ATLANTA -- As reported in last month's issue of  "World News & Nursing Report" a deadly new strain of tuberculosis has spread from South Africa to Europe, Canada and now, the United States.  This extremely strong strain called XDR-TB (extensively drug resistant) has now been documented in 35 countries world wide, with 16 new countries invaded in the first 3 months of 2007.

This month a U.S. citizen, a young male lawyer from Atlanta, Georgia, diagnosed with XDR-TB was not warned by his doctors to put off his long-planned wedding in Greece.  Knowing he had a form of tuberculosis, and that it was resistant to first-line drugs, he didn't realize until he reached Europe how far more dangerous it was.

DEFINITION OF XDR-TB

XDR–TB has been defined by the WHO Global Task Force as resistance to at least rifampicin and isoniazid in addition to any fluoroquinolone, and at least one of the three following injectable drugs: capreomycin, kanamycin and amikacin. The existence of XDR–TB was first mentioned in March 2006 in a report published by the US Centers for Disease Control and Prevention and WHO. XDR–TB has been found in all regions of the world but is rare. MDR–TB usually has to occur before XDR–TB arises. Experts believe that wherever second-line drugs to treat MDR–TB are being misused, there is a risk of XDR-TB.

FAILURE OF HOMELAND SECURITY

What follows is a nightmarish story of how he refused to listen to the CDC who ordered him into isolation, specifically to officials in Italy to be treated. This order included "not to fly on commercial airlines." They also informed him that he was put on the "no-fly list", and that his "passport had been flagged."

He later told newspapers that "knowing it was nuts" he and his wife decided to "sneak back into the U.S. through Canada".

Knowing he could expose others to a disease with no cure, he managed to avoid the U.S. "no-fly" list by driving to Prague, Czech Republic and flying on Czech Air Flight #410, to Montreal, Canada.   There he easily entered the U.S. by automobile as U.S. border guards waved him through.

He later said that he voluntarily went to a New York hospital, and was flown by the CDC to Atlanta. When asked why he did it, he said, "I was afraid if I didn't get back to the U.S., I wouldn't get the treatment I needed."

From national bulletin boards to on-line forums people everywhere asked a simple question.  How could he manage to return to the country when he was identified as the U.S. government identifies any terrorist trying to enter the country?  Where was the Homeland Security that the government said was in place?

RECYCLED AIR ENDANGERS ALL THE PASSENGERS OF BOTH FLIGHTS

Authorities and newspapers have reported that the young man with the XDR-TB has endangered the lives of approximately 30 people sitting near his seat 12C, on the Prague to Montreal flight.

Additionally, they've reported that he's endangered the lives of approximately 50 people that sat near his Row 51 on his initial flight to Europe, from Atlanta to Paris (Air France Flight #385).

However, not reported by either authorities or newspapers is the fact that both planes use recycled air filtration systems that have a ratio of 50:50 fresh to recycled air.  On a trans-Atlantic flight every person aboard breaths the same air many thousands of times.

The Federal Aviation Administration regulations (found at www.faa.gov/regulations_policies /faa_regulations, No. 25.831) state that an airliner's ventilation system must be designed to provide each occupant with at least 0.55 pounds of fresh air per minute. That translates to about 10 cubic feet of air a minute. On a typical passenger jet, the ratio of fresh to recycled air is about 50-50.

According to a 2003 Report, entitled, "Aircraft Air Quality: What’s Wrong With It and What Needs To Be Done" submitted to the Aviation Subcommittee of Transportation and Infrastructure Committee of the House of Representatives by the Association of Flight Attendants, the flight attendants specifically cite a problem with "inadequate ventilation". Their concern is that inadequate ventilation on airplanes results in "the increased risk of disease transmission."

Diana Fairchild, an expert in aviation air health quality writes, "The latest information about transmission of tuberculosis on jets says that only those passengers seated "near" the contagious individual are at risk!"

Adding, "Hmm, it seems to me it also depends upon where the contagious passenger is seated in relation to the aircraft's air vents and outflow vents, the amount of air being pumped into the cabin, the duration of the flight, the departure location which determines humidity in the cabin for the first few hours, the passenger load, the number of times the contagious individual coughs, if that passenger coughs on the way to the lavatory, if you're the next one in that lavatory...."

She says, "by the way, I've been contacted by several international flight attendants who have TB. They obviously didn't have it when they were hired, or they would not have been hired by the airlines."

Confidential sources are now telling us that planes recycling systems may have contaminated every person on both planes. Out of fear of alarming the public, losing their jobs, or getting accused of not speaking out sooner, these people are afraid to speak out in public.

As a result, there may be hundreds of passengers from both planes spreading XDR-TB right now.  To date, no attempt has been made to contact or test these passengers, and if necessary isolate them.

PARTICULARLY DANGEROUS TO PEOPLE WITH HIV/AIDS

Worldwide attention was focused on South Africa when a research project publicized a deadly outbreak of XDR–TB in the small town of Tugela Ferry in KwaZulu-Natal. Of 536 TB patients at the Church of Scotland Hospital, which serves a rural area with high HIV rates, some 221 were found to have multidrug resistance and of these, 53 were diagnosed with XDR–TB.

Fifty-two of these 53 patients died, most within 25 days. Of the 53 patients, 44 had been tested for HIV and all 44 were found to be HIV-positive. The patients were receiving anti-retrovirals and responding well to HIV-related treatment, but they died of XDR–TB. The study results were presented at the International AIDS conference in Toronto in August. Since the study, 10 more patients have been diagnosed with XDR–TB in KwaZulu-Natal. Only three of them are still alive.

SERIOUSNESS OF XDR-TB

Dr. Mario Raviglione, the Director of the STOP TB program at WHO stated, "Multidrug-resistant TB - or MDR-TB - which is resistant to the two most powerful first-line drugs, exists in countries around the world as a result of bad practices over the past decades and the slow pace of adoption of DOTS. MDR-TB is alarming levels in Eastern Europe, Central Asia, and in parts of China." 
"Still worse is the appearance of XDR-TB - shorthand for Extensively Drug-Resistant TB - a form of TB resistant not only to first-line drugs but also to second-line drugs, making treatment nearly impossible in some cases."

NO NEW TB DRUGS ANTICIPATED FOR AT LEAST FIVE YEARS

No new TB drugs have been developed for four decades. There are several promising new candidates, but none will be available for at least five years. More investment in TB drug development is needed to guarantee future drugs supplies. A further complication is the interaction of antiretroviral drugs with TB medication, while little is known about the interaction between second-line TB drugs and anti-retrovirals. Second-line TB drugs are less effective and more toxic than the first-line options. “In some cases the side-effects are extremely severe. It can be a choice of going deaf or not being treated,” said Dr Karin Weyer, TB Research Director at the South African Medical Research Council.