An Atlanta-area man --- infected with a rare, potentially deadly type of tuberculosis --- is under federal quarantine at Grady Memorial Hospital with an armed sheriff's deputy outside his door following his odyssey on international flights, including some to smuggle himself back into the country.
The globe-trotting tale of the man, his fiancee, their wedding and honeymoon abroad --- and conflicting recollections of what he was told about his disease and whether he could travel --- culminated Tuesday with the Centers for Disease Control and Prevention issuing an international health alert.
The CDC is working with airlines to contact passengers who took two transatlantic flights --- a May 12 Air France flight from Atlanta to Paris and a May 24 Czech Air flight from Prague to Montreal --- to alert them that they may have been exposed to extensively drug-resistant tuberculosis.
The disease, also known as XDR TB, is difficult to treat and can cause severe illness and death. Only 49 cases of it have been identified in the United States between 1993 and 2006, according to the CDC.
"I didn't want to put anybody at risk," the Fulton County man, who declined to be identified because of the stigma attached to his diagnosis, said in a telephone interview with The Atlanta Journal-Constitution. "We just wanted to come home and get treatment."
Since January the man, who said he has no symptoms and feels healthy, has met regularly for treatment with Fulton County health officials. He said they and CDC knew he had drug-resistant TB before he left the United States but did not prohibit him from leaving when he told them about his upcoming wedding in Greece.
He questioned why nobody told him to cancel his wedding before he left Atlanta --- and why the CDC waited until he was on his honeymoon in Rome to order him into isolation.
"I'm a very well-educated, successful, intelligent person," he said. "This is insane to me that I have an armed guard outside my door when I've cooperated with everything other than the whole solitary confinement in Italy thing."
At a news conference Tuesday, CDC Director Julie Gerberding announced that the agency had taken the rare action of issuing a federal public health isolation order against the man, which allows the CDC to hold people against their will to protect the public. Gerberding believes the isolation order was last used in 1963 in a case involving a potential smallpox exposure.
"Normally when someone has tuberculosis, we influence them through a covenant of trust," Gerberding said. While saying tests show the man is at extremely low risk of transmitting the disease, Gerberding said the agency is urging passengers who sat in nearby seats and rows during the two long trans-Atlantic flights receive TB tests as a precaution, and that others who traveled aboard the flights be offered the opportunity to be tested if they have concerns.
CDC officials did not release any details about where the man sat on the flights or how many people may have been exposed. They said they would be working with the airlines to contact passengers directly. For now, they said, they're focusing on the trans-Atlantic flights because --- while the risk is very low --- it's where people would have had the most extended period of exposure to him.
"We're balancing both the needs to protect individual freedoms and the responsibility to protect the public," Gerberding said.
"We also want to reassure people who weren't on these flights that the risk of exposure in random air flight is extremely low," she said.
CDC officials note that air travel carries a relatively low risk of infection with TB of any kind.
Because of antibiotics and other measures, the overall TB rate in the United States has been falling for years. Last year, it hit an all-time low of 13,767 cases, or about 4.6 cases per 100,000 Americans. Tuberculosis kills nearly 2 million people each year worldwide.
"What is unusual about this circumstance is that this patient's tuberculosis organism is extremely resistant to the TB drugs that we would normally use to treat infection," Gerberding said.
Gerberding and CDC officials gave few details about what prompted the issuance of a federal isolation order, other than saying the "covenent of trust" had been breached. "In this case the patient had a compelling personal reason for traveling," she said, noting that the man broke no laws in his travels.
The man at the center of the international health incident said his TB ordeal began in January. Because he has felt healthy, the disease was detected by accident, during a chest X-ray for something else. It uncovered a small mass in one lobe of his lung. A sputum test came back negative for TB, but a more sensitive culture test confirmed the diagnosis.
"So they started putting me on the standard four-drug treatment," he said. And they tested his fiancee and other close contacts for the disease: None of them had it.
But it turned out his TB was resistant to the first-line drugs --- and the second-line drugs. So county officials stopped treatment. The man said he and his private doctor --- with the agreement of government health officials --- made plans for him to undergo cutting-edge treatment with specialists at National Jewish Medical and Research Center in Denver after his honeymoon.
The treatment will involve surgical removal of the mass coupled with drugs to kill the infections. The man said he's been told the course of treatment could take 18 months --- and that the only place that can do it is the Denver hospital.
"The county health department knew I was going over to have a honeymoon. We had a meeting before I left," the man said. He acknowledges that the health department told him they "preferred" that he not to travel. But reluctant to cancel his long-planned wedding, the man said he asked what does "prefer" mean? Does it mean I can't, the man asked.
But even when health officials were quizzed, the TB patient said they never told him he couldn't travel. He told officials he'd be going ahead with his wedding and noted that they didn't tell him to take any precautions, even around close family and friends.
"We headed off to Greece thinking everything's fine," he said. He said he contacted the AJC to make sure his side of the story was heard.
Dr. Steven Katkowsky, director of public health and wellness for Fulton County, said it's his understanding that the man was "advised not to travel."
"I didn't hear that conversation," Katkowsky said, "certainly the recommendation would be that if you have an active infection with tuberculosis, you ought not to be getting on a commercial airliner."
Katkowsky said after that conversation, the department attempted to hand-deliver a medical directive, dated May 11, to the man telling him not to travel, but his home address was vacant and he was not at his place of business.
Katkowsky and CDC officials say they only knew that the man's TB was resistant to many drugs before he left, but that the tests showing he had the most serious form of TB --- XDR TB --- only came back after he was in Europe. The test results came back on May 21, Fulton County officials said.
The man says he and his bride were in Rome on their honeymoon when they got a message to call the CDC. The CDC official said that they needed to cancel their trip and return home and that the CDC would call the next day with travel information.
The patient says he and his wife cancelled plans to move on to Florence the next day as they awaited the CDC's instructions.
The next day, instead of giving the couple travel arrangements, the man said a CDC staff member told him he'd need to turn himself into Italian health authorities the next morning and agree to go into isolation and treatment in that country for an indefinite period of time.
"I thought to myself: 'You're nuts.' I wasn't going to do that. They told me I had been put on the no-fly list and my passport was flagged," the man said.
The man said the CDC told him he could not fly aboard a commercial airliner with his disease. "We asked about the CDC jet and they said no, there wasn't funding in the budget to use the jet," he said.
Dr. Martin Cetron, director of the CDC's division of global migration and quarantine, did not respond to repeated requests for an interview. Cetron told the Associated Press: "He was told in no uncertain terms not to take a flight back."
CDC spokesman Tom Skinner said the agency was considering sending the CDC's jet to Italy to retrieve the man --- when he disappeared and didn't meet Italian health authorities.
"We're sitting in a hotel room in Italy and we're looking at each other and we're on our honeymoon and the authorities are coming in hours," the man recalled. They made the decision to run.
To evade the no-fly list, which they assumed only involved jets bound for the United States, the man and wife flew into Canada and drove a car into the U.S. At every check of their passports, he said they feared being caught, but weren't.
He said he called the CDC when he was back in the U.S. and agreed to the agency's request to drive first to a TB isolation hospital in New York City for some tests. That's where federal officials served him with the federal isolation order, he said. The agency ultimately flew him Monday on the CDC jet to Atlanta.
The patient is now in an isolation ward at Grady Memorial Hospital, said spokeswoman Denise Simpson.
The man said he wants people to understand he sneaked back into the United States because he feared for his life. An unsuccessful treatment in Italy would have doomed him, he said, because he said they lacked the expertise.
CDC officials are investigating how the man became infected with XDR TB. He said the agency thinks he may have gotten it while he was traveling in Asia doing fundraising work for hospitals.
To reach reporter Alison Young, call 404-526-7372.
Staff write Kevin Duffy contributed to this article.
What is extensively drug-resistant TB?
Extensively drug-resistant tuberculosis (XDR TB) is a relatively rare type of multidrug-resistant tuberculosis (MDR TB). It is resistant to almost all drugs used to treat TB. In the United States, 49 cases of XDR TB have been reported between 1993 and 2006.
How is XDR TB spread?
TB germs are put into the air when a person with TB disease of the lungs or throat coughs, sneezes, speaks or sings. These germs can float in the air for several hours, depending on the environment. People who breathe in the air containing these TB germs can become infected.
Why is XDR TB so serious?
Because XDR TB is resistant to the most powerful first-line and second-line drugs, patients are left with treatment options that are much less effective and often have worse treatment outcomes. XDR TB is of special concern for people with HIV infection or other conditions that can weaken the immune system.
Can XDR TB be treated and cured?
Yes, in some cases. Several countries with good TB control programs have shown that a cure is possible for up to 30 percent of affected people. But successful treatment depends on the extent of the drug resistance, the severity of the disease and whether the patient's immune system is compromised.
Sources: Centers for Disease Control and Prevention and the World Health Organization
MORE ON XDR TB
What are the symptoms?
The general symptoms of TB disease include feelings of sickness or weakness, weight loss, fever and night sweats. The symptoms of TB disease of the lungs may also include coughing, chest pain and coughing up blood.
Is it safe to travel where cases of XDR TB have been reported?
Although cases are occurring globally, they are still rare. HIV-infected travelers are at greatest risk if they come in contact with an infected person. Air travel itself carries a relatively low risk of infection with TB of any kind.
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