Case of TB traveler reveals holes in global disease control

The U.S. health authorities failed to notify their Italian counterparts that an American tourist with an extremely dangerous form of tuberculosis was staying in a Rome hotel this month until he was leaving the country, Italian officials said Thursday. That time lapse allowed him to leave Rome and fly to Prague and Montreal, potentially exposing dozens of people to an often lethal germ.

On May 23, a doctor from the Centers for Disease Control and Prevention in Atlanta, the CDC, reached the man, who was honeymooning in Rome from May 21 to May 24, by cellphone to inform him that tests performed before his departure from the United States had revealed that he had a form of tuberculosis that is resistant to almost all drugs, said Dr. Martin Cetron, a CDC official, at a press conference in Atlanta on Wednesday night. The test results had come back on May 22, he said.

They told the patient not to get on a commercial plane and were trying to organize either treatment in Italy or safe transport back to the United States - "begging and asking him to stay put, and not travel while we worked on some options," Cetron said. The man ignored that advice, flying to the Czech Republic and Canada before sneaking over the border into the United States, where he is currently in treatment.

But the U.S. officials did not reveal the man's presence to the Italian authorities - or to the World Health Organization in Geneva - until May 24, about the time he left Italy, both groups said Thursday. That made it impossible for local or international health and law enforcement officials to intervene in the case. Had they been informed, they could have visited the man's hotel to coax him into treatment, prevented him from boarding a plane, or even taken him into custody for forced quarantine.

Cesare Fassari, the spokesman for the Italian Health Ministry, said that had the Italian health authorities been notified in time, they would have "intercepted the man and invited him to be treated in the hospital" although he added that the man's "consent would have been necessary."
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The European and North American health authorities are now testing dozens of people who may have been exposed, although doctors say it is unlikely that the man infected anyone because he was not coughing. Tuberculosis does not spread easily; it requires prolonged and intensive exposure to the germs, which are coughed into the air.

The episode revealed holes in international cooperation systems for detecting and isolating people with infectious diseases, experts said. Such deficiencies could be disastrous if the victim were more contagious, as would be likely in an influenza pandemic.

"Despite technology and communication technology - e-mails and cellphones - we're not there yet, and there is the possibility for infectious people to cross borders without the knowledge of authorities," said Mario Raviglione, director of the World Health Organization's Stop TB department. "In this era of globalization you have to move really rapidly."

"We're all learning lessons from this case, particularly the U.S. Centers for Disease Control, I think," he said. "We need to think of this as a precedent so if you have avian flu, people will not escape control."

International health officials planning for an eventual flu pandemic have long worried about infectious patients eluding detection and isolation in the developing world, where disease surveillance is rudimentary.

The Italian Ministry of Health provided some more details on the man's stay in Italy, and sought to allay fears: The 32-year-old man was in Rome for 3 nights and 2 days as part of his honeymoon, the ministry said. He had no symptoms of his lung tuberculosis, and was diagnosed in January only by accident, when he had some X-ray tests after unrelated chest trauma. Tuberculosis can produces serious symptoms or none at all.

On his trip, the man flew from Atlanta to Paris and on to Athens, ending up on Thira Island, Greece. On May 21, he flew from Nikonos back to Athens and on to Rome. Because he was not coughing, only flights of over eight hours put fellow passengers at risk, and then only those passengers in the rows immediately around him, doctors said.

When CDC officials contacted the patient on May 23, they were facing an unprecedented situation and were "exploring all sorts of options" for handling it, Cetron said. The learning curve was steep.

Officials looked into how to alert international airports and started procedures to put the man on a no-fly list, though it was too late. They suggested he call the American Embassy, although it is not clear if any contact was made. The Embassy did not return calls for comment.
source:www.iht.com