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Update on CDC Investigation Into People Potentially Exposed to Patient With Extensively Drug-Resistant TB

Wednesday, May 30, 2007, 2:00 p.m.

DR. MARTIN CETRON, DIRECTOR OF GLOBAL MIGRATION AND QUARANTINE, CENTERS FOR DISEASE CONTROL AND PREVENTION: Good afternoon. I′d like to thank you and welcome you to this update on the XDR TB situation. My name is Dr. Martin Cetron. I′m the Director of Global Migration and Quarantine for the Centers for Disease Control and Prevention, and with me today for the briefing is Admiral Ken Castro, the Director of the Division of Tuberculosis Elimination.

We don′t have a lot of new information for you today, but we understand there′s a lot of interest and a lot of questions that you may have, and this is the reason we scheduled this media briefing.

I′d like to give you a short update on some of the information we have, and I′ll turn over some of the TB specific questions to Dr. Castro after that, and then we′ll open it for questions and answers.

The good news is about the patient. The patient continues to feel well and be asymptomatic. He is currently still in isolation at an Atlanta hospital, and he′s under the care of infectious disease specialists at this hospital.

The medical news that we have evolving also continues to be reassuring as Dr. Gerberding indicated yesterday. We believe that his degree of infectiousness is quite low, and as she indicated yesterday, is - even continues to be smear negative, that is, we don′t see the visible evidence of the tuberculosis bacteria on the stain, and we are still awaiting culture results from that, which takes several weeks.

We cannot and won′t talk further about this individual patient or the specifics of his medical care out of respect for his privacy, and that is a matter being handled between his health care providers and the patient.

We also know there′s been a lot of questions about the quarantine and isolation process about the orders, and I′d like to first take a step back to inform folks about the difference between isolation and quarantine.

Isolation as a public health tool is used when we ask for the restricted movement of an individual who′s already sick with a communicable disease, and in this case, XDR tuberculosis, who already has evidence of disease, and as Dr. Gerberding indicated yesterday, this patient has clinical evidence of pulmonary tuberculosis with extremely drug resistant strain.

Quarantine, on the other hand, is when this restriction of movement is applied to an individual who′s been exposed or suspected exposed but has not yet developed disease, and so there′s a clear distinction.

As such, this patient is under an isolation order that was issued by the CDC. It is not a court order. It is an administrative order under the authority of CDC and under the Public Health Service Act statute to be able to issue this order to restrict his movement in order to protect the public′s health.

And while as we indicated yesterday the probability of his being highly contagious is smaller, the consequences of spread of this germ are extremely high because of the extreme drug-resistant nature of this organism and the potential threat that this would pose to others who may be infected, especially those whose immune system may be compromised for any reason.

It is very, very rare for us to use federal authority to issue an isolation or quarantine order under the Public Health Service Act statute, and the reason for this is that when these are needed, the vast majority of times the state and local health departments have the authority and their own laws to take care of those situations.

In this instance, the reason for use of a federal isolation order is because of the nature of international travel and potential for interstate spread, and so under the Public Health Service Act statute, the authority exists for the use of federal isolation and quarantine to prevent the importation and interstate spread of communicable infectious diseases, and we don′t take this authority lightly. This authority is used, in this case, as it applies to an individual, although occasionally this authority is used as it may apply to a conveyance for some cargo.

In this case, the individual is under this isolation order in part because of the international arrival and because of the need to transfer him across state lines. We certainly hope that in the very near future that this federal isolation order will be able to be lifted and to resume a more normal approach to the covenant of trust for protecting the public′s health risk in that situation.

This is an ongoing situation and will likely unfold further. I′d like to also inform you about the contract tracing information.

This investigation is just beginning. We′re just initiating this. It is very challenging as you′re well aware. There were multiple flights involved, only two of which that we have been highlighting as ones of concern to us because of the long duration, greater than eight hours in nature, and the confined setting of an aircraft cabin with many people on board, and so our focus has been on these two international flights, but we are piecing together the full itinerary and have a list available to you of all of the flights, including the very-the smaller flights within Europe.

The contract tracing investigation, as Dr. Gerberding indicated yesterday, is not an instantaneous process. We need to reconstruct the airline flights, request the manifest through multiple government sources and multiple airlines internationally, then take that manifest information, identify where the individual sat and from there try to develop and retrieve locating or contact specific information in order to find those individuals. This is a cumbersome and difficult and challenging process. We wish that this were something that could occur much more swiftly, but currently this takes time.

It is for this reason that we′ve also elected to share publicly with you the names of those flights, and we have some information about the specific seats that we can make available in order to have those persons who may self identify to us by calling the CDC info line, 1-800-CDCINFO,(1-800-232-4636) in order to give very specific advice in terms of managing the risk. This contact investigation is a cooperative international effort with multiple countries and partners, and it is proceeding in that vein, and we are still learning more as we speak, but let me give you a little bit of additional information in terms of the numbers of individuals some of the specific flights.

The outbound international Transatlantic flight that occurred on May 12th from Atlanta, arriving May 13th in Paris was an Air France flight number 385, and this was also, we learned, a Delta co-chair 8517. In total there approximately 433 passengers on board with 18 crew. This flight, although routinely scheduled for just over eight hours, we understand had some delays and potentially up to 30-13, excuse me, 13 hours in duration, and thus qualifies under the WHO guidelines.

The persons according to the WHO guidelines who we focus on and follow are the two rows in front, the row of the index case, and two rows behind, so these five rows in total constitute somewhere in the range of 40 to 50 passengers who would be a priority for initiating outreach and contact, and as well as all 18 crew members on that flight.

The other flight, and at this point in time, we know from the patient approximately where he sat, and from our international partners somewhere in the bottom part of the plane, between rows 14 and 57, likely somewhere around row 51, but we don′t have the specific seat number at this time and are working that issue currently.

On the return flight, which was much more recent, our Canadian partners have received the manifest and have much more information. The patient sat in seat 12C. This occurred on May 24th from Prague to Montreal on Czech Air Flight 0104. There were 191 passengers and nine crew on this flight. Approximately 30 persons were in that risk area, two rows in front, two rows behind, who are the highest priority for actively seeking and following up at this point. That flight, too, is reported to have left at greater than eight hours in duration.

The other flights which we can make available to you after this involved the routing from Paris to Athens from Athens to Thira (ph) Island in Greece on Olympic Air from Mykonos to Athens, Athens to Rome, Rome to Prague, and again, the other and the last return on Prague to Montreal, and as you′re aware, the passenger, the patient and his spouse traveled by vehicle over land from Montreal into the United States, and we made contact with him on Friday afternoon between Albany and New York City, and then Dr. Gerberding informed you voluntarily and swiftly the patient was isolated in New York City on Friday through the weekend until we were able to arrange his transfer down here.

I want to emphasize that the focus of the international air contact investigation is really right now on those two Transatlantic flights. We will also provide a schema of those flights, the aircraft types and rows, and anyone who was on those flights who wishes further information for contact and follow-up which would include a baseline skin test and a repeat skin test in eight to 10 weeks can call CDC info, 1-800-CDC INFO. We will also actively be reaching out to those individuals once we have the full manifests and the passenger information.

The latest contact investigation will go in an international framework is the citizens of their respective countries will be contacted by the public health authorities in those countries as we share and distribute, and we′ve been actively having conference calls on a daily basis with international partners in this regard.

I think at this point I′d like to turn the update over to Dr. Castro to give you some update on the TB and the XDR TB status, and then following that we′ll take some questions.

Sure. My name is Martin Cetron, and that′s spelled C-E-T-R-O-N, Director for Global Migration and Quarantine at CDC.

Admiral Castro?

DR. KENNETH CASTRO, DIRECTOR, DIVISION OF TUBERCULOSIS ELIMINATION: Thank you. Good afternoon. Again, I′ll reiterate. I′m Kenneth Castro, C-A-S-T-R-O, Assistant Surgeon General in the public health service and Director of CDC′s Division of Tuberculosis Elimination.

Tuberculosis continues to be one of the most common communicable diseases throughout the world with the World Health Organization reporting approximately 8 million persons per year and accounting for about 1.6 million deaths. The process of extensively drug-resistant tuberculosis was recently defined as recent as 2006 implying that we′re dealing with bacteria that are resistant not only to the most important first line drugs, but you′re also losing some of the most important second line drugs, leaving relatively few choices for appropriate treatment, and the reason for the concern and not wanting anyone infected with these type of strains.

The flights, as you′ve heard, of concern is a flight that′s over eight hours in duration, and we usually rely on established criteria based on previous investigations that have set the scientific basis for these type of policies. Our standard operating procedures are always to identify persons who′ve been exposed, offer an initial evaluation at baseline, repeat the evaluation within about two months to identify anyone who′s been recently infected.

In the case of tuberculosis, there are two stages to tuberculosis. One that we most commonly call latent tuberculosis, so after exposure to air that contains these bacteria, you can become infected. Then following that infection, it may take some time for you to develop the antibodies that would manifest in the - as a positive skin test. That′s why we do the follow-up investigation within about two months, and no more than three, after the exposure has occurred.

It is important to identify that persons who have latent tuberculosis infection pose no threat whatsoever to those around them. They carry a risk of progressing to developing tuberculosis disease if they have debilitating conditions such as a heavy infection, such as cancer, poorly controlled diabetes, and several other conditions, and that′s why we also want to make sure to acknowledge that patients on the flight who may have not been seated in the vicinity that we′re targeting get offered the ability to be tested.

We will then make sure that the appropriate medical evaluations take place and the respective countries of origin and as you heard Dr. Cetron, we are working with the authorities to accomplish that, both in the United States and overseas, and it′s been very rewarding to see the response from all our partners, both in North America as well as in Europe, as an initial response.

Dr. Cetron, let me turn this over to you.

DR. CETRON: I wanted to just also update the other flight numbers for the smaller flight so that people wouldn′t be under the mistaken impression that all of the routing between those, and so let me go through them systematically. We′ll also make them available on the CDC web site after this press conference.

So the flight from Paris to Athens was on May 14th. It was Air France carrier, and the flight number is 1232. On May 16th Athens to Thira Island in Greece was on Olympic Air, flight number 560. On May 21st, Nikonos to Athens on Olympic Air 655. May 21st, Athens to Rome on Olympic Air 239, and May 24, Rome to Prague on Czech Air 0727, and then again May 24, Prague to Montreal on Czech Air 0104, and that was the recent Transatlantic return.

At this point I′d like to open the floor for questions. We′ll start with some questions in the room.

UNIDENTIFIED PARTICIPANT: Can you explain again why you′re concentrating just on those two flights and less so on the other flights?

DR. CETRON: Yes. TB is spread via an airborne route with prolonged and continued exposure, and from some of the evidence that Dr. Castro shared with you yesterday on previous flight investigation, flights shorter than eight hours in duration did not pose a significant risk, and so we′re really concentrating on those prolonged flights with greater than eight hours in duration.

UNIDENTIFIED PARTICIPANT: Is it possible that people on the smaller flights could be infected, or is that just not even plausible?

DR. CETRON: Dr. Castro?

DR. CASTRO: The risk of tuberculosis infection in a short flight is very low. So much so that we haven′t targeted these flights. Of course we acknowledge that people are going to be worried, and that′s why we′re making available opportunity for those who are concerned to seek medical guidance and get tested, so the fact of the matter is I would assume that we′re not going to find any infection but we will certainly make sure that we deal with the concerned citizens who want to be tested.

DR. CETRON: Yes, we appreciate people′s concerns...

UNIDENTIFIED PARTICIPANT: ...eight hours is the cutoff?

DR. CETRON: That′s the cutoff according to CDC and WHO guidelines.

DR. CETRON: We can understand that that′s their perspective and they have shared that perspective with us. We were told other things by those involved. Neither Dr. Castro nor myself were in that conference. CDC was not, you know, engaged in that discussion, but it is our understanding that a family conference was held with Fulton County Health Department and clinicians and the patient and his family, and that they were advised that he had multi drug resistant tuberculosis disease with an indication of pulmonary tuberculosis and advised against travel, and so that′s where you have it. It has been clear that there wasn′t a legal order issued to the patient, although in terms of not traveling, but it′s a different understanding about what took place and what occurred in that conference. I would suggest since-that we weren′t directly involved in that that question be more appropriately directed to the officials of the Fulton County Health Department.

UNIDENTIFIED PARTICIPANT: We understand that this man′s wife is not infected, does not have any symptoms. Do we know about his other friends and family? Have other people been tested, and if so, has anyone been infected?

DR. CETRON: So the investigation of contact tracing goes beyond the air contacts, as you′re alluded to and is quite appropriate, and that is just beginning, and we are understanding that the close contacts on the ground are being reached to now to have that testing, and I′m not aware of the results of that. It would take some time for that to occur, but you′re correct that the wife, on her initial testing, we understand had tested negative.

DR. CETRON: I think we′re greatly reassured by her initial negative test. Of course, as Dr. Castro indicated, there′s a long incubation period, and those are baselines that need to be repeated, and she needs to be followed, and I think that is reassuring. We also don′t know at what point in time that the patient himself was exposed, and that is an ongoing part of the epidemiologic investigation as well, so we′re still working through that. It′s really early, but those are encouraging findings.

UNIDENTIFIED PARTICIPANT: Doctor, you talked about the patient′s-or the passengers who may have been sitting next to this patient. Can you talk about people who may have been in the terminal, who may have been sitting next to him for long periods of time, hour, hour and a half before they boarded the plane. Are they in any danger?

DR. CETRON: You know, by and large, as Dr. Castro indicated, tuberculosis is spread through prolonged contact, and the kinds of casual contact that you may see in a line or even passing in the street or in the airport outside of it is not the kind of contact that transmits tuberculosis, so those people should be reassured. This is not the kind of pathogen that is transmitted by short casual contact, and that′s why we focus on these long-haul confined spaces with contained air circulation.

UNIDENTIFIED PARTICIPANT: You mentioned that it looks like you′re looking at about 50 or 80 passengers total between the two flights that you′re concerned about, 30 in one and 40 to 50 in the other. How many of those have you been able to reach, and also, you mentioned that long periods of time is when you have to spend with somebody where you could possibly be infected.

What about people who work with him, spend eight hours or more in a confined space with him. How are you checking on those people because you don′t know how long he′s been exposed, and finally, you′re not revealing his name for privacy reasons. Is that a legal or is that a medical decision, and at what point does the public have the right to know, for instance, co-workers, et cetera, versus the personal privacy rights?

DR. CETRON: I′m going to defer to Dr. Castro for the contact tracing characteristics. Dr. Castro′s has been doing this for years and years for tuberculosis. Focusing on those 80 or so, this is the priority for given the risks as the science we have it currently today. We are reaching out more broadly and we′re working through you to have those people who were on those two long-haul flights to contact us if we aren′t able to reach them through that specific contact information.

We are still trying to get not just the manifest and the name and the country of citizenry but actual locating information for those individuals. This takes time, longer than we like and longer than is necessary in an era where we have to track emerging pathogens across air flights, and we hope that system will be fixed and streamlined and improved in the future, but that takes time, which is why we′re hoping that you will help us bring these folks forward so they could be evaluated. It is important to note that there is a long incubation time and that people won′t develop pulmonary tuberculosis after exposure in an overnight fashion. This is a process that goes weeks to months, and so there is time. Now there is an urgency in getting a baseline skin test so that that can be compared and we can identify a recent conversion.

With regard to the contract tracing of his work contacts and so on, I′ll defer to Dr. Castro.

DR. CASTRO: Than you. I alluded to our standard operating procedures for any time anyone with tuberculosis is found, and what we normally do is we have a gradient of investigations that start with the closest contact and keep moving out as you identify persons with infections. If you test the close contacts as was alluded in one of the questions, find no evidence of infection, you′re not very justified to keep testing many other persons.

On the other hand, if you start finding infection, then you start testing people who are, you know, more casual contact, so you start with the family, workplace, leisure, and you cover all these areas. The local health department is addressing that and that investigation is taking place.

I′d also like to go back to a question that was asked about the potential risk of infection. There are several factors that contribute to the risk of infection. One is the extent of pulmonary disease. Second, the symptoms available, and third, whether the smear, the respiratory secretions, present the bacteria as seen under the microscope. We have reassuring evidence from the relative paucity of symptoms, the fact that the smear has been negative by microscopy, positive by culture, that this would be less infectious than the usual person.

However, it′s also important to acknowledge that as Dr. Gerberding acknowledged yesterday, in places like San Francisco and Vancouver, they have demonstrated that about 17 percent of their TB cases seem to be accounted for by people who are smear negative but culture positive, so clearly the concern is there. We can offer a certain level of reassurance, but the reassurance will really come with the investigation and the actual facts that unveil during the investigation.

DR. CETRON: I′d like to take some calls from the phone. The first caller, please.

OPERATOR: Thank you, doctor. Our first question comes from Robert Bazell of NBC News. Your line is open.

ROBERT BAZELL, NBC NEWS: Hello. Thank you for taking the call. I have a question about airplanes. Did the CDC offer to fly this man home from Europe when they made contact with him in Europe? He has told me that he did, but that there was no such offer. Tom Skinner was quoted as saying there was. Could you clear that up?

The second thing is, why did you fly him to Atlanta when there are reports that he′s ultimately getting his treatment in Denver?

DR. CETRON: Those are great questions. Thank you. When we reached him, finally caught up with this individual in Rome, one of my quarantine officers spoke to him to share the information about the progressive culture results, and to make clear under no uncertain terms should he use commercial aircraft. We also indicated that we were looking at a working option to safely arrange his transport back to the United States.

That would require some time. We indicated a couple of places where he could reach out and get some assistance, including the American Embassy. We also identified a former CDC colleague that worked for Dr. Castro in the TB division, a U.S. physician who was working with the Ministry of Health in Italy, that could help identify possible places to be evaluated in Rome, and that we needed to get back to them.

At the time, we were having high level discussions at CDC, including these of CDC assets to fly to Rome and retrieve this person, and having the discussions. As people know, that is not a snap of the finger kind of thing to do, having those discussions. They were underway at the time, and plans were being made for that as one of the options, along with other systems and including other forms of air ambulance etcetera.

Unfortunately we were told by our colleague that when she went to the hotel to find the individual in order to convey more of this information that things were ongoing that he was no longer there, so those options were constrained by the fact that we no longer knew where the individual was for a fair period of time.

Did I answer both of those questions?

OK. Maybe one more question from the phone, Lauren Neergaard, AP.

OPERATOR: Thank you. Lauren Neergaard, your line is open from the Associated Press.

LAUREN NEERGAARD, ASSOCIATED PRESS: Hi. Thank you. If you could tell us a little bit more about the points where he alluded you and how you might improve that in future cases, especially with diseases that would spread through more casual contact. Did you actually consider asking Italy to quarantine him locally? And can you talk us through how the no-fly list, the steps of that went in place and where perhaps the airlines didn′t catch him? And then you also alluded to the difficulty in contact tracing through airlines. I know you had been working to create an electronic database with the airlines. Where does that stand?

DR. CETRON: That′s a great set of questions, Lauren. We were exploring all sorts of options to remove the public health concern that he represented, not just to the U.S. citizens but others around, and as I indicated, one of our former CDC colleagues worked with the Ministry of Health, and we were looking at options for, you know, the temporary isolation and assessment phase in Rome as well as other potential options that are underway.

We reached out on Thursday afternoon to federal partners to see what options there were to get help in identifying where the individual may be and what we could do to alert potentially folks at international airports so they would let us know if they had found him.

Unfortunately, at the time those discussions were ongoing, we had subsequently learned that the patient around that same time was already landing in Montreal via Prague on that flight, so while we reached out to our federal partners and colleagues to use these tools, it was really sort of too late at that point in time.

You′re right about the manifest problem. We′ve had this for years. Those of you who followed some of the issues we′ve been developing are aware that we have the new proposed quarantine rule which would include the ability to request and access electronic manifest records within 24 hours that require some database adjustments. That rule has gone through public comment. We′re compiling those comments and hope to move forward to a final rule on electronic manifest information with the fields that we need in public health to find people, the locating information is different, and being able to build that into a system. So that, we hope to be able to expedite and bring to closure very quickly.

I think what the question from NBC about why he had to go to New York and why he was transported to Atlanta, that was the first time we connected with this individual, and New York City was the nearest point which we could isolate him and evaluate his condition and confirm that the previous lab results which were now quite old that he was still, you know negative. We needed that period of time so he was issued a temporary federal isolation order in New York City in order to accomplish that evaluation where he spent the weekend.

The patient was offered by me a number of different options in terms of where to from there. One option included staying in New York City if he wished to begin and initiate treatment. Another option was to come home to Atlanta on the CDC aircraft escorted in a safe way, and a third option was potentially to move to National Jewish.

That option required additional logistics which couldn′t be accomplished at that time, and the patient opted for a decision-he called back to us and said, "I′d like to come to Atlanta," so that′s why he was transported in that fashion.

UNIDENTIFIED PARTICIPANT: Can those logistics be accomplished now?

DR. CETRON: We′re working right now on a plan to ensure that the patient can safely move across interstate lines and get the care that he wishes and he′s at National Jewish Hospital, you know, in Denver, but that will take-again, that-we′re working on those plans.

UNIDENTIFIED PARTICIPANT: Doctor, you said a second ago in response to Lauren′s question that you were having discussions with other federal officials about the no-fly order. You found out he was already landing in Montreal. How did you find that out?

DR. CETRON: We subsequently interviewed the patient up in New York City by our Epi team and he told us the flight that he took from Prague to Montreal and what time that flight touched down. We went back and looked and it was at the same time we were actually initiating the conference call with federal partners.

UNIDENTIFIED PARTICIPANT: You found out later. Also, to clarify, you haven′t actually been in contact-or health officials have not been in contact with anyone yet on those flights, those two ...

DR. CETRON: Through the manifest, we haven′t reached actively to any of those individuals that I′m aware of as of this morning′s international conference call.

Now, really the real answer to that is that this contact investigation is going on in several countries, and, you know, each country is working that issue, so I can′t speak other than from the U.S. perspective. But we have received as of Dr. Gerberding′s call yesterday reports back to us of several individuals on these implicated flights and have been begun providing that information, what they need to them. So people have been reached, but through the manifest system that I described on the active side outward, we have not-for the airline investigation, not reached them yet.

UNIDENTIFIED PARTICIPANT: And how many people on each of those five flights in Europe?

DR. CETRON: Yes. The smaller flights. We′re still reconstructing the number, the seating and the number of passengers on the smaller European flights of-that were of short duration.

UNIDENTIFIED PARTICIPANT: If the patient is going to be going to Denver, is that something that you would actually be carrying out?

DR. CETRON: The patient′s transport to a National Jewish Hospital in Denver, in order for him to get the care he needs, would be under - because it′s an interstate movement and because of his situation, it would occur under a continuation of the CDC isolation order. And we will prepare all of the logistics and arrangements to do that in a safe manner that protects public health. That transport is being worked in conjunction with the patient′s insurance provider. And exactly the specifics of that logistics, I′m not aware of where we are in that. But we will be involved in that transport to make sure that there′s no public health risk.

UNIDENTIFIED PARTICIPANT: And as was brought up earlier, how are you trying to balance the patient′s right to privacy, with the public′s right to protection?

DR. CETRON: I think the way to balance that is for us to basically through interviews with this patient identify the circle, the concentric circles of contact that Dr. Castro indicated to find those people. It′s really, you know, not as large a number of folks. It′s still a challenging number but it′s not thousands and thousands. And it′s a contact investigation that we reach out to those individuals who believe they were exposed.

The passenger - the patient has been fully compliant in giving us the names of these different flights, and helping us to assist in identifying those who may be at risk and that′s how we′re doing that. I don′t think, publicly naming the individual, which we never do, has any advantage in achieving that part of the contact information, since this is not a disease that′s spread by casual interactions with the public.

UNIDENTIFIED PARTICIPANT: Has his condition worsened from before he left for Europe? And is he showing any actual symptoms now?

DR. CETRON: I believe that his condition is stable from what′s been reported to us. And in terms of symptoms he has evidence of pulmonary tuberculosis with this drug resistant organism. But he doesn′t have the over symptoms of active hectic cough or coughing up lots of sputum or coughing up blood, God forbid, we are very grateful that he′s a healthy individual.

And so all of these things contribute to the fact that is infectiousness risk as Dr. Castro indicated to others is on the lower end of the spectrum but certainly not zero. And as I indicated earlier, the context of the pathogen he has is one in which the consequences of spread are quite high. So that′s why we′re taking the actions we have.

UNIDENTIFIED PARTICIPANT: Would you consider this a blatant disregard for the public′s healthy? Or do you really believe that at this point in the investigation, that he didn′t think he was doing anything wrong? And number two, could he face any sort of penalty, any sort of fine, any sort of charges for what he′s done?

DR. CETRON: As Dr. Gerberding indicated yesterday, the patient had, from his own perspective, compelling reasons to travel. And there were no legal orders in place preventing his travel, and no laws were broken. Since we′ve issued our federal isolation order, he′s been fully compliant. And, you know, I believe figuring out that aspect of the past is not nearly as important as taking the perspective and moving forward, aligning his interest and needs for care and treatment to get well and the public health interest and needs in the same place, right now is where our focus is.

UNIDENTIFIED PARTICIPANT: What can you tell us about what this gentleman does for a living, where he works, even in what county he works, and what words of advice would you give to the other passengers on those long flights, who may not have sat within two rows forward or back of him, but who are probably a little worried about right now?

DR. CETRON: Right. And as Dr. Castro indicated, I′ll let him to speak to that. We are reaching to all of the passengers, that goes beyond the WHO guidelines in providing information, some basically reassurance, and some, the fact that they have the opportunity to get baseline skin testing, and then repeat skin testing in two months. And we will continue to engage in consulting with their providers, and health departments and how to manage it. We all hope that there will be no secondary transmission or cases related to this, and we′ll all be greatly reassured.

Regarding his employment and place of employment and all of those things, I don′t have that information. And I′m not - we′ll be actively finding those contacts.

DR. CASTRO: I can reassure you that without having to disclose personally identifying information, the health department has that information and is reaching out to those individuals who need to be tested.

DR. CETRON: I′m going to take a call from the phone, please. Richard Knox, NPR.

RICHARD KNOX, NPR: Thank you very much. I′m still not clear, why the ball was dropped in several time and places here in this narrative. For instance, in letting him travel in an era of XDR TB when any XDR TB could be potentially deadly.

DR. CETRON: I′m going to repeat what I thought I heard. Did CDC of public health let him travel with XDR TB?

RICHARD KNOX: I′m sorry. I had a problem with my headset. It′s not clear why the ball was dropped by anybody or who it was dropped by at several points. First of all, when he had MDR TB, in an era of XDR TB, is it a good idea for anybody to travel and what could have been done to prevent it from happening in the first place?

And secondly, the no fly order that was issued, do we have any information as to why Czech Airlines didn′t know about that?

DR. CETRON: OK. Richard, I think, you know, there′s a difference of opinion about whether anybody condoned his travel, I think it′s very clear from the conversations we′ve had with the health department, that they clearly told him not to travel. And they were aware, and he was aware that he had MDR TB, at least on the 10 of May, before he traveled on the 12. And he was clearly instructed not to. My understanding is that a written affirmation of that was being prepared to hand to him and arrived after he had all ready departed. And so that′s where that gap occurred.

And as Dr. Gerberding indicated yesterday, in many ways we balance individual freedoms and public good. And we depend on a covenant of trust, and not every one of these situations, in fact the vast, vast minority of situations of infectious tuberculosis drug resistant or otherwise, require legal restraining orders in order to keep people from moving, in order to encourage them to do the right thing. The preferred approach is to work with that covenant. And as she indicated in this case, the individual had a compelling interest from his own perspective to initiate that travel out of the country.

I think you were then referring to the ball drop on the return site from Rome. And as I indicated to you, by the time we knew he was missing from Rome to initiate all of those other aspects, the opportunity to intervene through these partner means through notifying airlines and so on was past, because he was all ready landed or about to be landing in Montreal.

So yes, if we had found that out earlier. But again, there were clear, several communications between my staff, and the individual in Rome begging and asking him to stay put, and not travel while we worked on some options.

DR. CASTRO: I′d like to add a reminder that there′s a six hour difference in time zone, so that they are six hours ahead in Europe, so that by the time we were waking up a half day has passed at the other end of the world.

DR. CETRON: I′m going to go with the phone again, and L.A. Times please.

STARE SONG (ph), L.A. TIMES: Hi, yes, it′s Stare Song. I was wondering if you could straighten out the timeline for me a little better. Like when did the CDC know that you had the extensively drug resistant kind of tuberculosis. And then, you know, how exactly was he contacted? And then, then when he dropped out, how did you get back in contact with him again, in the U.S.?

DR. CETRON: Yes, my way of contacting him in New York was via his cell phone number, which was provided to us by trying to reach out to family and figure out how to get a hold of him, and how to find him. We had asked family how to find him and that′s the way we contacted him in Rome, as well.

So my understanding of the timeline and we′re still verifying a lot of these dates, is that the meeting with the patient and his family and the health department occurred on the 10 of May, at which time his MDR TB was documented by laboratory results. And that we - in our program at CDC in headquarters learned about his multi drug resistant TB. That he had all ready traveled to Europe occurred on the 18, and of course, as you′re aware he departed on the 12.

We reached him - the XDR results came on or around the 22 of May so this was an evolving situation. And one of my staff, Dr. Kim of the Atlanta quarantine station had been engaged in this, reached him on his cell phone on the 23 after multiple attempts. I think that′s when he finally got through.

So that′s the sequence of events as we′ve been able to reconstruct it. It′s very unfortunate that this whole situation wasn′t prevented on the front end. Like I said, there are different perspectives on who said what to who when. I think that′s not the focus of what we need to be concentrating on right now. It′s about getting this patient, cared for, and treated and well. And it′s about doing that in a way that protects the public health, and that′s where our focus is.

I′ll take one more - a couple of more calls from the phone. Bloomberg.

JOHN LAUERMAN, BLOOMBERG NEWS: Hi, it′s John Lauerman from Bloomberg. If you told him not to take this flight under any circumstances from Rome, I don′t understand why there′s no legal recourse or why he hasn′t - could you not have ordered him into isolation at that point?

DR. CETRON: We were in conversations with the Ministry of Health in Rome to exactly see what those options are. Remember, this is an American citizen in another country and U.S. jurisdiction is not at play here. We were working. Those are complex international and inter jurisdictional issues that need to be worked with. And we′re working those as quickly as we could. Unfortunately, they weren′t fast enough to alter what his prior plans where. You know, his prior plans to return were much later in June, and that′s what his stated intent to return was to us.

So we were trying to work that situation as quickly as we could recognizing it′s across multiple time zones, in an international diplomatic way. And it′s regretful that we weren′t able to stop that. And we certainly will be learning lessons there and looking to improve on those systems, but I think it′s also quite understandable. And as I said right now, the focus is really what we need to be doing from here forward.

I′ll take another call from the phone, Lisa Stark with ABC.

LISA STOCK, ABC: Hi, thank you so much. To follow-up on what you′ve been saying, so you were in touch with him on the 23rd in Rome. He got on a flight, I believe the next day to come back and you - and just to clarify, you′re saying in that timeframe you don′t feel there was anything you could have done to make sure that he, you know, after he had already obviously in a sense disobeyed one order not to travel, there was nothing you could have done at that point to insure he didn′t get on another flight? And, as a follow-up, what holes if any in the system does this point out to you?

DR. CETRON: We did everything that we could by reaching out to the various systems and tools that we had. The - but, you know, and we reached out immediately upon our awareness of that.

Again, their time is had and by the time we learned that he was gone and we′re reaching out to that because that was not an expressed intent of anything that occurred in the conversations between the patient and our quarantine officer. He had already moved on, we had somebody from a former CDC staff going out to his hotel to try to ensure, you know, this situation and control it the best we could.

What it points out is that, you know, this is - this is a cooperation of public good, public trust, this covenant of trust and we need to rely on people to do the right thing and we don′t move quickly to compulsory orders for our isolation or quarantine for that matter and we take the use of those quite seriously as well as using all available tools.

Can we - can we improve on our systems? Absolutely. There will be many lessons learned from this, but at this point forward, you know, we′ve got to work to resolve this current situation and then really deal with how to get this guy treated at this point. We′re going to not have time for too many more questions, I′m going to ask Larry Altman from New York Times.

LARRY ALTMAN, NEW YORK TIMES: Yes, what isn′t clear at all is what his initial symptoms were when he went for treatment, how he was first diagnosed, what the interval was. I′ve heard that it was back in January, we′re talking about May here. There seems to be a huge gap there in terms of why he had a chest film, how the diagnosis was made, he was - it was done for other reasons, we′re told in order to understand this, can you go right back to when the initial attempt to diagnose the pulmonary tuberculosis was made?

DR. CETRON: Well, what we understand is that the diagnosis was incidental. And again, we′re valid - verifying all these facts. I′m going to ask Dr. Castro to speak to the timeline in terms of the laboratory results. But, he had an incidental chest x-ray either for orfall or for some unrelated reason and the lesion in the right upper lobe was determined on that incidental chest x-ray. He had no risk factors or reasons to believe that that was tuberculosis and underwent a procedure to diagnose that it was that procedure which identified the fact that the findings ultimately grew out MTB.

Now, culturing microbacterium tuberculosis, especially when the organism load is small can take many weeks. But, I′ll defer to Dr. Castro to explain that so that time between the procedure to evaluate this right upper lobe lesion and the actual culture result of tuberculosis took some time, and then the drug susceptibility testing of that tuberculosis took some time. In the interval between the diagnosis and the culture result and the susceptibility results he was placed on treatment which ultimately was not effective treatment. So, that initial treatment was stopped.

DR. CASTRO: Larry, thank you for the question, this is Ken Castro. As you know, tuberculosis is a very slow growing organism and that adds to the - a layer complexity. It takes usually between 18 to 21 days for a culture to become positive under the best of circumstances. Then, if positive you add another couple weeks for drug resistance testing.

So you can see already a month interval easily going by before you have any results where you can hang your hat on. In a person with a load of baceli or bacteria that is not high, it′ll take even longer. So that′s what we′re up against. And this point to an underlying weakness of the tools we have and the reason why for a long time many of us have been clamoring for the research and development to develop - to have new tools that are rapid and accurate and reliable for the diagnosis of tuberculosis, and similarly for the drugs that are going to be needed.

Here you have a situation where there′s a person who′s running out of treatment options and where we need to have additional drugs to offer these types of individuals. So that calls for the investment in research and development in tuberculosis for both new tools as well as to enhance our capacity to do well by these individuals.

DR. CETRON: I think a couple more questions from the room and then we′re going to need to wrap up shortly. So somebody didn′t ask a question so far? There′s - there′s one in the back. Go ahead.

UNIDENTIFIED PARTICIPANT: (OFF MIC)

DR. CETRON: It would have helped and our - I′ll repeat the question for those on the phone. The question was, was the patient wearing a mask on the flight back? There′s some uncertainty about that. And, we do know that they had a supply of masks with them. We′re getting two different answers to that - to that question. But yes, it would have helped some. But again it wouldn′t have - it wouldn′t have removed the risk necessarily entirely. Right up here in the front.

UNIDENTIFIED PARTICIPANT: It seems that you′ve already indicated that lessons will be learned from this. Dr. Gerbeding mentioned that too. It′s kind of an indication for what happens with a rapid spread globally. It seemed like there was a lot of luck involved, luck that the patient himself wasn′t there to get the legal document.

And so, therefore it - maybe that′s why there is no legal ramifications, he never actually got the official letter. And, lucky for the rest of us that he wasn′t - he isn′t sicker, fortunately for him especially because this would be a much bigger crisis if he would have been.

At what point do you take that extra step, especially given how slow communication is to the airlines to get the manifest to reach these people who were in close contact? When do you cross that level to say OK, it′s better to let people know who this person is so they know immediately that they were in contact with them, publicly releasing his name, public health issue versus maintaining his privacy?

DR. CETRON: The individuals who had close enough and prolonged enough contact to a tuberculosis case are known to the individual as well as the others. And so, we think it can be done that way. And, you know, we have to be very clear here about not applying too much stigma. This is an individual who is unfortunately infected with an extremely drug resistant strain of TB. And the individual does not need to be stigmatized or victimized on that. And I don′t really - and that′s right in a respect that we have to be very careful to - I don′t - I think we can achieve the public health objectives without disclosing this individual′s name and invading his privacy. And that′s an important principle for us to uphold.

DR. CASTRO: What - let me just add that the guidelines are (INAUDIBLE) basically call - first of all let′s use common sense, anyone who′s sick should not be getting on an aircraft. We heard this from Dr. Gerberding yesterday. And that′s a basic principle for any contagious disease. So that we start with that.

And then the realities of how well can you accomplish this? How many of you have been at airports recently and what it - what are the logistics of getting some of these things done on a real time basis are issues that we′re grappling with.

But, we need to start by having public education and make sure that those of us who are sick with respiratory diseases refrain from travel. That is the baseline of the first recommendation for preventing tuberculosis transmission during airline travel. And then there′s a sequence of other recommendations based on the criteria once you find someone did indeed unfortunately travel with tuberculosis.

UNIDENTIFIED PARTICIPANT: How many - how many people have you contacted that - in the people that you need to contact? And what is your goal in terms of finally getting in touch with the circle that you talked about?

DR. CETRON: The inner circle that we discussed, including individuals, close family contacts and immediate, work contacts, plus this group of two rows in front the row behind, our goal is to reach every one of those individuals if possible.

UNIDENTIFIED PARTICIPANT: By when?

DR. CETRON: As soon as possible. And, we can only do that as soon as the systems will allow.

UNIDENTIFIED PARTICIPANT: How many have you actually contacted?

DR. CETRON: In different settings they vary. His family has been aware, I′m not sure what the status is of the workplace contact investigation. Some of the close plane contacts have had communication with CDC and the outreach on the other side. Like I said, CDC is not doing this in isolation, each country is contacting its own citizens. And so, we convene everyday to get an update on the status of this international contact investigation.

UNIDENTIFIED PARTICIPANT: And, the whole number together...

DR. CETRON: It′s in the range - it′s in that range, yes it′s in that range. It′s - now that′s not everybody on all the planes who we will ultimately hope to reach and to communicate with as we said, but that inner sphere.

We′ve been going on for longer than an hour, I′d like to thank you all for coming. I hope this was useful. We will be committed to providing you additional updates as needed. Thanks very much.

END

####

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