1. Crisis in the Sky: A Case Study in Communication at the CDC Team Synergy Emerging Leaders in Public Health February 26, 2009 1

2. Introduction May of 2007—CDC suspects Andrew Speaker has XDR-TB Despite warnings, Speaker travelled abroad potentially infecting thousands of people and creating an international public health crisis How did this crisis occur? Where was the breakdown in communication? Did the agencies involved have the power to stop Mr. Speaker? 2

3. Why All the Fuss? Tuberculosis (TB) Contagious disease Considered a global pandemic 2 nd only to HIV in mortality of adults worldwide Treated using 3 antibiotics over a 6-9 month period Treatment is difficult at best MDR-TB & XDR-TB Cases increasing worldwide Treatment requires 4 or more second-line medications (which are less effective) for up to 2 years Surgery is sometimes required Higher complications and death rates 3

4. What does the WHO say about it? The World Health Organization recognizes: TB has been shown to be spread on planes In each case, spread occurred between passengers sitting within 2 rows of each other Other factors that contribute to the spread: The infectiousness of the TB patient The length of exposure to the TB patient; and, Seating proximity to the TB patient 4

5. Key Players 5

6. Centers for Disease Control and Prevention CDC is housed under the Department of Health and Human Services Included in its mission is disease prevention and control & environmental health Headquartered in Atlanta, GA (Fulton County) 6

7. The CDC Players Centers for Disease Control & Prevention (CDC) Office of the Director Coordinating Center for Infectious Disease (CCID) National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention Division of Tuberculosis Elimination (DTBE) National Center for Preparedness, Detection & Control of Infectious Diseases (NCPDCID) Global Migration & Quarantine Source: www.cdc.govwww.cdc.gov

8. Timeline of Crisis Event January 2007 Speaker had an accident and during routine chest x-ray, an abnormality was discovered Initial diagnosis—TB Takes 6-8 weeks for culture to grow, no definitive diagnosis in January March 2007 TB diagnosis confirmed Speaker does not have any symptoms Speaker begins standard drug treatment therapy 8

9. Timeline of Crisis Event April 2007 Speaker’s doctor informs Fulton County Health Department (FCHD) of TB diagnosis & treatment details FCHD begins the work up for Multiple Drug Resistant TB (MDR-TB) 9

10. Timeline of Crisis Event April 25, 2007 Speaker informs FCHD doctor of his overseas plans (to be married), but offers no itinerary of the trip April 30, 2007 FCHD preliminary cultures indicate Speaker has MDR-TB 10

11. Timeline of Crisis Event May 10, 2007 FCHD confirms Speaker has MDR-TB Private meeting held with Speaker, his doctor, and FCHD officials Speaker advised to stop taking his meds (since they are not effective with MDR-TB) and the CDC was contacted Speaker advised not to travel 11

12. Timeline of Crisis Event After May 10 th meeting: FCHD begins to review legal options restricting patients’ travel and consulted with the CDC  Speaker changes travel plans and leaves for Europe on May 12 instead of May 14 (as originally scheduled) 12

13. Timeline of Crisis Event May 12, 2007 Speaker leaves ATL for Europe traveling on 3 commercial flights. While Speaker travels: CDC is attempting to formally contact him with written travel restrictions FCHD is attempting to hand-deliver travel restrictions 13

14. Timeline of Crisis Event May 17, 2007 Samples previously taken are tested for XDR-TB CDC notified of Speaker’s overseas travel May 21 or 22 Preliminary XDR-TB tests are positive Speaker flies to Greece for his honeymoon on 2 commercial flights 14

15. Timeline of Crisis Event May 22, 2007 CDC Division of Global Migration and Quarantine contacted Customs and Border Patrol (CBP) CBP was advised that Speaker was a public health risk Information attached to Speaker’s passport 15

16. Timeline of Crisis Event May 23, 2007 CDC contacts Speaker in Europe and advises him to either turn himself into Italian Health Officials or return to the USA via private jet May 24, 2007 TSA advised to prevent Speaker from boarding any US bound flights Speaker returns to North America on 2 commercial flights Total # of commercial flights for entire trip = 7 Number of passengers exposed to TB > 600 16

17. The Confusing CDC Messages Mr. Speaker was given at least 3 messages from the CDC: 1.Tools are available to the CDC to keep Speaker from flying into the US 2.Speaker should turn himself into the Italian health authorities 3.Private jet arrangements to the US would cost Speaker $100k, but the CDC could arrange travel for $50k and charge him for it (This is inaccurate) 17

18. Read the Fine Print Paragraph 1, Article 40 of the International Health Regulations states that parties should not charge for appropriate isolate and quarantine requirements to protect public health (WHO 2005) 18

19. It Appears that Mr. Speaker… Believed he was on the “no-fly list” Chose to by-pass the expense of charter flights by flying to Canada, and driving across the border to NY (05/24/07) 19

20. Someone Drops the Ball Actually, Speaker’s name did not appear on the “no fly” list until 2 hours after landing in Canada Speaker was not detained at the US border because a customs agent determined that Speaker “ did not look sick ” despite his passport being flagged with isolation instructions 20

21. What Eventually Happened… Speaker checks himself into a New York hospital and he was placed in isolation Speaker is eventually transferred to the National Jewish Hospital in Denver, CO—they specialize in TB treatment. Speaker remained in Denver, in isolation for months Condition downgraded to MDR-TB No reports of any exposed passengers “catching” TB 21

22. Cut Out of the Loop Neither the WHO nor the Italian Ministry of health were notified of incident until May 24, after Speaker left Europe Dept. of Human Services did not provide formal International Health Regulations (IHR) notification until May 25 22

23. Communication Challenges Between health officials (CDC & FCHD) and Mr. Speaker Between CDC and FCHD B etween CDC and other federal partners B etween CDC and international partners 23

24. How the Legal System Got in the Way Both Federal and State governments have the authority to isolate and quarantine There is confusion on who has jurisdiction in matters such as this Neither the FCHD nor the CDC seemed to be aware of what power they actually had The law does not specify how the CDC can prevent individuals with communicable diseases from leaving the country 24

25. Recommendations to the CDC 1.CDC should start working with LHD as soon a possible 2.Person suspected of being infected should be placed on travel restrictions without delay 3. Advise Federal partners (including airlines and airports) to enforce travel restrictions If drug resistant TB (MDR or XDR) is suspected: 25

26. Additional Recommendations to the CDC 1.Implement and adhere to IHR guidelines 2.Notify WHO if suspected person have international travel plans 3. Research and investigate rapid MDR and XDR-TB testing implementation 4. Train US embassy employees to become health ambassadors for US citizens traveling abroad 26

27. There Were Benchmark Practice Examples to Follow… SARS was spread globally by airline passengers Passengers up to 7 rows away were infected Over 300 either contracted SARS or a secondary SARS infection in 1 super- spreading event 27

28. So What??? When communication is unclear, difficulties occur Cohesive, coordinated plans are essential in public health emergencies Laws should be in place to help, not hinder 28

29. Team Synergy Ruth Arumala Randi Burlew Lisa Clarke Donna Galbreath Katherine Lao 29