Transcript The CDC Response to the Andrew Speaker-XDR

Crisis in the Sky: A Case Study
in Communication at the CDC
Team Synergy
Emerging Leaders in Public Health
1
February 26, 2009
Introduction
• May of 2007—CDC
suspects Andrew
Speaker has XDR-TB
• Despite warnings,
Speaker travelled
abroad potentially
infecting thousands of
people and creating an
international public
health crisis
• How did this crisis
occur?
• Where was the
breakdown in
communication?
• Did the agencies
involved have the
power to stop Mr.
Speaker?
2
Why All the Fuss?
•
•
•
•
•
Tuberculosis (TB)
Contagious disease
Considered a global
pandemic
2nd only to HIV in
mortality of adults
worldwide
Treated using 3
antibiotics over a 6-9
month period
Treatment is difficult at
best
•
•
•
•
MDR-TB & XDR-TB
Cases increasing
worldwide
Treatment requires 4 or
more second-line
medications (which are
less effective) for up to
2 years
Surgery is sometimes
required
Higher complications
and death rates
3
What does the WHO say about it?
The World Health Organization recognizes:
• TB has been shown to be spread on planes
• In each case, spread occurred between
passengers sitting within 2 rows of each other
• Other factors that contribute to the spread:
• The infectiousness of the TB patient
• The length of exposure to the TB patient; and,
• Seating proximity to the TB patient
4
Key Players
5
Centers for Disease Control and Prevention
• CDC is housed under the Department
of Health and Human Services
• Included in its mission is disease
prevention and control &
environmental health
• Headquartered in Atlanta, GA
(Fulton County)
6
The CDC Players
Centers for Disease
Control & Prevention
(CDC)
Office of the Director
Source: www.cdc.gov
Coordinating Center for
Infectious Disease
(CCID)
National Center for Preparedness,
Detection & Control of Infectious
Diseases
(NCPDCID)
National Center for HIV/AIDS,
Viral Hepatitis, STD &
TB Prevention
Division of Tuberculosis
Elimination
(DTBE)
Global Migration
& Quarantine
Timeline of Crisis Event
January 2007
March 2007
• Speaker had an
accident and during
routine chest x-ray, an
abnormality was
discovered
• TB diagnosis confirmed
• Initial diagnosis—TB
• Takes 6-8 weeks for
culture to grow, no
definitive diagnosis in
January
• Speaker does not have
any symptoms
• Speaker begins
standard drug
treatment therapy
8
Timeline of Crisis Event
April 2007
• Speaker’s doctor informs Fulton County
Health Department (FCHD) of TB
diagnosis & treatment details
• FCHD begins the work up for Multiple
Drug Resistant TB (MDR-TB)
9
Timeline of Crisis Event
• April 25, 2007
• Speaker informs FCHD doctor of his
overseas plans (to be married), but offers
no itinerary of the trip
• April 30, 2007
• FCHD preliminary cultures indicate
Speaker has MDR-TB
10
Timeline of Crisis Event
May 10, 2007
• FCHD confirms Speaker has MDR-TB
• Private meeting held with Speaker, his
doctor, and FCHD officials
• Speaker advised to stop taking his meds
(since they are not effective with MDR-TB)
and the CDC was contacted
• Speaker advised not to travel
11
Timeline of Crisis Event
• After May 10th meeting:
• FCHD begins to review legal options
restricting patients’ travel and consulted
with the CDC
Speaker changes travel plans and
leaves for Europe on May 12 instead
of May 14 (as originally scheduled)
12
Timeline of Crisis Event
May 12, 2007
• Speaker leaves ATL for Europe
traveling on 3 commercial flights.
• While Speaker travels:
• CDC is attempting to formally contact him
with written travel restrictions
• FCHD is attempting to hand-deliver travel
restrictions
13
Timeline of Crisis Event
• May 17, 2007
• Samples previously taken are tested for
XDR-TB
• CDC notified of Speaker’s overseas travel
• May 21 or 22
• Preliminary XDR-TB tests are positive
• Speaker flies to Greece for his
honeymoon on 2 commercial flights 14
Timeline of Crisis Event
May 22, 2007
• CDC Division of Global Migration and
Quarantine contacted Customs and Border
Patrol (CBP)
• CBP was advised that Speaker was a public
health risk
• Information attached to Speaker’s passport
15
Timeline of Crisis Event
• May 23, 2007
• CDC contacts Speaker in Europe and advises him
to either turn himself into Italian Health Officials
or return to the USA via private jet
• May 24, 2007
• TSA advised to prevent Speaker from boarding
any US bound flights
• Speaker returns to North America on 2
commercial flights
Total # of commercial flights for entire trip = 7
Number of passengers exposed to TB > 600
16
The Confusing CDC Messages
Mr. Speaker was given at least 3
messages from the CDC:
1. Tools are available to the CDC to keep
Speaker from flying into the US
2. Speaker should turn himself into the
Italian health authorities
3. Private jet arrangements to the US would
cost Speaker $100k, but the CDC could
arrange travel for $50k and charge him
for it (This is inaccurate)
17
Read the Fine Print
Paragraph 1, Article 40 of the International
Health Regulations states that parties
should not charge for appropriate
isolate and quarantine requirements to
protect public health (WHO 2005)
18
It Appears that Mr. Speaker…
• Believed he was on the “no-fly list”
• Chose to by-pass the expense of
charter flights by flying to Canada, and
driving across the border to NY
(05/24/07)
19
Someone Drops the Ball
• Actually, Speaker’s name did not
appear on the “no fly” list until 2 hours
after landing in Canada
• Speaker was not detained at the US
border because a customs agent
determined that Speaker “did not look
sick” despite his passport being flagged
with isolation instructions
20
What Eventually Happened…
• Speaker checks himself into a New York
hospital and he was placed in isolation
• Speaker is eventually transferred to the
National Jewish Hospital in Denver, CO—they
specialize in TB treatment.
• Speaker remained in Denver, in isolation for
months
• Condition downgraded to MDR-TB
• No reports of any exposed passengers
“catching” TB
21
Cut Out of the Loop
• Neither the WHO nor the Italian
Ministry of health were notified of
incident until May 24, after Speaker
left Europe
• Dept. of Human Services did not
provide formal International Health
Regulations (IHR) notification until May
25
22
Communication Challenges
• Between health
officials (CDC &
FCHD) and Mr.
Speaker
• Between CDC and
FCHD
• Between CDC and
other federal
partners
• Between CDC and
international
partners
23
How the Legal System Got in the Way
• Both Federal and State governments have
the authority to isolate and quarantine
• There is confusion on who has jurisdiction in
matters such as this
• Neither the FCHD nor the CDC seemed to be
aware of what power they actually had
• The law does not specify how the CDC can
prevent individuals with communicable
diseases from leaving the country
24
Recommendations to the CDC
If drug resistant TB (MDR or XDR) is suspected:
1. CDC should start
working with LHD
as soon a possible
2. Person suspected
of being infected
should be placed
on travel
restrictions without
delay
3. Advise Federal
partners (including
airlines and
airports) to enforce
travel restrictions
25
Additional Recommendations to the CDC
1. Implement and
adhere to IHR
guidelines
2. Notify WHO if
suspected person
have international
travel plans
3. Research and
investigate rapid
MDR and XDR-TB
testing
implementation
4. Train US embassy
employees to
become health
ambassadors for
US citizens
traveling abroad 26
There Were Benchmark Practice Examples to Follow…
• SARS was spread
globally by airline
passengers
• Passengers up to 7
rows away were
infected
• Over 300 either
contracted SARS or
a secondary SARS
infection in 1 superspreading event
27
So What???
• When communication is unclear,
difficulties occur
• Cohesive, coordinated plans are
essential in public health emergencies
• Laws should be in place to help, not
hinder
28
Team Synergy
• Ruth Arumala
• Randi Burlew
• Lisa Clarke
• Donna Galbreath
• Katherine Lao
29