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Extensively Drug-Resistant Tuberculosis and Public Health—Reply
In Reply: We disagree with Dr Brewer regarding his CDC classification of Andrew Speaker. The CDC has recently revised its tuberculosis screening protocols for immigrant visa applicants, emphasizing the importance of TB cultures in addition to acid-fast bacilli (AFB) smear microscopy. The Centers for Disease Control and Prevention's Division of Global Migration and Quarantine (DGMQ) and Division of Tuberculosis Elimination (DTE) have posted new TB technical instructions for overseas panel physicians performing screening examinations for individuals applying for permanent visas.1 These technical instructions have been revised over the past 2 years with the accretion of new scientific evidence documenting TB transmission from smear-negative, culture-positive patients and the continued emergence of drug-resistant TB (MDR and XDR).2-4
The new technical instructions classify an individual with Speaker's signs and symptoms as class A pulmonary TB (active and infectious), not as class B1, as Brewer states. Consequently, if a man presenting like Speaker were an immigrant applicant (a comparison that Brewer posits) rather than a US citizen, he would be determined to have a class A "inadmissible condition." His condition would remain class A until rendered noninfectious via a drug regimen for his M tuberculosis isolate, relying on directly observed therapy. For persons with MDR-TB, "noninfectious" is defined as conversion to culture-negative TB, not simply as sputum-smear–negative by AFB microscopy (Martin S. Cetron, MD [Director, DGMQ], and Kenneth Castro, MD [Director, DTE], written communication, August 9, 2007. Dr Cetron is the federal health officer who implemented the provisional federal isolation order for Speaker to observe airborne infection isolation precautions.) Given the slow-growing nature of M tuberculosis, this may take several weeks to demonstrate.
The CDC's immigrant TB screening algorithm is not dependent strictly on symptoms but includes a mandatory screening chest radiograph and tuberculin skin test for all adult applicants (and children determined to be at risk). Under the updated technical instructions, persons with conditions resembling Speaker's should be identified by abnormal chest radiograph findings and by negative AFB smear but positive M tuberculosis culture results. Drug susceptibility testing would identify the need to administer drugs to cover specific patterns of drug resistance. Such individuals would be required to undergo directly observed therapy before being allowed to emigrate to the United States unless they received a medical waiver for admission.1 Furthermore, World Health Organization guidelines on TB and airline travel explicitly state that persons with MDR-TB must not travel on commercial airlines until determined to be "noninfectious" (culture-negative).5
To control TB, we will need many arrows in our quiver, ranging from the measures Brewer mentions to social distancing approaches including the isolation of those determined to have infectious and active forms of TB. Such measures, unfortunately, must include regulations for those few who refuse to adhere to protocols designed to reduce public health threats.
Financial Disclosures: None reported.
Howard Markel, MD, PhD
howard{at}umich.edu
Center for the History of Medicine
University of Michigan
Ann Arbor
Lawrence O. Gostin, JD
O’Neill Institute for National and Global Health Law
Georgetown University Law Center
Washington, DC
David P. Fidler, JD
Indiana University School of Law
Bloomington
1. US Centers for Disease Control and Prevention. Global migration and quarantine: technical instructions for tuberculosis screening and treatment. http://www.cdc.gov/ncidod/dq/panel.htm. Accessed September 4, 2007.
2. Behr MA, Warren SA, Salamon H, et al. Transmission of Mycobacterium tuberculosis from patients smear-negative for acid-fast bacilli. Lancet. 1999;353(9151):444-449.
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3. Maloney SA, Fielding KL, Laserson KF, et al. Assessing the performance of overseas tuberculosis screening programs: a study among US-bound immigrants in Vietnam. Arch Intern Med. 2006;166(2):234-240.
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4. US Centers for Disease Control and Prevention. Emergence of Mycobacterium tuberculosis with extensive resistance to second-line drugs—worldwide, 2000-2004. MMWR Morb Mortal Wkly Rep. 2006;55(11):301-305.
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5. World Health Organization. Tuberculosis and Air Travel. 2nd ed. Geneva, Switzerland; World Health Organization; 2006. http://www.who.int/tb/publications/2006/who_htm_tb_2006_363.pdf. Accessed September 4, 2007.
Letters Section Editor: Robert M. Golub, MD, Senior Editor.
JAMA. 2007;298:1861-1862.
RELATED LETTER
Extensively Drug-Resistant Tuberculosis and Public Health
Timothy Brewer
JAMA. 2007;298(16):1861.
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