The case of Andrew Speaker. Traveling internationally after being diagnosed with extensively drug-resistant tuberculosis (XDR-TB), U.S. citizen Andrew Speaker focused international attention on US and international quarantine regulations, developed long before the era of global human mobility. Speaker was the first individual quarantined by the US government since 1963.
Although the CDC advised him not to travel, he claimed to have been told that he was not infectious, hence made the personal decision to travel. CDC contacted him and told him to turn himself into Italian health authorities. He did not. Press reports said he feared he would die in Italy. Speaker by-passed his inclusion on the no-fly list by flying to Canada, then driving across the border into the US. Border guards were notified to stop him, but did not. It was reported in the press that the responsible border guard found him healthy in appearance and believed that the request to detain him was only advisory.
The issues: isolation and quarantine. Isolation is the practice of isolating an individual known to be contagious, commonly in a health facility, for the duration of the illness. Quarantine confines people who have been exposed to a communicable disease for the disease’s presumed incubation period.
Within the US, states and the federal government have the authority to enforce isolation and quarantine of persons infected with or exposed to a quarantinable disease [i]. The Speaker case focused attention on the weaknesses in these powers. They apply only to persons entering the country or crossing state lines. The number of infectious diseases covered is small, hence a new infectious disease threat must first be declared a quarantinable disease by a presidential executive order. The federal authority does not include the power to screen, trace contacts and direct therapy. Yet at the same time, the federal quarantine law is arguably unconstitutional because it allows detention without a hearing [ii]. Recent court rulings have clarified the legal rights of detained patients, including the right to counsel and a fair hearing. However, Center for Disease Control’s (CDC) 2005 regulations, still under review, propose short-term quarantine without hearing or counsel for several days. Thus many domestic questions remain, including the length of time an individual can be detained in isolation and what rules apply in quarantine situations. It is also unclear what evidence must be presented to justify the forcible detention of an individual who fails to comply with medical advice[iii].
The international dimensions. US federal isolation and quarantine authority does not extend to persons leaving the country. The CDC advised Speaker not to travel, but could not enforce the travel restrictions. The CDC then advised Speaker to report to Italian health authorities. Since federal law doesn’t apply outside of the US (unless specified by Congress), the CDC did not have the authority to enforce federal quarantine in another country. Speaker’s return through Canada raises concerns about the efficacy of federal “no-fly lists” and the system of quarantine stations at US ports of entry. According to a study carried out by the Institute of Medicine, US quarantine stations “…no longer protect the US population against microbial threats of public health significance that originate abroad[iv].” They are under-staffed and under-resourced.
XDR-TB as a global infectious disease paradigm. XDR-TB (resistant to any fluoroquinolone and 1 of 3 second-line drugs, such as capreomycin, kanamycin, and amikacin), although not more contagious than non-drug-resistant or multi-drug resistant TB (MDR-TB, resistant to ionazid and rifampicin), progresses rapidly and is fatal within a few weeks of diagnosis in about 80% of patients. As of March 2007, XDR-TB had been reported in 28 countries (see figure). The WHO has reported that drug-resistant TB is sharply higher in parts of the former Soviet Union in 2007, accounting for more than 20% of new TB cases, for example, in Baku, Azerbaijan[v]. Almost 10% of 544 TB patients studied in 2005 in Tugela Ferry, a rural town in the South African province of Kwa-Zulu Natal, were diagnosed with XDR-TB[vi]. The affected individuals were primarily miners and most were infected with HIV/AIDS. There is rising concern that XDR-TB may limit, or even reverse, the public health gains achieved in Africa as a result of the increased availability of HIV/AIDS drug therapy.
International laws and regulations. Speaker’s case draws attention to the role of international law in addressing emerging infectious diseases. The new International Health Regulations (IHR) that were developed over a number of years by the World Health Assembly of the WHO were adopted in 2005[vii]. According to the IHR, the Director General must determine whether a particular situation constitutes a public health emergency of international concern. Although the WHO was notified about the Speaker case, a WHO global task force initially concluded that XDR-TB does not so qualify, although more recent WHO guidance supports interference with freedom of movement as a last resort if an XDR-TB patient willfully refuses treatment[viii]. While the IHR represent an historic effort to provide a framework for international health cooperation, but they do not have the force of law and nations are not bound by WHO recommendations[ix] . Moreover, recent experience in South Africa, where XDR-TB patients rioted reveal the limitations of isolation and forced treatment, which cannot be done on a scale sufficient to contain a large-scale epidemic.
Global health governance. More than 30 new diseases, including Ebola and Marburg hemorrhagic fever viruses, legionnaires disease, and West Nile virus, have emerged and spread from less to more developed countries in recent decades. There is a growing recognition that wealthy nations have roles and responsibilities in raising the health status of poor nations, although current programs tend to focus on a small number of high profile diseases, such as HIV/AIDs. A much more comprehensive approach to global health and global health governance is increasingly seen as essential in today’s world of high human population density and mobility where all nations are vulnerable to the rapid spread of infectious diseases[x].