Monday, October 22, 2007

Government claims that a Mexican businessman infected with a highly contagious form of tuberculosis posed no serious public health risk by taking numerous domestic flights are based on faulty research and limited data, said a top Harvard physician who specializes in disaster medicine and infectious disease.

“This policy is ill-founded, poorly researched, and puts the population at risk,” said Dr. Greg Ciottone, one of the world’s leading authorities on disaster medicine, including terrorist attacks and the threat of biological warfare.

World Health Organization tuberculosis guidelines, adopted by the Department of Homeland Security (DHS) and the Centers for Disease Control and Prevention (CDC), only require airplane passengers to be notified of exposure to tuberculosis if the flight lasts more than eight hours.

“If the powers that be, who directly impact the health and well-being of this country, are going to stand by this theory that if you spend up to 7 hours 59 minutes next to someone with active TB you don’t need to be tested, then people will become ill,” said Dr. Ciottone, who is director of the Operational Medicine Institute and editor in chief of Disaster Medicine.

The Washington Times first disclosed last week that internal DHS documents reveal that Amado Isidro Armendariz Amaya had an active case of Multi-Drug Resistant Tuberculosis (MDR-TB) and was traveling unfettered in the U.S. since November, entering the U.S. at least 76 times and taking multiple flights.

Citing the WHO guidelines, neither the CDC nor Homeland Security notified any passengers who flew with Mr. Armendariz that they were exposed to his “dangerous and highly contagious” form of tuberculosis, the same strain involved in the case of Andrew Speaker, whose ability to sneak into the U.S. from Europe via a May flight to Canada prompted national headlines and congressional hearings.

The agencies did, however, notify Mr. Armendariz’s family and the customs broker in El Paso, Texas, with whom he usually did business, Customs and Border Protection officials said. Both his immediate family and the customs broker tested negative, CBP officials stated.

“He travels to the U.S. to purchase construction equipment used in constructing high rise buildings. He deals frequently with a local customs house broker. The CDC is attempting to identify the Customs House broker and when they do, they will provide CBP with the information,” read an internal DHS e-mail.

Airline passengers on at least 11 flights Mr. Armendariz took in the U.S. were not notified by the CDC, which based its decision on the WHO guidelines.

Not notifying the passengers is a mistake, Dr. Ciottone said.

“They should be tested, and if positive should undergo treatment as anyone who converts a skin test would,” he added. “They can also yield important data that will help us better understand transmission of this disease. We simply don’t know enough about the transmission of tuberculosis on planes based on the current data.”

Dr. Ciottone said the guidelines are based on limited studies for all strains of TB done more than ten years ago that, among other flaws, did not even include in the study sample any passengers who had other risk factors for TB before the plane took off, such as spending time in certain foreign countries.

A 1996 article in the New England Journal of Medicine admitted that the studies done to date could not exclude transmission of tuberculosis on flights under eight hours.

“Our investigation provides evidence of the transmission of M. tuberculosis from passenger to passenger and from passenger to flight crew aboard commercial aircraft,” the report states. “Although the possibility of transmission from the index patient [infected person] to other passengers on flights 1, 2, and 3 [shorter domestic flights] cannot be excluded, the evidence is most compelling for flight 4 [a flight of more than eight hours].”

In 1995, CDC officials met with representatives from the Federal Aviation Administration, the Air Transport Association, the Council of State and Territorial Epidemiologists, and the National Tuberculosis Controllers Association, as well as medical consultants from major airlines to develop guidelines, using six studies of possible transmission on commercial aircraft.

In 1998, the first set of guidelines were promulgated by the WHO and adopted by U.S. officials, including the eight-hour flight standard. Last year, the WHO altered its guidelines to say that no passenger with an active case of MDR-TB should fly on any plane.

Capitol Hill lawmakers called for an investigation last week questioning why federal officials let in Mr. Armendariz and why other federal agencies weren’t immediately alerted.

According to internal DHS e-mails, Mr. Armendariz did not abide by Mexican Health Department treatments for MDR-TB for more than five years before Mexican officials notified CDC counterparts in El Paso. While Mr. Armendariz traveled on business throughout the U.S., he had “an active case of contagious tuberculosis,” the documents state.

It was not until April 12 that Mr. Armendariz began regular treatments at a clinic in Juarez, Mexico, the DHS e-mail states. According to CBP officials, Mr. Armendariz used a fake name when he started treatment and Mexican health officials didn’t have accurate information when they alerted CDC and customs officials on April 16.

DHS officials and customs agents interviewed by The Times on the condition of anonymity for fear of retribution stated that they never saw an official health alert in April and question why the Mexican government never notified U.S. law-enforcement authorities earlier.

Mr. Armendariz’ sister and father died of the same illness in Mexico.

Customs officials would not provide the original “alias” provided by Mexican Health officials or the first alert issued by the CBP in April. It wasn’t until June 1, that El Paso Customs and Border officials issued a health alert with the infected man’s actual name. It would be another week before DHS officials notified the Transportation Security Administration to put Mr. Armendariz on the “no-fly list.”

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