Traveling TB scare sends ‘wake-up call’

A state health expert touts two tuberculosis patients' interceptions

The odyssey of a Georgia man who traveled to Europe and back with a fatal form of tuberculosis underscores the importance of Hawaii's detection system, recently tested successfully with two TB cases screened and discovered on a ship, a top state health official says.

Andrew Speaker's case "is everybody's wake-up call," said Dr. Jesse Wing, chief of the state Health Department's TB Control Program. "Now is the time to discuss our infection control practices."

Wing said a ship arrived about a month ago with one apparent TB case and that health officials found a second case through an aggressive screening effort on the ship.

"His doctor thought he had pneumonia," she said. "The data we had showed a latent TB infection."

She said she could not discuss details of the cases, but said the first patient was taken off the ship and treated. The second patient also was given some medicine and planned to catch a flight to Asia the next day, Wing said.

However, she said his tests "looked a little unusual," so she called the laboratory at 3:30 a.m., then the lab's scientific director at 6 a.m. He said they looked positive for TB from preliminary information, so she called the ship.

The man had already left for the airport, so she called her colleagues in the Centers for Disease Control quarantine station, she said. They found him in the boarding lounge and persuaded him to stay in Honolulu, she said.

"We were able to identify an early case of TB, document the information very quickly and coordinate with quarantine to detain the patient and save a person from coughing for a 10-hour flight to Asia," she said.

"We were lucky we had good rapport with the patient. He was willing to come with us. We started him on medications, and when he was no longer infectious, we cleared him for travel and put him on a flight with medications for the rest of the course. Hopefully, he will do fine."

In Speaker's case the Georgia lawyer has "extensively drug-resistant" tuberculosis, which has not reached Hawaii, but has been reported in 37 countries, including a few cases in the United States.

"We need to discuss how to handle XDR tuberculosis if it comes through Hawaii," Wing said. "We need to review regulations to see if they're up to date with what we need for XDR now that it's in our airspace.

"It's going to require much higher vigilance. It has a higher fatality rate, and we don't have adequate medications. We're talking in house about what we would do about infection control, medications, isolation and the capacity of the lab to detect this. There are many pieces to the puzzle and many partners."

Hawaii has one of America's highest TB rates because of a large immigrant population. In 2006 there were 116 cases, up from 112 in 2005. Hawaii had no multidrug-resistant TB cases last year, but it has had drug-resistant cases, Wing said.

Robert Tapia, retired officer-in-charge of the quarantine station, helped establish a system where immigrants who come here with abnormal chest X-rays classified as A or B, acute or less acute, are directed by quarantine officials to the Lanakila Clinic, she said.

The TB program has been able to rescreen more than 95 percent of the immigrants, which is "quite good," she said. "We have a list, and if they don't come to us, we call them and go find them. We are able to find a lot of TB cases.

"It's a nice tidy little system that the quarantine station and TB program have been able to put into place. It is very good for the state of Hawaii because we find cases. This is the usual immigrant stream."

Wing said discussions are being set up with the state Health Department to review regulations and laws and make sure they are up to date. She said she is also talking to hospitals to make sure there is adequate capacity to isolate and treat patients.

But cases like that of the Georgia lawyer would fall into the large realm of other visitors who come to Hawaii, she said. "That's the big wild card: visitors and students, people who do not need to go through any kind of medical screening."

Also, she said, TB symptoms can be nonspecific: night sweats, fever, weight loss and prolonged cough, which could be from many things.