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To the Editor: The Commentary by Dr Markel and colleagues¹ regarding the recent case of extensively drug-resistant tuberculosis (XDR-TB) in Andrew Speaker raises important points about the balance between public health and civil liberties. Missing, however, is an understanding of the public health risk engendered by his travels, of whether changing quarantine laws reduces this risk, and of how best to control global XDR-TB.

Mr Speaker reportedly was asymptomatic; his TB was coincidentally identified during evaluation for another problem.² Each year, thousands of individuals posing a similar risk for TB transmission enter the United States with the knowledge of the US Centers for Disease Control and Prevention (CDC).³ Immigrants, refugees, and those seeking asylum in the United States who are 15 years or older undergo mandatory TB screening; those whose chest radiograph findings are consistent with active TB and who are sputum-smear–negative (like Speaker) are classified as B1 (active TB, not infectious). The CDC recommends that individuals classified as B1 receive follow-up and treatment after travel to the United States, not before. This approach seems reasonable, since in the United States entrants classified as B1 rarely cause secondary TB cases.⁴

Because no evidence suggests that Speaker's Mycobacterium tuberculosis is more transmissible than other TB strains, the rationale for prohibiting him from traveling while allowing thousands of others who pose a similar minimal risk of TB transmission to do so must be the identification of XDR. Entrants classified as B1 are not screened for multidrug-resistant TB (MDR-TB) or for XDR-TB, although many come from countries where rates of TB drug resistance are higher than those in the United States.³ Some entrants may have MDR-TB or XDR-TB. Changing quarantine laws without changing screening practices will not address this risk.

XDR-TB is a new name for an old problem—the ability of M tuberculosis to develop resistance to many if not all available drug therapies when not properly used. XDR-TB has existed in the United States since 1993.⁵ Tuberculosis, regardless of its resistance profile, can be contagious. In the absence of effective infection control practices and treatment, it can cause outbreaks with high mortality rates, particularly among persons coinfected with the human immunodeficiency virus. The large-scale MDR-TB outbreak in the United States was contained by improvements in infection control, diagnosis, and treatment, not by quarantine laws.⁶

Financial Disclosures: None reported.

Timothy Brewer, MD, MPH
timothy.brewer{at}mcgill.ca
McGill University Medical School
Montreal, Quebec, Canada

1. Markel H, Gostin LO, Fidler DP. Extensively drug-resistant tuberculosis: an isolation order, public health powers, and a global crisis. JAMA. 2007;298(1):83-86. FREE FULL TEXT 2. Grady D. TB patient says officials are trying to blame him to cover mistakes. New York Times. June 9, 2007. http://www.nytimes.com/2007/06/09/us/09tb.html?ex=1339041600&en=bfc0823548ad1b99&ei=5088&partner=rss. Accessibility verified September 13, 2007.3. Recommendations for prevention and control of tuberculosis among foreign-born persons: report of the Working Group on Tuberculosis Among Foreign-Born Persons, Centers for Disease Control and Prevention. MMWR Recomm Rep. 1998;47(RR-16):1-29. PUBMED 4. DeRiemer K, Chin DP, Schecter GF, Reingold AL. Tuberculosis among immigrants and refugees. Arch Intern Med. 1998;158(7):753-760. FREE FULL TEXT 5. Centers for Disease Control and Prevention. Extensively drug-resistant tuberculosis—United States, 1993-2006. MMWR Morb Mortal Wkly Rep. 2007;56(11):250-253. PUBMED 6. Frieden TR, Fujiwara PI, Washko RM, Hamburg MA. Tuberculosis in New York City—turning the tide. N Engl J Med. 1995;333(4):229-233. FREE FULL TEXT

Letters Section Editor: Robert M. Golub, MD, Senior Editor.

JAMA. 2007;298:1861.

RELATED LETTER

Extensively Drug-Resistant Tuberculosis and Public Health—Reply
Howard Markel, Lawrence O. Gostin, and David P. Fidler
JAMA. 2007;298(16):1861-1862.
EXTRACT | FULL TEXT  

RELATED ARTICLE

Extensively Drug-Resistant Tuberculosis: An Isolation Order, Public Health Powers, and a Global Crisis
Howard Markel, Lawrence O. Gostin, and David P. Fidler
JAMA. 2007;298(1):83-86.
EXTRACT | FULL TEXT