Open Forum ..TB infections in airlines

Scary. On the 29th December I had written for the Times of India, and blogged (look under current events) abut the 10 things that 2006 will be most remembered for. Amongst them was an almost missed bit of news from the WHO that a new, completely drug resistant strain of TB had developed. I predicted then that the greatest carriers of TB would become the Airlines with people packed together like Sardines for up to 16 hours at a time. And what with the airlines notorious for not recycling air to save money. Imagine my astonishment when the story of an American man carrying this drug resistant strain became headline news recently ! But is this just one isolated case that was discovered, or are there thousands of people carrying these germs flying everyday ? How much of a risk are we all at ?


Those of us that have spent most of our lives in India have lived constantly with the presence of TB. My Grandmother (who I never met) had died of it, and I have had two of my domestic employees treated for TB. One even had to go to a TB sanatorium for 6 months. But just as we were getting used to the idea of a TB free world, it has hit us again.
The problem with TB is that someone can go years without ever discovering that they have TB. And people with weak immune systems, such as those with AIDS infections are particularly vulnerable. As are children.
So what can we do ?
1. Airlines must hold some responsibility to provide an infection free atmosphere to it’s passengers.
2. We too must take it seriously now. I think we as responsible people need to get ourselves checked periodically and NOT travel if we are carrying the infection.
What else should we be doing ?
Are we that come from the developing world now going to asked to go through not only extreme security checks at immigration but also screenings for infectious diseases ?
Shekhar

33 Responses to “Open Forum ..TB infections in airlines”

  1. ravi swami says:

    I recently flew to Europe on a budget carrier and got back with a bad chest – the atmosphere in those planes is a breeding ground for infections..
    My mother (like many Asians ) was discovered to have a dormant form of TB which flared up just after my father passed away, and was prescribed drugs to clear it up for more than year, during which it was advised that we limit contact with her..
    What to do ? – make people aware that it has never actually been eradicated, and not just in people from the “3rd” world, and that air travel, especially budget carriers, should be more vigilant and aware of the risk in packing people together, under stress (usually) – once again , profit seems to over-ride such health concerns…

  2. kedar says:

    hmm…scary!…

  3. Sid Singh says:

    Developing nations have been working for years to eradicate TB. One of the ways they have been doing this is trying to make sure every infant recieves the BCG vaccine, which would protect them from ever developing latent or active TB.
    However, it is now clear the the BCG vaccine is not really effective. It is effective for infants for a few years, especially if they receive multiple doses. The effect of the vaccine wears off for adults, and adults who have recieved a BCG vaccine in infanthood are pretty susceptible to it.
    Source: http://www.metrokc.gov/HEALTH/tb/bcgvaccine.htm
    There is research being funded into developing new vaccines or increasing the efficiency of the BCG vaccine. The Gates foundation for example supports such research:
    http://www.gatesfoundation.org/GlobalHealth/Pri_Diseases/Tuberculosis
    http://www.gatesfoundation.org/GlobalHealth/Pri_Diseases/Tuberculosis/TB_Backgrounder.htm
    The reason that a new vaccine requires funding is that the pharma companies do not have an incentive in funding this research themselves – the vaccine will not be purchased in the developed nations.
    How do you find out if you have latent or active TB?
    You take a TB skin test/PPD test:
    http://en.wikipedia.org/wiki/Tuberculin_skin_test
    If you get a positive diagnosis, you follow up with an X-Ray to see if you have active lung TB. If you had BCG as an adult, you may get a positive PPD test even if you don’t have latent/active TB.
    Many Indians will test positive and likely have latent TB. Over time the probability of the latent TB developing into active TB will decrease, unless you become HIV+, in which case your chances increase.
    Also, people with lung TB are infectious when they are coughing. Once they start the medication (the course runs for about 9 months), they become non-contagious in about 2 weeks. Doctors will perform a sputum culture test to ascertain if you are infectious or not.
    The TB bacteria is very slow growing compared to other bacteria too. It divides every 16 to 20 hours (http://en.wikipedia.org/wiki/Tuberculosis), which means that when you do a culture test and grow it in a controlled environment, it can take 6-8 weeks before confirmation that it is the TB bacteria. Before that, biologists may look at the sputum sample under the microscope to see if they can spot the bacteria to get an initial confirmation.

  4. Sid Singh says:

    BTW Shekhar, about your comment of aircrafts being “the greatest carriers of TB” – I would say that the largest sources of transmission would still be developing nations, especially hospitals, buses, trains and other crowded places.
    The role that aircrafts play is in carrying it across in the fastest way. In the past a disease would be transmitted much more slowly across continents, not aircraft transmit it much faster. If there is an epidemic in any given local area, it is much more likely today for it to spread worldwide within days or even hours.
    In developed nations, the most effective breeding ground for the TB bacteria is among homeless people. This is a detailed Seattle area report underscoring this:
    http://www.metrokc.gov/HEALTH/tb/TBreport2005.pdf
    The challenge with having homeless people infected is getting them to take the medication regularly for 6 months so they get cured and stop spreading the bacteria as well.
    Healthcare and emergency workers in the US take the PPD skin test annually to make sure they have not developed TB.
    Infants in the US are not given the BCG vaccine because:
    1. TB is controlled by quarantining the patient and treating them.
    2. The vaccine is not effective for long.
    3. The vaccine intereferes with the PPD test.

  5. Sid Singh says:

    I agree with your 2nd point about getting ourselves checked periodically.
    However, there is a good chance if you grew up in India that you would test positive for latent TB and negative for active TB. Now what do you do?
    You have the option of taking one of the TB medications (likely Pyrazinamide) for 6 months so you are completely treated. Patients with active TB have to take 4 or more medications for 2 months and then 2 or more for the remaining 4-7 months.
    However there are two drawbacks to taking Pyrazinamide knowing that the chances of your latent TB developing into active TB are low and decrease with time:
    1. It’s side effects may affect the functioning of your liver.
    2. If you are living in India or keep visiting, you have to consider the chances of contracting the TB bacteria again.

  6. kavitha says:

    What’s infinitely scary is the reality that the strains get more resistant and harder-to-detect with advances made in treatment. Consider this instance — PPD skin test comes out negative. X-ray shows no signs of infection of the lungs. Sputum culture is negative. This happened to somebody very close and dear to my heart, presumed to have access to the advanced health care system of a developed nation. It was 2 months of hellish experience shuttling between the primary care physician and a slew of “specialists” specializing in every conceivable part of the body. As a last resort, at the end of the 2 months, she was asked to do an MRI which revealed spotting in a part of the brain! After a follow-up spinal tap in the ER, they declared that a strain of TB bacteria had infected her brain. It was traumatic enough to hear the MRI result, and more so now to hear that it was a TB strain in the brain! She was confused between a sense of utter helplessness, anger with the system that took two months to diagnose, and disbelief that it could be a TB strain in the brain. A lot can degenerate in two months, considering that the bacterial strain incubating within her body had un-intervened time for procreation in those two months. It can be rationalized as the quirk of unfortunate coincidences of being at the wrong place at the wrong time with the wrong doctors etc. etc. The reality remains that doctors/specialists were unable to correlate symptoms to the cause soon enough. Each specialist was looking at the part, rather than the whole. Whether the strain could have transcended the blood-brain barrier and infected the brain, had the diagnosis been sooner, we’ll never know.
    How “specialized” in their understanding can doctors in developed nations be anyway to understand “diseases of the developing world”, and the myriad aberrations in the way they manifest themselves? With due respect to the sophistication of medical care in developed nations, there’s still a huge void in terms of wholistic, integrated care.

  7. kavitha says:

    The following may be slightly tangential to the “TB infections in airlines” blog…but was triggered by the post and stems from a socially relevant health consciousness.
    Just got back from a grocery store where the cashier very casually licked his forefinger to separate one defiant grocery bag from the stack. I squirmed at that sight. Visions of a billion bacterial organisms that had just been transferred from his saliva to his finger to my grocery bag and potentially later to me, engulfed my thoughts as I stood behind the counter. This was not the first time I saw somebody do this. In the past, I had the courage to tell others to refrain from the act. Yet I felt tongue-tied today. Don’t know why. That I may be looked at as a jerk by the cashier who was doing his best to keep the line moving fast? As I drove back, I was angry with myself that I did not do what I had done in the past – and was resolved to take to that cashier a gift of a little container with a sponge soaked in water, the next time I go there. To make his job easier, to help him keep moving the line fast, and to protect myself from being a vulnerable target for potential infection.
    I risk being looked at as a jerk with a paranoia of some sort, but at least I know I am doing my bit in raising the awareness in someone who *could* be that one person carrying a deadly strain of a potentially infectious disease. After all, I shop there often enough to have a bit of self-interest as well!
    Shekhar asked “What else should we be doing?”…
    The next time you see this happen to you, under similar circumstances or otherwise, hope you will have the courage to tell the other that they might unintentionally be doing a disservice to their customers, friends or family. Each little effort matters — many little drops make the ocean after all.

  8. Rinil says:

    I have recently gotten very involved with homeopathy and alternative medicine. So I found out that Thuja is a great homeopathic medicine for curing and preventing all sorts of diseases including allergies, inherited and accumulated toxins, etc…It’s also a great way to immensely boost your immune system. Just because this new strain of TB has cropped up, that doesn’t mean we should stop living our lives! Instead, making sure that we are as healthy as possible with a good immune system is the key!!
    Rinil

  9. Navin says:

    Yep, I agree…..nowadays airlines have become carriers of not only passengers, but carriers of major health risks too. Apart from infectious diseases like TB, another serious condition which cramped spaces in airplanes are responsible for is DVT (Deep Vein Thrombosis). Colloquially called the Economy class syndrome, DVT is the formation of a blood clot (“thrombus”) in a deep vein. It commonly affects the leg veins, such as the femoral vein or the popliteal vein or the deep veins of the pelvis.
    Can DVT be prevented?
    “Taking drug thinning drugs such as aspirin is one way to cut the risk of developing a clot. Taking a low dose of aspirin before a long flight, for example, may reduce risk as does walking around in the cabin.
    Foot exercises while sitting down – rotating the ankles and wiggling the toes – prevents the blood pooling in the feet and then struggling to climb up through the veins.
    Special foot cushions have been developed so passengers can exercise while sitting at their seats.”
    source: http://news.bbc.co.uk/1/hi/health/medical_notes/c-d/986364.stm
    While I can’t do anything to prevent any infectious diseases while flying (other than by just being cautious), I’ll definitely make it a point to move around a bit in the aisle every hour or so when I take a long non-stop flight to London this week. Am going to Yorkshire to attend the IIFA Awards next weekend. Will you be attending the event, Shekhar? Hope to meet you there, if you are.
    Cheers!
    Navin

  10. Sid Singh says:

    Kavitha, regarding over-“specialization” of doctors, this is not just in the medical field, but everywhere else. As our knowledge about things becomes more specialized, we will have to break them up into components and have different people go out and study each component in more detail.
    The key to still make it all work is teamwork. An effective medical team will have the right balance of all specializations and use them to correctly diagnose and treat.
    It is very true that immigrants have a very tough time getting a diagnosis when they are infected with a disease that is more prevalant in their country of birth. The doctors they are seeing just have not seen many cases to have the exeperience to diagnose. You are just better off trying your luck in your country of birth where (unfortunately) your doctor may see multiple people with the same disease week after week.

  11. Sid Singh says:

    I was watching a presentation that Bill and Melinda Gates gave to the employees of Microsoft about the work thier foundation is doing, and at one point Bill Gates talked about how diseases that are transmitted by people on airplanes etc. are overblown and no one cares about the millions dying in the 3rd world from traditional diseases, because people travelling by air are mostly rich people.
    Oh My God, a rich person died of DVD while on an airplane, what a tragedy.
    Oh, and a thousand people died of AIDS or TB today, but they were in thier poor homes, so we don’t care that much.
    Oh My God, the rich people in airplanes might get TB on the plane. They can avoid the poor people hospitals and the jhuddi-jhopdis, but oh my God, they still need to fly!

  12. amit says:

    Ohhh! that’s contagious … and PRETTY SAD also …

  13. Harpreet says:

    May be just like the very sturdy child polio campain,another campain for TB identity be done for frequent travellers.

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  15. SAMUEL says:

    Run a mile

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  19. como esta vie says:

    I totally hear you…
    A few years back, I contracted a severe case of shingles* after a very stressful work assignment abroad. I was supposed to fly out the day I was diagnosed, but I was extremely contagious. So I promptly made my way over to the airline office (this was Northwest/KLM) – first the regional office, then the airport itself – to explain the situation. No one listened, even though I explained that my traveling then put the entire airport and airplane at risk. They insisted that I pay them $300 to change the date. Essentially, I paid to keep the airline and other passengers out of harm’s way!! The whole thing was ridiculous…and I’ve never flown them since…
    *http://www.medterms.com/script/main/art.asp?articlekey=5476

  20. shekhar says:

    dear como, u so did the right thing and I will remind myself never to fly Northwest again. And thank you for sharing, shekhar

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