it right, means he hasnt really got a chance in Hell of being around here in about three years. The thrust of the post was that it was some Republican plan to take over and coerce people into submission and that isnt true Revere. The Democrats were suggesting it right along with Harkins and Gerberding was making statements like they needed to do it better. Really? Because if doing it better means picking him up as a federal public health hazard we have bigger fish starting to fry. Would I have done it? Yep. Reluctantly though and God help us all of the extreme right or the extreme left ever get this kind of authority as anything other than a one off adventure.
Why are we here? There is a major difference in terrorism and someone being sick, a line in fact. Speaker became a bio-terrorist in a couple of countries definition when he didnt do what he was told by his host nation and thats when he crossed the line. I would have thought he might have made a better decision, but didnt. He just wanted to go to Santorini and then head back to Colorado for treatment, not knowing the wheels that he started turning. Given, TB is all over the planet but it doesnt mean that we should just say, "oh well." and let it slide. It doesnt mean that we should have to wear the Star of David on our lapels either.
Did we do enough or too little here? Thats going to be the question that has to be resolved in Congress. All of the answers that come back may not be what we want to hear. Even if the answers come back worng we should make sure that this stays very middle of the road, else they might round you up 20 years from now for having a defective gene..
Prediction: the people who will have the absolute least influence on where this policy goes will be epidemiologists specializing in tuberculosis.
Fred: I'm afraid you will be right.
Revere, I totally agree with your comments and concerns about the possible abuse of isolation and quarantine powers.
That said, I wanted to comment on your statement that there has not been documented transmission of "active" TB on a plane. Although this is true, the casual reader might conclude from this that TB is not likely to be transmitted on a plane.
However, as you know, TB "infection" can be transmitted on a plane (and in other places) and whether or not active disease occurs after infection depends on other factors such as the status of the host's immune system.
I just got home roughly an hour ago; the cats, Meep and Princess, were insolent, diffident, and generally seriously pissed off. My estranged wife had dutifully dropped by to feed, water, and clean their two litter boxes every few days, during the ten days that I had gone back home, to the Midwest. She dumped the cats on me to begin with (she and my daughter discovered them -- only a few days old -- tucked under the leaves of a tree in their back yard, about a year ago).
But the good news is that I understand cats; we are much the same sort of creature.
Now, I'm the designated feeder, water provider, vet bill recipient, (butt of the various "cat jokes"), etc.
But I have no problem with any of that. My problem is that I had to fly into, and out of, O'Hare airport this afternoon; apparently designed in an effort to foster the idea of "state of the art air travel." It is an absolute fucking zoo. Anyone whom you might encounter there, who is actually smiling, is utterly suspect; they cannot possibly possess an IQ above 75. These are almost exclusively employees.
These are the trenches at Verdun, and the Marne; only the restrooms are cleaner.
Image is, obviously, far more important than substance, here.
For two-and-a-half-hours, I observed literally tens of thousands of travelers, going to nearly every point on the globe; all of them breathing the same air, touching all the same surfaces (most amusing was watching one dumb asshole brushing his teeth, while he was standing at a urinal; not sure how he rinsed the toothbrush, though).
Two-and-a-half-hours at O'Hare. We are in very, very dangerous territory, here.
O'Hare is hell...without a doubt. But do not ever -- ever -- fly through Atlanta, if you can possibly escape the venue. It is Hell-and-a-half. I swear.
epifreek: I quite agree. The fact that there have been no active TB cases traced to air travel seems to me mainly an artifact of how difficult it is to detect such cases. And we know infection does occur, although in the contact tracing studies it is still quite uncommon. TB isn't flu. My point, however, is that shutting off the airplane possibility is not possible or effective, because of the huge number of undetected cases and the collateral damage of trying to do so; nor would it be effective in the larger sense for exactly the same reason. People get TB quite a lot in this world and it isn't from airtravel. There is just a lot of TB out there, which is why if XDR gets a foothold it will be a serious problem. Yes, very, very plausibly it is possible to get TB, even active TB, on an airplane. Or a bus. Or a train. Or in a classroom. Particularly in a hospital. Etc., etc. I am concerned that the airplane case will be an excuse or a msitaken reason to fashion a cure worse than the disease, from a society viewpoint.
Dylan; Spoken like only a person can speak who has just traveled through O'Hare or Atlanta.
The reason TB and other diseases are transmissible in places where people gather is because people inhale droplets that other people exhale. In enclosed places these droplets persist for longer and at higher concentrations than in unenclosed places.
There are technical "fixes" that reduce this transmission, the use of HEPA filters, UV lights, more frequent air changes, that sort of thing. Why aren't those things considered? Not because they are not effective. I suggest it is because it is not "tough" to fight disease transmission with air filters, it is "tough" to fight it with draconian police state tactics.
The level of effort to reduce transmission by 2 logs (99%) is fairly straightforward to calculate (but it is a lot). What kind of police state tactics would be required to reduce transmission by 99%? I think it is a level that would be completely unacceptable.
Since there are likely many travelers with undiagnosed diseases, an early draconian police state tactic would have to be universal health care so that undiagnosed cases become much more rare. The cost of that would dwarf increased air filtration to get 99% reduction.
What I would like to see would be an analysis of what it would cost to reduce transmission by 99% by various methods. Or better, a cost vs transmission reduction. I think that sort of analysis would show that you can't get to where we would like to be via draconian police state tactics.
Dylan,
The last two times I had to fly, I had connecting flights through Atlanta Hartsfield. The last layover was long enough for me to contemplate what Dante's reaction would have been had he been able to observe the scene.
My husband flies as a professional pilot for a major airline. He has been to almost every airport in the USA and several in other countries. By far the worst in his opinion is Newark. Atlanta takes a close second and he has to sit around there ALL the time waiting in between flights (pilots don't fly all the time and they don't get paid to sit around waiting either).
He uses hand gel, wipes, and takes a good supply of each on all his trips. Since he started this, he has not come down with ONE cold or flu illness. He flies a trip a week every week of the year some 3 to 4 days plus hotel stays in between.
Revere, is the more correct statement that there has never been a major study of the air/surfaces in airports and on airplanes? I know of just one, in the 80's and they found TB on the surfaces along with fecal matter, E coli. I have no idea what an airport could contain. The only saving grace is that someone comes by every couple of hours and wipes everything down with disinfectant.
So what is more correct? Its not that there hasnt been a documented case, or that the study has never been done. I dont know where to even look to find out.
Randy: I know of no documented case of active TB from air travel. The only evidence is a few cases of skin reaction conversion (I gave some of the links in an earlier post). There was extensive contact tracing (thousands). I don't know what study you are talking about with TB (M. tuberculosis?) on an airport surface. Highly doubtful and I'd like to see a citation for that. Refer to my post on checking the evidence for why there isn't more data.
Might be that they dont WANT to do any testing..... Airlines are just now recovering from 9/11 to the same traffic levels. Cant have anyone knowing whats out and on there.
The test and I am trying to find it myself, was a test that basically was some university student of some kind trying to finish up his senior thesis, Embry Riddle? Anyway they went thru and were checking behind a "cleaning crew" to see what the could find.
-Pillows with lice in them.
-Trash chutes with ham sandwiches and boarding passes down them in front and back of the sandwich that were six months old.
-Peanuts with fur growing on them on the floor, pretzels too.
-Toilets that had fecal matter on them.
-Handles with the same.
-Air filters with Med flies stuck in them, fecal dust.
-Surface test, all of the bacteria you would expect to find and then whatever the bug name is for TB on it. Black mold-isnt that aspergillis?
-Belly they found a leak from a toilet and so much pee/blue disinfectant it had corroded a rib strut.
-Potable water contaminated with ordinary green slime.
Yeah, I am looking for that report. It was done in the early to mid 90's and only came across it looking for something else.
Randy: Very unlikely a student would be able to culture mycobacteria. It can take months to grow under very specific conditions. However if he or she did, it would almost certainly have been M. avium or M. intracellulare (the so-called Mycobacterium Avium Complex of MAC), which is an opportunistic infection, mainly of AIDS patients. Leprosy is also a mycobacterium and is hardly contagious at all. People live closely with Hansen's disease patients for years and don't get leprosy. So finding a mycobacterium in the environment wouldn't mean anything special.