FW: PRO/EDR> Tuberculosis - USA (03): (TX ex CA) susp. long-distance bus exposure, RFI

[Maffei, Joanne]

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Subject: PRO/EDR> Tuberculosis - USA (03): (TX ex CA) susp. long-distance bus exposure, RFI


TUBERCULOSIS - USA (03): (TEXAS ex CALIFORNIA), SUSPECTED, LONG-DISTANCE BUS EXPOSURE, REQUEST FOR INFORMATION
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Date: Mon 2 Sep 2013
Source: CBS DFW [edited]
<http://dfw.cbslocal.com/2013/09/02/greyhound-passengers-complain-sick-rider-allowed-to-stay-on-bus/>


Some Greyhound bus passengers are questioning whether they were exposed to an illness after they say they were forced to share a bus with a sick passenger. "We both noticed how sick he was, and then he started coughing and hacking up blood," says [one of the passengers].

She and [a] fellow passenger are now concerned that they may have been exposed to tuberculosis after riding alongside the sick passenger for nearly 2 days. She says he boarded the bus in Los Angeles, California on Saturday [31 Aug 2013?]. She says as the bus continued east, his illness appeared to worsen. "He was coughing and hacking," she explained. She says riders grew restless and demanded that the bus driver remove the sick passenger. Greyhound confirms the driver pulled over in west Texas and called paramedics.

"They stopped in Van Horn and called an ambulance," [she] recalled.
"The ambulance said we couldn't test him for TB because it would take
2 days." The ill passenger was allowed to continue on the trip if he agreed to wear a mask. But riders say the man was deaf, and there was a communication break down. "Both different drivers said 'Put hands over your mouth or hold this over your mouth;' he would not do it,"
[she] said.

[The passenger] said she and dozens of others wanted to get off the bus, but paramedics convinced them to stay on. "I'd already been with him a day and a half," she said. "The ambulance said it wouldn't make any difference if (I had) already been exposed." [The other passenger] also said new passengers were allowed to board.

Once the bus reached Dallas, passengers were given complaint forms to voice their concerns, but [2 passengers] say they need more than a pen and paper to address their worries. "If we've been exposed, then everybody we come in contact with from now on can be exposed, so we're real concerned about our families," said [one of the passengers].

Greyhound says it has no record of where the [ill] passenger is at this time or whether he went to the hospital. Company executives told CBS 11's Sharrie Williams that the bus driver followed correct protocol and that the sick passenger did wear the mask as he was instructed to.

CBS 11 contacted Dallas County Health and Human Services about this story, which is offering free TB tests to anyone who was a passenger on the bus.

--
Communicated by:
M. Randolph Kruger
<mail...@bellsouth.net>

[Before a tuberculosis (TB) contact investigation is initiated, prompt and accurate information regarding the possible index patient (the ill
traveler) is required. However, at this point, we do not know whether the ill bus rider was coughing up blood because of pulmonary TB or some other disease, e.g., a lung neoplasm. The National Tuberculosis Controllers Association and CDC issued an extensive document detailing guidelines concerning investigation of TB exposure and transmission and prevention of future cases of TB through contact investigations (CDC. MMWR Recommendations and Reports. December 16, 2005 / 54(RR15);1-37. Guidelines for the Investigation of Contacts of Persons with Infectious Tuberculosis Recommendations from the National Tuberculosis Controllers Association and CDC. Available at:
<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a1.htm>).

The CDC says in this document that a contact investigation should be considered if the routine chest radiograph of the index patient is consistent with pulmonary TB, e.g., shows the presence of cavities in the lung (<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a1.htm>).
Persons with sputum smear showing acid-fast bacilli (i.e., possible _Mycobacterium tuberculosis_, the organism that causes TB) or culture-positive sputum and cavitary TB are assigned the highest priority for a contact investigation.

The CDC says that health departments are responsible for conducting TB contact investigations. In the case of a possibly contagious TB patient traveling within the United States, multiple jurisdictions may be involved. The CDC suggests that officials from the health department that initially encounters or counts the index patient should lead the investigation and notify the health departments in other jurisdictions regarding contacts residing in those jurisdictions.

However, in the case of an index case with a possible contagious disease on an air flight (see <http://www.cdc.gov/quarantine/contact-investigation.html>), the CDC Quarantine public health officers at the airport determine whether the index case was contagious during a flight. If the index case is judged as having been contagious during the flight, the CDC Quarantine Station will start a contact investigation: CDC 1st calls the airline to confirm where the index case sat. Then CDC requests the flight manifest for passengers seated near the index case. CDC provides the exposed passengers' contact information to state and local health departments. These agencies then try to locate these passengers and inform them about their exposure and what to do.

The CDC suggests that cough frequency and severity are not necessarily predictive of contagiousness in a patient with pulmonary TB (<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a1.htm>). In an enclosed space, the volume, exhaust rate, and circulation of air shared between an infectious TB patient and contacts, the duration of exposure, and the degree of proximity between the contact and the index patient can influence the likelihood of transmission. For example, airline passengers who are seated for over 8 hours in the same or adjoining row as a person who is contagious are much more likely to be infected than other passengers.

According to the WHO
(<http://www.who.int/ith/mode_of_travel/tcd_aircraft/en/index.htm>):
"Ventilation rates [on aircraft] provide a total change of air 20-30 times per hour. Most modern aircraft have recirculation systems, which recycle up to 50 percent of cabin air. The re-circulated air [on airplanes] is usually passed through HEPA (high-efficiency particulate
air) filters of the type used in hospital operating theatres and intensive care units, which trap dust particles, bacteria, fungi and viruses."

The circumstances on a long-distance bus ride are unknown.
Transmission of _Mycobacterium tuberculosis_ has been confirmed on military vessels at sea, commercial aircraft, passenger trains, and school buses (references can be found at <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a1.htm>).

The evaluation of contacts of TB patients is detailed in the CDC MMWR document (<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a1.htm>).
Some contacts may be more at risk for TB progression than others. The contact's age and medical conditions affect the likelihood of TB disease progression after infection. An age of under 5 years, silicosis, diabetes mellitus, gastrectomy or jejunoileal bypass surgery, and immune status are important factors. Contacts receiving immunosuppressive agents, including more than 15 mg daily of prednisone or its equivalent for over 4 weeks, multiple cancer chemotherapy agents, anti-rejection drugs for organ transplantation, and tumor necrosis factor alpha (TNF-a) antagonists increase the likelihood of TB disease after infection.

A recent review on transmission of airborne pathogens in public ground transport found that while guidelines exist for contact tracing after exposure to certain infectious pathogens during air travel, no guidance documents specifically address response to potential exposure on public ground transport; the authors noted that for long-distance railway or bus/coach trips, passenger data (e.g., name, telephone number, email address) may not be routinely collected, making contact tracing very difficult, and so, consequently, the risk of infectious disease transmission as well as the public health impact of transmission of airborne communicable diseases during such travel remain largely unknown (Mohr O, Askar M, Schink S, Eckmanns T, Krause G, Poggensee G. Evidence for airborne infectious disease transmission in public ground transport - a literature review. Euro Surveill.
2012;17(35):pii=20255. Available online at:
<http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20255>). - Mod.ML]

[A HealthMap/ProMED-mail map can be accessed at:
<http://healthmap.org/r/2Jna>.]

[see also:
Tuberculosis - USA (02): (WI) MDR 20130721.1836650 Tuberculosis - USA: (CA) fatal, homeless persons 20130224.1556939
2009
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Tuberculosis, airplane exposure - USA ex Germany 20090317.1081
2008
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Tuberculosis, MDR, airplane exposure - USA ex India 20080103.0019
2007
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Tuberculosis, MDR, airplane exposure - multicountry (05)
20071130.3861
Tuberculosis, MDR, airplane exposure - multicountry (04)
20070803.2519
Tuberculosis, MDR, airplane exposure - multicountry (03)
20070731.2462
Tuberculosis, MDR, airplane exposure - multicountry (02)
20070728.2430
Tuberculosis, MDR, airplane exposure - multicountry 20070727.2418 Tuberculosis, XDR, airplane exposure - multicountry (04)
20070609.1888
Tuberculosis, XDR, airplane exposure - multicountry (03)
20070601.1778
Tuberculosis, XDR, airplane exposure - multicountry (02)
20070530.1752
Tuberculosis, XDR, airplane exposure - multicountry (USA, France, Canada, Czech Rep.) 20070529.1738] .................................................ml/msp/mpp
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