Tuesday, June 05, 2007
Defining contagiousness
As a general rule, doctors hate saying "maybe." It shows a lack of confidence and a degree of uncertainty to which medicine is unaccustomed. So, you can imagine my consternation when I had to say it repeatedly this morning on television. The question: Is Andrew Speaker contagious or not?

Well, maybe... sort of. Alright, yes is he is contagious, but not very. Make sense? There are several things doctors look at when determining whether someone is likely to transmit an infectious disease. One is whether he or she is sick (coughing, sneezing with fever). A second is whether a sputum test is positive - meaning bacteria are present in the saliva. In Andrew Speaker's case, both those tests suggested he was not contagious, and may not be now. He did, however, have a third test come back positive, which is a culture test. That means, doctors had Speaker cough onto a slide, and, although no bacteria were initially present, after a few days they did show up when placed in a culture medium. Based on all of that, the hospital where Speaker is staying issued a statement saying he is "relatively non-contagious" and may even consider taking him out of isolation, although he would still wear a mask.

To be clear, there is still a lot of concern surrounding Speaker. Here is one way of looking at it: When examining risk, you really have to balance the likelihood of transmitting the bacteria with the seriousness of the disease. In this particular case, it sounds like the likelihood of spread is low, but the potential consequence is very high. That is especially true with XDR-TB, where there are very few treatment options.

So, now after hearing all of this, which is admittedly confusing even for the medical establishment -- does it make you more or less understanding of Speaker's decision to fly internationally?
Simply the seriousness of the disease and the potential consequence should have given him pause. Even though the likelihood of transmitting bacteria and spread is low an intellegent individual should reason that there was a risk to others and the right thing to do would not to take the risk for others, especially on a plan. The public already knows how the air travel with circulated air is not the healthiest place to even avoid a common cold. This lawyer had to know this fact BUT He had a plan - yes, a very important plan - you don't get married everyday but if you can afford to get married abroad and have a spectacular honeymoon you can afford to cancel the event to keep others safe. His choice was simply an act of selfishness @ the end of the day.
Hi Dr. Gupta!

Does it make me more understanding?

NO.

I also don't really understand how you can be "relatively non-contagious". You are or you aren't. I don't like MAYBE. I like YES or NO. That he could have MAYBE infected one person out of everyone he came in contact with is simply unconscionable. He was only interested in himself and no one else, period.
It isn't just about balancing the seriousness of the disease with the chance of transmitting it. That's a silly and overly simplistic way to frame the question.

Even normal TB involves months of careful treatment, frequently observed by health agencies to ensure proper compliance. The inconvenience, expense, and stress of that is an equal factor. The chance of transmitting it, the gravity of the disease, and the burden to the person that could be potentially infected should be weighed. Quality of life does matter and I think it would be difficult to imagine your own disrupted twice every day for 6 months or more so that someone could watch you take your medicine. I would even venture a guess that Andrew Speaker would be pretty non-compliant if it wasn't XDR TB.

A parallel example is an HIV positive person choosing to wear or not to wear a condom. If their partner is healthy, each individual encounter has a relatively small risk of HIV infection. But the seriousness of the disease and the burden of treatment would lessen that person's quality of life should they become infected. The jeopardy of those two factors alone should encourage people to do the right thing for their health and the health of others.
Dr. Gupta,

Nicely put. As a second year medical student who just finished studying TB and medications for treatment of the disease, this case has been very interesting to follow. How I describe it to my family and friends: I have an albino friend, the gene for albinism is considered dominant, however the reason every other person isn't albino is the presence of that gene in the US populaton is very low (aka incidence). It stinks AS had to make a choice to get back to the US. However it would be nice if, when people argue that 1.6 million people die from TB every year - that more people would be willing to donate money to drug programs in those impoverished nations where those millions of people are dying!
That is something more news worthy than one man making a mistake.
Thanks for listening,
Irene
Ross University Medical School
Yes, I think that the statement is just reiterating of what is already known and it just makes it more clear that Mr. Speaker should not have travelled at all.
Hi Dr. Gupta!
Even though I am not into medical field, I noticed that the specialists missed something very important with the Sputum test. Following the news I heard Mr. Speaker's first two SPUTUM tests negative. The third one(a culture test) being positive.
I assume Mr. Speaker was already undergoing treatment(antibiotics administered intravenously). Is it not true that once the antibiotics are induced and then samples were taken for testing, they show negative results as the antibiotics are active in a patient?
Don't forget about the varying degrees of another person's ability to contract the disease. We musn't forget that the human body is a complex thing, and everyone is different -- medicine can never be as simple as "down to a science."
I think the break down was the tenancy for health care bureaucracies to deal with unique situation with the less than stellar judgment, total inaction, massive indecision, and incredible flank covering.

While the authorities waffled on the issue on whether he should travel or whether he was contagious or not (as if that issue could be resolved with 100% certainty with bureaucratic indecision), he, like any of us, refused to put our lives on hold for months or years. And why not?

If he was not contagious, why shouldn't he travel to Europe, maybe for the last time. If he was possibly contagious, why did they NOT say that very thing? If he was not contagious AND they didn't want him to travel, why should he be treated like he IS contagious? We don't (or we aren't supposed to) ban people with NON-contagious diseases from traveling for unreasonable fear that someone can "catch it", do we?

Even now the authorities protesting that "They warned him (warned him of what??)" are the ones changing their stories day to day while every one associated with Mr. Speaker tells one similar story. If you were an investigator, who would you believe?

He should have been told "You have a possibly drug-resistant form of TB and that you could be contagious, possibly spreading this dangerous form of TB to others. That is why you should not travel until we know for certain that you are NOT contagious". If any reasonable person was told that, I don't think they would travel until the TB contagion issue was resolved. To this day, not even the authorities said they stated that to him. They did say that they "warned him not to travel" without addressing the contagion issue.

Then when the authorities decide that "hey, he possibly could be might be contagious after all", the CDC offers NO AVAILABLE RESOURCES to get him back to the US for adequate treatment. They had the resources and chose not to make them available to him for no good reason.

Imagine that you have NOT been getting reasonable answers from authorities for weeks and they now tell you another set of different stories when you are stuck in a foreign country and can ONLY get adequate treatment in the US for a disease that you believe not to be contagious, I think I would be sorely tempted to fly back to the US as fast as possible by any means. I can't say if I would or not. I can totally understand Mr. Speaker's total confusion and frustration with authorities.

After all of this media circus dies down, I hope that Congress has a serious hearing on finding out the real story behind this TB fiasco.

By the way, HOW did he contract this uncommon and dangerous form of TB? Nobody in the CDC talks about that. I think that is the most scary part of this story.
I understand that HIV is an infectious disease that is transmitted via blood, semen, or breastmilk. Will the hearings currently going on in Congress affect persons living with HIV and who are at greater risk for drug resistant strains of TB?
This does make more sense to me now, but it also makes me wonder if the patient knew that the test would take a few days, and so that's why he changed his departing flight to a few days earlier... perhaps he was aware that a positive test would keep him in the US and prevent him from travelling. In any case, I think his actions are negligent and dangerous, and I can't think of anything he could say that might change my opinion.

What Mr. Speaker did is of a potentially far more serious consequence, but this makes me think of all the employees who trudge into work even when they are ill and running a fever, or the parents who send their children to school even when they know the child is very sick. Even if they are sent back home later in the day, dozens of people are still exposed, and possibly infected in the meantime, yet I don't see such a public outrage for these daily scenarios. Our culture takes good health and the body's ability to recover for granted.
Regarding the Speaker story and his explanation of his travels with T.B.: Speaker talked about (on Anderson Cooper interview tonight; 6/6/07) the old movies that feature the symptoms of the disease --- therefore he has a least of heard of it (T.B.). Even asymptomatic, this bright attorney, who knows he has a diagnosis of tuberculosis - how could he even think about going on a plane! If I had a diagnosis of TB. (any variety), I would be on the web or pulling out my medical book and learning more about the disease. Anyone who has even heard of t.b. would have that much common sense; one would ASSUME he could be contagious - that would be enough to know to quarantine him or herself. I don't buy his explanation -he is at least guilty of being selfish. [I certainly wish him and his family well, but please don't excuse away your ignorance of being "contagious", whether that be "highly" contagious, "partially" contagious, "perhaps" contagious, or "not at all" contagious. Wouldn't you lean on the side of caution with a diagnosis of tuberculosis?] (Comment by Veronica H. of Cols., Ohio.
There seems to be a lot of hysteria over this. If Speaker was told he wasn't contagious, was told he could continue working as a lawyer, going to court, seeing clients, etc. -- i.e., if he wasn't told that he should be remain home under quarantine -- then I don't see why he couldn't fly.

It is hard to believe that if he had been told he was contagious that he would have put his fiance, daughter and others at risk. It just doesn't pass the smell test. So I believe Speaker.

The only real issue here is did the CDC consider him contagious or not? And what was Speaker told? If the CDC felt he was contagious, then they should have made it clear!

We should stop blaming Speaker and start blaming how the CDC handled this whole thing.
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