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XDR-TB case exposes health officials, public to ethical aspects of quarantine
Ethicist: Public welfare can mean loss of individual freedoms
The public health threat posed by Andrew Speaker, the Georgia lawyer who traveled to Europe and back as he learned that he not only had tuberculosis, but an extremely drug-resistant tuberculosis (XDR-TB), warranted the first federally ordered quarantine in 44 years.
What it probably also deserved, one public health ethicist says, was quicker action to isolate Speaker sooner, and the director of the Centers for Disease Control and Prevention (CDC) says the case has revealed some potential for improvement in handling future quarantine cases. And though the CDC and National Jewish Medical and Research Center later announced, in early July, that additional testing had revealed that Speaker is suffering from multidrug-resistant tuberculosis, not XDR-TB, those lessons remain viable.
Depriving an individual of his or her liberties for the sake of the public good is not entirely uncommon in the United States, or the rest of the world. The Atlanta-based CDC, which made attempts to persuade Speaker to refrain from travel in May before he left for Europe, and then obtained the federal order forcing him into isolation when he returned to the United States, has said events unfolded in a way that allowed Speaker to leave on his own before the government had what it believed was enough evidence to curtail his movements.
Emphasizing that he has no first-hand knowledge of the CDC's actions, and that hindsight is 20/20, public health ethicist Marc Hiller, DrPH, an associate professor of health management and policy at the University of New Hampshire, says the actions taken by the CDC to isolate Speaker "were fully appropriate."
There have been a few criticisms suggesting the government overreacted, given that Speaker was not symptomatic and, according to CDC Director Julie Gerberding, MD, MPH, posed "a low transmission hazard — but not zero." But most questions have been directed at how Speaker — who was known to have tuberculosis, and at least drug-resistant tuberculosis (but not XDR-TB) before he left the country — could leave the country, travel through Europe, and then fly back to North America and drive into the United States from Canada without being apprehended.
That's the question Hiller says is foremost to him, as an ethicist — not whether Speaker's individual rights were threatened as he planned a wedding trip to Europe, but whether more could have been done to protect the public earlier.
"It's a struggle to balance promoting and assuring the public's health and well-being while protecting individual rights and liberties," says Hiller. "While the preservation of individual liberty is a long-cherished ideal in a democracy and in health care, it must be viewed as secondary when an individual's health (or disease) status threatens the health — and in this case, possibly the lives — of others, particularly potentially large populations." (See box.)
"If one reviews the history of public health in the United States, whether it be extreme pandemics such as the Spanish influenza outbreak in 1918 or the infamous case of Typhoid Mary, clearly the need to restrict individual rights and spread of contagion is merited in order to protect the health and lives of the public, or the overall social good of society."
The pursuit of Andrew Speaker, and the potential exposure of dozens of people on the flights he took back to the United States, could have been avoided had he been placed in isolation — an everyday practice in health care settings in which someone with a staph infection, meningitis, or TB is removed from the general population and isolated from contact with others.
Quarantine is a more population-based approach that seeks to separate exposed individuals, who still appear perfectly healthy even though they've been exposed, for a period of time to see if they develop symptoms.
"Why was he not isolated and treated for the disease prior to his being able to expose other people?" Hiller asks. The federal quarantine order that the CDC obtained to allow it to force Speaker into isolation "was a wise, prudent, protective measure, but could have been prevented if he'd been isolated sooner."
CDC relies on 'covenant of trust'
In media briefings in late May, after Speaker had been placed in isolation in Denver's National Jewish Medical and Research Center, Gerberding said in most cases, people diagnosed with tuberculosis are trusted to isolate themselves.
"[W]e influence them through a covenant of trust so that they don't put themselves in situations where they could potentially expose others," Gerberding explained. "In this case, the patient had compelling personal reasons for traveling and made the decision to go ahead and meet those personal responsibilities."
Speaker and Gerberding have issued somewhat differing accounts of what Speaker knew at the time he and his fiancee flew to Greece: The CDC says he was told he had drug-resistant TB and should not travel; he says he was told he was not a contagion risk and thought the decision to travel was up to him.
A federal isolation order was issued, allowing the CDC to put Speaker into quarantine when he was found; that order, the first of its kind since a 1963 order was issued for a person exposed to smallpox, was vacated once he was in isolation in Colorado and state quarantine powers took over.
"It did not become known to CDC until after the patient had left the United States that his bacteria were resistant not only to the first-line drugs [but also] the second-line drugs, which categorizes in the extremely drug-resistant category," Gerberding explained.
"Again, our job here is to balance the need to protect people from exposure to this very, very serious organism with the recognition that, as an individual, the patient needs and wants and should have the very best medical treatment."
Hiller says isolation and quarantine of people with infectious disease has been around throughout history, and has always been a subject of debate. That debate is perhaps greatest in the United States, where any imposition on personal freedom is eyed carefully.
"It puts one of our most cherished values — personal liberty — at odds with an equally cherished value, that of protecting the public welfare," he points out. "What public health tries to do is to prioritize that second value, protecting public welfare. But it's easier to look back and say we have been over-aggressive in protecting the public welfare than to say we erred when we could have prevented an unnecessary public risk."
TB case may be first of many
The precautions taken in the case of Andrew Speaker — federal and state intervention to contain a potential contagion threat — may be something the public becomes more familiar with in coming years, Hiller says.
"I think as far as where we're going, public attention has been focused far more on this in recent years due to the SARS epidemic and threats of bioterrorism," he points out. "Efforts are under way to broaden a more common, standardized approach to these questions, and to develop and promote some standardized legislation."
Public education, he says, "should be the primary conversation."
"It is critical for the public at large to be aware of the importance of prevention as well as the necessary steps to prevent spread of infection to the greatest degree possible," he adds.
Quarantine is a strong, blunt approach to protecting public health, Hiller points out. Because it can affect large numbers of people in a very disruptive way, educating the public on the need for adherence when quarantine restrictions are in place, and putting protections in place that will prevent those who are subject to the restrictions of a quarantine from being penalized, either by discrimination or loss of employment and other rights.
"It is absolutely important to promote transparency, for public health officials to bear the responsibility of communicating a justification for their actions when quarantine action is taken," Hiller concludes. "The public deserves to know why a quarantine might be necessary and why certain individuals may be required to sacrifice some of their liberties.
Gerberding says the CDC learned much in this regard from the Speaker case.
"We acknowledge, certainly, that CDC and many others have learned a lot in this process," she said. "We've already conducted one after-action analysis [in early June] to go through what happened as of the end of last week, and we will be continuing to go through this kind of analysis to … learn from this so that, if we are ever in this situation again in the future, it will be easier for everyone involved."
Gerberding says some legal questions arose, particularly around use of the federal quarantine action, since the CDC was dealing with a U.S. citizen who wanted to leave the country, rather than someone wanting to enter the United States or move around within the country. And international regulations (agreed on by the CDC, World Health Organization, and others) "are wonderful statements of principle, [but] the operational details of things like who should pay to move a patient, or who should care for a patient in isolation or quarantine, are not spelled out in those regulations."
Editor's note: Speaker's latest diagnosis, MDR-TB, vastly improves his prognosis as well as the outlook for anyone who might have been exposed during his flights in Europe and to the United States, doctors at National Jewish say; however, the CDC says the amended diagnosis does not mean the CDC and federal authorities reacted inappropriately in searching for and detaining Speaker, and warning his fellow travelers.
Hiller concurs, pointing out that the goal of quarantine is often to isolate people who appear healthy, to determine if they are carrying a contagion. A definitive diagnosis is not part of the criteria for ordering quarantine, he says.
Mitchell Cohen, MD, director of the CDC's Coordinating Center for Infectious Diseases, says that's the case in this particular patient.
"[R]egardless of the revisions of the patient's drug susceptibility at this time, the public health actions that CDC took in this case, and are continuing to take, are sound and appropriate," Cohen says. "After all, the public health response to drug-resistant TB infections, either MDR-TB or XDR-TB, is the same under the World Health Organization's TB and airline travel guidelines that were published in 2005.
"Without question, people with these infections should not be flying on commercial airlines and if they do, an effort should be made to notify and evaluate passengers who are seated near them."
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