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Border alert on TB patient disregarded

A man infected with an extremely dangerous strain of tuberculosis was waved into the United States at a border crossing even after a routine check of his passport set off an urgent warning, authorities said Thursday.

Andrew Speaker, 31, a personal-injury lawyer from Atlanta, arrived at the Canadian border May 24 after disregarding explicit instructions from the Centers for Disease Control and Prevention to remain in Italy — where he was on his honeymoon — for fear of spreading his potentially deadly strain of TB.

Speaker's father-in-law is a microbiologist at the CDC in the Division of Tuberculosis Elimination. Robert Cooksey issued a statement Thursday saying that he "wasn't involved in any decisions my son-in-law made regarding his travel, nor did I ever act as a CDC official or in an official CDC capacity with respect to any of the events in the past weeksÂ…. I would never knowingly put my daughter, friends or anyone else at risk from such a disease."

Cooksey also said that he had never tested positive for TB and was certain that Speaker did not contract the lung ailment from him or from the CDC's labs.

Speaker knew he had a severe strain of TB before departing to marry Cooksey's daughter, Sarah, on a Greek island in mid-May. He only found out later, when he was in Rome, that it was the rarest and most lethal of TB strains, resistant to most antibiotics.

Very few hospitals in the U.S. are equipped to handle that strain of TB; early Thursday morning, Speaker and his wife were flown by private air ambulance to one of them, National Jewish Medical and Research Center in Denver. He looked tanned and fit upon arrival — he has never exhibited any symptoms of TB infection — but he wore a blue mask, as did his entourage of doctors and nurses.

Speaker will remain in an isolation room in Denver for months as a medical team tries to wipe out the bacteria in his lungs with powerful antibiotics and, if necessary, surgery.

He will not be able to take his customary jogs. He'll have few visitors. His only view of the outside world will be a patch of grass and a few patio chairs. The antibiotics used to treat him may cause severe nausea, seizures, hearing loss and kidney problems. Still, his attending physician, Dr. Gwen Huitt, said Speaker was in good spirits.

"He's very relieved to be in Denver and moving on to the next stage in his life," she said.

Speaker has said his desire to get treated in Denver — where he'd been told the best specialists worked — compelled him to rush back to the U.S. from his honeymoon, taking a secretive, circuitous route to avoid being flagged as a health risk at American airports.

His defiance potentially exposed hundreds of airline passengers and crew to tuberculosis. It also could expose Speaker to lawsuits from those fellow travelers, should they become infected.

"There's a general duty not to put any [others] at undue risk," said Gregory Keating, a law professor at the University of Southern California. "I think he's got a problem."

Authorities said Speaker did not break any laws because at no point during his international travel was he under a court order to stay put.

From Rome, Speaker and his wife flew to Prague and then to Montreal. They drove to the border crossing at Champlain, N.Y. At the checkpoint, both their passports set off warnings when scanned into a computer. The alerts instructed the guard to isolate and detain Speaker, and immediately call health authorities.

But the inspector, who has since been removed from border duties, apparently concluded that the travelers looked healthy. They spent no more than two minutes at the checkpoint before crossing into the U.S., said Homeland Security Department spokesman Russ Knocke.

The lapse at the border outraged Sen. Charles E. Schumer (D-N.Y.), who called for a federal investigation.

"Today it was one sick and very irresponsible person who slipped through, but tomorrow could bring much worse," Schumer said. "There is just no excuse for this. God forbid this was someone bent on doing us harm."

As soon as Speaker crossed the border, he moved to comply with federal authorities. On May 25, as he and his wife drove south from Albany, he answered a cellphone call from the CDC, which had been frantically trying to reach him, and agreed to check himself into an isolation unit in a New York City hospital. From there, he was transferred to his hometown of Atlanta, where he was kept in a hospital room under armed guard.

When he arrived in Denver on Thursday morning, U.S. Marshals escorted his ambulance to the hospital. His is the first federal government-ordered isolation since 1963.

Speaker's medical odyssey began in January, when he injured a rib and went in for a chest X-ray. The picture showed a lesion in his lung. His physician suspected TB, even though Speaker had none of the classic symptoms: no fever, no night sweats, no coughing up blood.

It took months to confirm the diagnosis through a lab culture.

"Tuberculosis is a very slow-growing organism," said Dr. Kenneth Castro, director of the CDC's Division of Tuberculosis Elimination. "A month interval easily [can go] by before you have any results you can hang your hat on."

If the patient has a low bacteria load — as Speaker does — "it'll take even longer," Castro said.

On April 23, Speaker's doctor referred him to a Fulton County, Ga., tuberculosis clinic. Two days later, he had his first appointment and was immediately put on a standard course of three antibiotics.

Further tests for drug resistance came back on May 10 — and they were alarming.

His fiancee had tested negative for TB. But Speaker was infected with a multi-drug-resistant strain. He could have picked it up in his many travels abroad. He could have harbored it, in a latent phase, for years. In any case, the drugs he had been taking were useless. Without treatment, the bacteria that cause TB can attack the spine, brain and kidneys, causing death.

In a meeting May 10, county officials gave Speaker the diagnosis, which the CDC was working to confirm. In turn, he informed doctors of his plans to fly to Europe in a few days for his wedding.

Exactly what was said next remains in dispute.

Speaker has said the authorities told him they'd rather he not fly on a commercial plane, but did not order him to stay home.

"He specifically asked if he was not permitted to go. They said, no, we prefer you not to go, but we're not [telling] you not to go," his father, Ted Speaker, told CNN. Father and son practice law together in Atlanta.

County officials said they expressed more than a preference. "He was advised very strongly not to travel," said Dr. Steven Katkowsky, director of the Fulton County Department of Health and Wellness.

The next day, May 11, the county prepared a written medical directive. It can't be enforced like a court order, but the intent was unmistakable. "The letter did not say 'We prefer.' It said, 'You are directed,' " Katkowsky said.

But Speaker never got that letter.

It is unclear where he spent May 11, but he was not at work when county officials arrived with the directive. They mailed a copy to his home, but it was too late.

His bride's academic year at Emory University School of Law had wrapped up. The couple had registered for wedding gifts: frying pans, martini glasses, a pepper mill, a $60 blown-glass vase. On May 12, they boarded an Air France jet to fly from Atlanta to Paris, then on to Athens.

On May 18, as they celebrated their marriage on Santorini — an island famed for its sheer red cliffs and black-sand beaches — the CDC confirmed the diagnosis of multi-drug-resistant TB. Other test results on May 22 showed Speaker had a still more severe strain of TB, known as XDR, or extensively drug resistant.

On May 23, a CDC quarantine officer reached Speaker at his Rome hotel with the news. The officer begged Speaker not to move, asking him to turn himself in to Italian health officials while the CDC worked to get him safely back to the U.S., said Dr. Martin Cetron, the CDC's director of global migration and quarantine.

Speaker heard the conversation differently. In a phone call to the Atlanta Journal-Constitution on Tuesday, he explained that he thought he'd languish indefinitely in an Italian hospital. He feared he might die without help from specialists in Denver.

The next day, Speaker and his wife fled.

Health officials are recommending that airline crew members and passengers who sat near Speaker on his transatlantic flights get a skin test for tuberculosis as soon as possible and a follow-up test in eight to 10 weeks. But they said Speaker was not highly infectious, a conclusion they based on clinical tests and his lack of symptoms.

Along with concerns about border security, the case has raised questions about the government's ability to respond quickly to a public health crisis. Four years ago, the CDC commissioned a report on quarantines. Author Mark Rothstein talked with law enforcement, public health authorities and other first-responders — and found that no one was ready for an emergency.

The response to Speaker's infection indicates not much has improved, said Rothstein, director of the Institute for Bioethics, Health Policy and Law at the University of Louisville.

"There are numerous technical and logistical questions," he said, "and this is not on anyone's radar."

*


jia-rui.chong@latimes.comstephanie.simon@latimes.comnicholas.riccardi@latimes.comTimes staff writers Lynn Marshall in Seattle and Jenny Jarvie in Atlanta contributed to this report.

Copyright © 2015, Los Angeles Times
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