COMA: Interview with Liz Garbus for HBO Special

Traumatic Brain Injury (TBI) is a major international public health issue. It is estimated that as many as 5 million US citizens may have had TBI and the incidence is higher in Europe and South Africa. Young males (15-24), infants and children under age 5, the elderly over age 75 are all more likely to suffer TBI than the general population. Transporation accidents are the leading cause of injury, followed by falls and violence.

Award winning filmmaker Liz Garbus has done it again with a quiet, restrained film Coma about TBI, which will air on HBO July 3, 2007. I interviewed Liz earlier today and, paraphrasing our conversation (I did not record it):

JC: What sparked your interest in this subject?

LG: Sheila Nevins, President of HBO Documentary Films approached me about the idea when the nation was so polarized over the Terry Schiavo case - persistent vegetative state was not understood by the public. And for me as a parent, as we did the film, it became about the Mothers. Mothers don't ever abandon their children - it cuts across all classes, even people who can't afford to give up their jobs to take care of their kids - they do. Mothers are tireless advocates for their children, no matter what.

JC: I was struck by how understated and low key the film was - could you talk about that please?

LG: It was a long process - we shot 200 hours of film at JFK Johnson Rehab Center
following these four families who allowed us into their lives - it was a very unique and privileged situation that we had. We were observing the emergence of consciousness - a slow, painstaking phenomenon. So the approach is restrained to honor their struggle - to treat it with dignity. These families are living in a twilight zone between life and death - and we witnessed some amazing moments - like Sean [young man in vegetative state] crying...

JC: The neuropsychologist, Dr. Giacino, was the key player of the Rehab Team. I found that to be true in my own TBI work - but most people aren't aware of the role of the neuropsychologist.

LG: Yes, I wasn't familiar with the field beforehand, but I found him to be the Guide to the Brain, the Mystery Explorer, our Guide to Outer Space of Consciousness. He was the one who did a battery of tests and helped the families understand what has happened, what is happening. Although you can't give a prognosis, he provides a road map of what can be expected.

JC: You did an amazing job of showing the willpower of the individual...

LG: It was a great honor last night - we had a screening of the film for HBO and Tom [one of the four amazing patients in the film] and his fiancee came. They are living a happy, loving life now, and that's as much as any of us can ask for, isn't it? Tom's stubborness, anger, drive - with brain injury you are locked inside yourself - but the anger and frustration pushes you to recovery.

JC: I always say that anger is a very underrated emotion - the frustrations brain injured people endure are intense.

LG: Tom was pissed - cognitively he knew he was in Rehab - he knew he had to do some things to improve but he was like, why do you want me to throw these rings on this stick? Some of the therapies struck him as ridiculous. And he had this condition we talk about in the film - anosognosia - so he lacked insight into himself - it was part of the brain damage.

JC: So what are some things you would like people who watch the film to come away with?

LG: There's a larger social argument - funding to keep intensive rehab. Private insurance companies stop paying for aggressive therapies if there is no improvement after 6 weeks - but studies show that people improve for up to a year post injury. So that means people with top potential are languishing in nursing homes due to lack of funding.

JC: So I take it you're going to go see Sicko [Michael Moore's film premieres June 29, 2007]?

LG: Yes, we went to a screening - and I hope this draws attention to an important subject and sparks a lot of debate.

JC: And the other points about your film you want people to come away with?

LG: It's about the power of family, the power of love. Life is fragile. I'm a parent and I went home every day and just hugged my kids and remembered every moment with them is special...For the families involved I hope a community develops from this - a community of support for TBI patients and families.

JC: Thanks for your time and thanks for bringing attention to this important subject.

Thank you Google Images for use of Photo.

For more about TBI see:

CDC Concussion Management Tool from Medicine for the Outdoors written by our Chief Medical Officer, Paul Auerbach, MD

and this 18 minute video clip, on HBO's website.

Labels: Coma, family, HBO, Liz Garbus, mothers, persistent vegetative state, TBI, Terry Schiavo

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Ovarian Cancer Updates to Symptom Search and the Limits of Web 2.0

We were having our usual weekly Symptom Search meeting to discuss our most favorite product to date. One of our fabulous Marketing type people said, "Hey, have you seen the new report out about ovarian cancer and early warning signs?" Well, actually no, we hadn't. But my Symptom Search Partner, Product Manager Jack & I wanted to get right on it and update our baby to reflect the new findings. He sent me the US News and World Report link, which was great but, being a clinician I said, No can do without the clinical reference.

Despite our differences - at Healthline he is Class Valedictorian and I am Class Clown - and we butt heads regularly - he's a great guy. Within a matter of minutes, he sent me a link to the Journal of the American Medical Association (JAMA). The article is three years old, but it may have been the basis for further studies by University of Washington researcher Dr. Barbara Goff which led to the consensus paper by the American Cancer Society and other organizations. Our team went to work updating Symptom Search based on these new findings, and we are proud to report the results can be found on our website today. We hope this helps save lives.

It also points out, in my mind anyway, the limitations of Web 2.0, some of which I alluded to in yesterday's post. As a nurse and a clinician, I am bound by professional ethics no matter what capacity I serve - in healthcare. When it comes to matters of life and death, sickness and health, people need information they can rely on. So that's my line in the sand. Yes, websites are "infotainment". Yes, big pharma advertises on it. Yes, we blog away with a loose editorial policy. It comes down to our own professional ethics as clinicians within our organizations to say we can't really include this unless there is evidence to back it up. I recently joined the Association of Healthcare Journalists and it is a joy to be privy to the emails dicing and slicing the big rag stories - like yesterday's LA Times piece, Echinacea not to be sneezed at after all? Journalists have a code of ethics also and they critique each others handling of sensitive subjects. Questions like all echinacea is not created equal were raised and people ripped apart the statistics quoted in the study. Web 2.0 is all about "democratization or divide" as one commentator puts it. Web 2.0 is about tagging vs. taxonomy. In medicine and healthcare, we need a hybrid.


Thank you Movement on the Wire for use of photo A Mother Lost...

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Upcoming Events: HBO's COMA, IHI's Shared Quality Agenda & Medicine 2.0

Summer should be a time to kick back and take it easy (I think?) but it's going to be a busy month here at Healthline. First up, HBO is airing a new documentary, Coma, on July 3, 2007. Directed by documentary filmmaker and producer of Ghosts of Abu Ghraib Liz Garbus, the two hour special follows the lives of four families of brain-injured patients at JFK Johnson Rehabilitation Institute Traumatic Brain Injury (TBI) Model System in Edison, NJ. I had the opportunity to preview the film last night and found it refreshingly subtle. As a former neurotrauma ICU RN and TBI/catastrophic case manager, this is another one of those areas I'm passionate about. Garbus delicately teases out the subtle differences between persistent vegetative state (as in the Terry Schiavo case) and minimally conscious state (as in the case of Terry Wallis). Healthline is going to feature some more stories about TBI - Garbus' film triggered a flow of memories of some of my unforgettable patients I should share with readers - and we will update our popular Symptom Search to include more conditions associated with TBI. More about the upcoming show after I interview the director later this week...

The Institute for Healthcare Improvement (IHI) was kind enough to provide me with a press pass to attend the important upcoming conference, Engaging with Physicians in a Shared Quality Agenda here in San Francisico later this month. IHI is a not-for-profit organization dedicated to improving the delivery of health care internationally. They strive to accelerate the continual improvement of health care delivery in areas of safety, effectiveness, patient-centeredness, timeliness, efficiency and equity. There programs are legendary for being demanding, energetic, challenging and smart. Looking forward to sharing their vision and ideas with our readers.

Healthline Connects will be hosting Medicine 2.0 Blog Carnival on July 24, 2007. The brainchild of Bertalan Mesko of Scienceroll, whose professed hobby is the relationship of medicine and Web 2.0. Well, I prefer Health & Web 2.o, but healthcare bloggers, step up to the plate. You're doing the dirty work but start writing about it. What does Web 2.0 mean in your work and what is your vision of the future? I want to hear/read all your best stuff! For the uninitiated, Web 2.0 was coined by tech guru Tim O'Reilly in 2003 (correct me if I'm wrong). He's intriguing in that he studied Classics and his honors thesis "explores the tension between mysticism and logic in Plato's dialogues..." Cool. Check out the Web 2.0 Meme Map developed at one of O'Reilly's brainstorming sessions. Now think about applying it to the delivery of healthcare. Cool...Blogging, RSS, the wisdom of crowds are all Web 2.0 features. How do we square that with Evidence Based Medicine? Do you want the "wisdom of crowds" when you're trying to titrate your amiodarone drip? Didn't think so...

Finally, a group of us are going to see Michael Moore's Sicko this Friday. We'll let you know our reaction.

Thank you richardmasoner for use of photo of US CDC graph.

Labels: Coma, documentary, HBO, Liz Garbus, quality improvement, Sicko, Symptom Search, TBI, Tim O'Reilly, Web 2.0

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Voices : Somalia Situation is so bad. Everyday Killin

Our friend in Somalia continues to write to us: " I am not so old. I i have a big family my situation is really is not good. Somali situation is so bad. No peace. Every day killin and so many problem. fate bad. last month war. Every thing is chenged...really no peace somali at all. We are with our mother. This is our situation. Please tell me how can you help us...Thank you so much.

Her/His (?) words are evocative, like poetry.
Medicins Sans Frontieres/Doctors Without Borders (MSF) has been delivering aid in the country for 16 years, despite lack of a central government. They report that the escalation in violence in April and May, 2007 has destroyed the public health system. I found an MSF doctor who blogs from Sudan at Suddenly...Sudan. I posted a comment to his blog asking him to help us contact an MSF office in Somalia as a starting point for our friend. I also joined the organization so I can post to their Bulletin Board. We will keep at it and keep you all updated.

Sadly, the Washington Post reports things look worse instead of better, as the situation may be building up toward war between Ethiopia and Somalia. According to the report, the US Government is supporting the Ethiopian military action in Somalia because of alleged ties with al-Qaeda. Experts have already called it "Iraq on a small scale". A Global Anti-Aggression Campaign is forming, condemning Ethiopia and its collaborators, including the US. A Peace Summit is scheduled for July 20, 2007 in Mogadishu. Meanwhile roadside bombs are exploding daily, people are dying, and reports indicate that the Somali government just can't accept that the opposition is real.

What do bombs do to people? According to the CDC primer on Mass Casualties: Explosions and Blast Injuries:

• Injuries are predominately blunt trauma or penetrating wounds
• Explosions inflict multi-system life-threatening injuries on many people simultaneously
• Explosions are categorized as high-order explosions (HE) or low-order explosions (LE)
• HE are supersonic, overpressurization shock waves like TNT, C-4, Semtex, nitroglycerin, dynamite, and ammonium nitrate fuel oil (ANFO)
• LE are subsonic explosions like pipe bombs, petroleum based bombs, and guided missiles
• Each of the above causes a different pattern of injuries [WARNING: graphic images]

Categories of Injuries:

1. Primary:Blast lung, inner ear rupture, abdominal hemorrhage and perforation, eye rupture, concussion (without signs of traumatic head injury)
2. Secondary: eye penetration, blunt injuries
   
3. Tertiary: fracture and traumatic amputation, closed head injury
   
4. Quartenary: burns, crush injuries, asthma, COPD, angina, closed and open head injury
   

The CDC site provides more detailed information. There is just one thing they forget. One thing I hear whistling around the edges of my reader's emails. Heartsickness...sadness...depression...traumatic stress disorder. How do we keep people's heart's and spirits together when their worlds are blowing up and their bellies are empty?

See World Refugee Day: Bleak Picture for Somalis and Iraqis for more about this important topic.

Other potential leads:

• Representative Donald M. Payne D-New Jersey Chairman US House Foreign Affairs subcommittee on Africa and Global Health
• Georgette Gagnon, Human Rights Watch Deputy Director for Africa

Thank you ctsnow for use of photo Tank on street of Mogadishu.

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Thank you Dr. Jones, for Grand Rounds, 3.38!

Dr. Val Jones & the Voice of Reason hosted Grand Rounds, the weekly round-up of the best medical writing in the blogosphere of the week. She shares some fascinating, sad and entertaining stories over at Revolution Health. I want to thank her for including my post (it must have been that photo of the beloved Dr. Watson that won her heart - and mine!) Big Leap Forward in Understanding Genetics Underlying Prevalent Diseases.

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Global Healthbeat: Somalia, Country of War

We received an email from a reader in Somalia: "Can you help me. Somalia is a country of war."
War is the ultimate public health crisis, and Somalia, that beautiful strip on the coast of East Africa, home to ancient mariners, frankincense and myrrh has been paying far too long.

Somalia facts:

• Somalia has been without an effective central government for 16 years
• Warlord fighting, famine and disease have left 1 million dead - that is 10% of the population
  
• Life expectancy: 45 years
• Since April, 2007 the capital Mogadishu has been barraged by fighting between government forces and the Islamic Courts Union (ICU)
  
• The bloody struggle has resulted in yet another mass migration of the internally displaced. Access is limited, reporting is spotty, electricity is unreliable, but our understanding is that 400,000 are displaced. War crimes against civilians are reported by the UN.
• we understand they are without food, water, shelter and need IMMEDIATE humanitarian relief
• human rights abuses against women and children are rampant
  
• Somalia is now the world's most dangerous place for Minority groups.

WHAT can we, the international community do to help? Those close to the situation have these suggestions: Mobilize media, NGO and government interest to get food, education and jobs. More pressing survival concerns of water, sanitation, shelter and protection exist. The problems of security and access continue.

Healthline readers - let's help our friends in Somalia. Let's call, write letters, post YouTube videos bringing attention to perhaps the most dangerous place on earth. Who knows what our reader had to go to just to write to us. Let us do whatever we can to extend our hands back...

Thank you, Abdurahman for use of photo Welcome - Have a Deer.

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Biotechnology Comes of Age: Acquistions

Zip code 28077 - if you are into biotech, you know that's the US postal code for DNA Alley. A hot center of life sciences and technology along Interstate 270 in Gaithersburg, Maryland. Medimmune, the most successful of the region's biotechnology firms, succumbed to investor/shareholder pressure to seek a buyer earlier this year. Industry analysts speculate that MedImmune's board held onto its independence out of sentimental attachment and should have sold sooner. AstraZeneca is seeking to acquire Medimmune for $15.6 billion, the biggest deal in a flurry of deals reported by the Washington Post today.

MedImmune, maker of FluMist and Synagis, was founded 19 years ago by former government scientist Wayne T. Hockmeyer. Medimmune has its research campus in Gaithersburg and its manufacturing center in Fredrick, Maryland. Per the Company History provided on MedImmune's website, the company was incorporated as Molecular Vaccines in 1987. The name was changed to MedImmune in 1990 and the IPO was released in 1991. RespiGam was the first medication it produced which was licensed by the FDA.

RespiGam is a really interesting drug - given intravenously, it is a vaccine against Respiratory Synctivial Virus prepared with sterilized human plasma immune globulins. It is given to prevent RSV in children under 24 months old, with bronchopulmonary dysplasia or a history of premature birth (less than or equal to 35 weeks gestation). In 1995, MedImmune formed strategic alliances with Baxter Healthcare Corporation (multinational), Human Genome Sciences, and BioTransplant. That same year, MedImmune acquired exclusive, worldwide rights to human papillomavirus technology developed at the University of Rochester. In 1996, MedImmune built the Maryland Frederick Manufacturing Center (FMC). MedImmune and GlaxoSmithKline formed a worldwide human HPV vaccine alliance in 1997. In 1999, MedImmune acquired US Bioscience whose product portfolio included oncology and infectious disease products. 2001 was a big year for the corporation: MedImmune entered the world of nanoparticles with Vitaxin- a monoclonal antibody linked or conjugated to a radioactive isotope targeting cancer cells, acquired Aviron, a biopharmaceutical company focused primarily on the development of vaccines, and the FDA approved its Enhanced Yield Process (EYP) for expediting production of its products. 2002: MedVentures, Inc. (venture capitalist subdivision for developing treatment or prevention products for human disease), acquired exclusive rights to develop products against the newly discovered human metapneumovirus. 2003: FluMist was approved, the Board of Directors announced a buyback of $500 million of common stock. 2004: MedImmune and Medarex announce plans to develop and commercialize fully human antibodies for autoimmune diseases. 2005: MedImmune expanded its patent estate with reverse genetics technology acquired from Mt. Sinai School of Medicine.

AstraZeneca is a multinational pharmaceutical company with a product portfolio focused on cardiovascular, neuroscience, gastrointestinal, infectious, oncologic diseases. At any rate, its a Brave New World, people. Make sure your kids stay in school and study science. Make sure you and your kids have basic literacy in science so that you, and they, understand decisions that are made that effect life on our planet. Does this bode well for the future? Are we going to use science to solve some of the problems that cause human suffering? Or...

Thank you wanderinghome, for use of photo Back Against the Wall.

Labels: biotech, life sciences, stay in school

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Unsolved Mysteries: The Continuing Saga of our XDR-TB case

XDR-TB and all other emerging, infectious diseases have had my attention for a while. For some background information, read:

• XDR-TB: Extremely Drug Resistant, Extremely Scary
• Runaway Bridegroom: XDR-TB Comes (Back) to America

One of my colleagues here at Healthline is a microbiologist, and she was kind enough to help me track down some information to try to answer some of the unanswered questions in the case of our runaway bridegroom. I asked her about the process for identifying the strain of TB a patient has. She said, " In the old day, multiple drug resistance was rare, so TB susceptibility testing was not routinely done. The steps in the process are

• Obtain the specimen [sputum] from the patient
• Identify the bug (microorganism causing the infection)
• Subculture the bug to grow a pure culture: this is where the process can get bogged down, just growing enough inoculum to test
  
• Use the pure culture of the bug to test for drug resistance"

She went on to say "Patients with TB are treated empirically." This means patients are given the usual medications used to treat the causative organism, in this case the bacterium Mycobacterium tuberculosis(M. tuberculosis) ." Susceptibility tests are done only after patients fail to respond to empirical treatment and typically, the most common drugs would be tested. If the patient's sputum sample was resistant to all common medications, then additional medications would be tested. The National Jewish Hospital is/was way ahead of the Public Health Department in developing new drug susceptibility tests."

National Jewish Medical and Research Center, Global Leader in Lung, Allergic and Immune Diseases, is on the international radar because that is where our most famous TB patient since Mimi in Puccini's operaLa Boheme is being treated. Would it take 4 months to test the sputum sample? No. Focus Diagnostics Reference Laboratory indicates the studies would be done in 14 to 21 days from the time they received the pure isolate of the microorganism culture. My microbiologist colleague reports that the culture can be grown from a liquid sample within a week, and if you have just "...a single colony on a solid culture, it can take up to 6 weeks..."

I am no math whiz, but I'm pretty sure that is a little over 2 months. OK. So the scenario I imagine is that he falls, has a chest X-ray, TB is diagnosed and reported to the county public health office and he is treated empirically. He proceeds with his wedding plans. His TB doesn't respond to treatment and the lesion in his lung gets bigger. The only part of this that still doesn't add up to me is Dr. Cooksey, his father-in-law, TB investigator for the CDC. Would not he have discussed his case with him?

• According to the Atlanta Journal-Constitution, Dr. Cooksey "...prepared his son-in-law's specimen for DNA testing as part of his regular duties."
• The CDC's own website reports that Drug Susceptibility testing takes one month. The HPLC genotyping is most likely the aspect of testing Dr. Cooksey is involved in.
  
• AJC reports that Mr. Speaker feels the Fulton County public health officials and the CDC are casting aspersions on his character to "deflect questions about their own actions"
• What actions would those be? Working hard to try to solve some of the most challenging problems of humanity? Dedicating their lives to helping others?
  

Another source of my information is the CDC itself. I receive their Clinician Updates via email, and am on the Terrorism Listserve. Yesterday, I received CDC Clinician Communication: Information from Clinician Outreach and Communication Activity (COCA). The June 7, 2007 communique is a particularly robust "...summary of clinical guidance...of persons potentially exposed to XDR-TB on two transatlantic flights." Per this communique to Health Professionals who may be involved in evaluation and treatment directly impacted by this case, the CDC states:

• If a person is infected, it can take 8-10 weeks after exposure until the tuberculin skin test (TST) to become positive
• A first round of TST should be done as soon after exposure as possible, and a second round repeated in 8-10 weeks after exposure
• Consultation with a TB expert, one experienced in managing MDR and XDR TB, is highly recommended in any contact who is positive, who is suspected of having the disease or who is immunocompromised
• Resources for TB consultation include State TB Control Offices
• and the Regional Training and Medical Consultation Centers under the Division of Tuberculosis Elimination with the CDC
• Then there is the issue of the contacts of the contacts...
  

The case has triggered international investigations in Greece, Canada, the US and Italy. The DHS border guard who allowed the patient back into the US without detaining him has been suspended. Georgia State law does not allow health officials to restrict a patient's movement unless h/she violates a written directive. Mr. Speaker eluded being served a written directive when his fiancee (daughter of CDC TB expert) advised him to leave the country early so that he could rest and relax. Dr. Katkowsky, Director of the Fulton County Department of Health and Wellness, stated the patient changed his flight plan after he was advised not to travel during a May 10, 2007 family care conference. Health officials knew at this time he had MDR-TB.

• May 11, 2007 Fulton County Health officials wrote up a medical directive advising Speaker against traveling. A county disease investigator attempted to hand deliver the directive to Speaker at his home and business.
  
• May 12, 2007 A county disease investigator attempted to hand deliver the directive to Speaker at his home an business, but learned he had already left the country. He had informed health officials that his departure date was May 14, 2007. Sources confirmed that Mr. Speaker called Air France and asked to leave on an earlier flight.
• May 17, 2007: Health officials learned that Mr. Speaker has XDR-TB. Sources say he was instructed to go into voluntary isolation in a hospital in Italy. Speaker already knew enough about his diagnosis to have pre-arranged to be treated at National Jewish Hospital with medications and surgery. He had been told he had "...one chance to get the treatment right."
• Mr. Speaker was "...appalled..." that the CDC and the government was not going to help him out by footing the $140,000 bill for the private air ambulance.
  

Thank you alexanderljung for use of photo Partial microscope bacteria view.

Labels: CDC, consumption, La Boheme, microbiology, TB

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Big Leap Forward in Understanding Genetics Underlying Prevalent Diseases

The Wellcome Trust Case Control Consortium (WTCCC), a collaboration of 24 leading human geneticists analyzing thousands of DNA samples from patients suffering prevalent human diseases, have announced breakthrough research findings. Hailed as a "...new chapter in medical science...", genetic variants have been found for:

• depression
• Crohn's disease
• coronary heart disease
• hypertension
• rheumatoid arthritis
• Type I and Type II diabetes

Researchers involved with the studies are optimistic that these discoveries will lead to greater understanding about how diseases develop, who is at risk, and facilitate production of individualized therapies.

Some of the fascinating findings:

• Type I Diabetes and Crohn's disease share a common gene, suggesting similar biological pathways!
• An obesity gene as well as three new genes linked to Type II Diabetes

• The WTCCC used gene chip technology, which is not unlike microchip technology, enabling scientists to scan hundreds of thousands of DNA markers at once.

The WTCC is a UK based research group set up in 2005 with $18 million in funding.

Thank you jurvetson for use of photo Playing with DNA featuring James Watson!

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Thank you Inside Surgery for Grand Rounds 3.37

Healthline is proud to have six of our blog team featured over at this week's Grand Rounds at Inside Surgery, (formerly Surgery and You). The Wall Street Journal selected Inside Surgery as one of the best surgical sites on the web, March 20, 2006. Grand Rounds is a weekly round up of the best medical writing in the medical blogosphere. Thanks for including my post, Integrating IT into the Fastest Growing Sector of the US Economy - Healthcare. In addition to our Healthline writers, you will find some informative and entertaining writing - time much better spent than watching Grey's Anatomy reruns!

I'm a big fan of Bertalan Mesko, Hungarian medical student and blogger of ScienceRoll,
whose tragically funny piece, 10 Tips for How to Acquire a Disease, is featured. Another fav, Tara C. Smith over at Aetiology writes about the impact of the shortage of health professionals in Africa in Waiting for antiretrovirals.

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Runaway Bridegroom: XDR-TB Comes (Back) to America

If it wasn't so tragic for everyone involved, the unfolding saga of runaway bridegroom Andrew Speaker would make a screenplay starring the late Peter Sellers. I try to avoid blogging about the more sensational health news stories, but I wrote XDR TB: Extremely Drug Resistant, Extremely Scary back in March of this year. I feel a surreal detachment about emerging diseases - are the microorganisms going be our undoing? In the case of Mr. Speaker, there are more questions than answers. While I do regret that any patient's anonymity has been so completely compromised, at this point I join the fray in examining the troubling questions posed by his case, in the hopes that public interests will be better protected in the future.

• The big question is - how does an otherwise healthy young man from Atlanta Georgia get a tennis ball sized XDR-TB in his chest in the first place? We have MDR-TB in the US, and have had only 49 cases of XDR-TB cases since 1993.
  
• He was first diagnosed with TB in January, 2007 after a chest X-ray to rule out a rib fracture following a fall
• Tuberculosis is a Notifiable Disease/Condition in the State of Georgia. That means once the diagnosis was made by Mr. Speaker's health providers, authorities at the Georgia Division of Public Health would have been notified in January. Tuberculosis is a disease that must be reported IMMEDIATELY (others can be reported within 7 days, one month or 4-6 months).
  
• Reportable diseases are then reported to the national CDC on a voluntary basis.
  
• Mr. Speaker's father-in-law, Robert Cooksey, has worked at the Centers of Disease Control (CDC) for 32 years as a research microbiologist in the Division of Tuberculosis (TB) Elimination. Coincidence? Dr. Cooksey released this statement, "...I do not have, nor have I ever had, TB. My son-in-law's TB did not originate from myself or the CDC's labs, which operate under the highest levels of biosecurity." OoooK...
• Dr. Cooksey attended the wedding in Greece
• Dr. Cooksey helped diagnose his son-in-law's condition
• Dr. Cooksey helped track him down in Europe
  
• May 10, 2007: Mr. Speaker met with "local health officials" before planning his honeymoon to Greece. I'm sorry, maybe it's just me, but anytime you have to meet with local health officials before you do anything, maybe you need to just make other plans? An "official" said "Of course, I prefer you not travel." Mr. Speaker's father was present at this meeting and tape recorded it. Wow.
  
• This is way beyond any wedding plans I, or any of my friends ever made. I never had my dad come and tape record meetings with anyone for anything. I'm really getting confused. Someone help me out here. Just because you own a tape recording in which health officials say you are not contagious does not exonerate you. The fact that you feel you need to tape a conversation about your health status before you engage in an activity where you will be coming into contact with many other people might tip you off that you just want to stay home.
• Steven Katkowsky, MD, Director of Fulton County Department of Health and Wellness, said Mr. Speaker was told his traveling would be against medical advice. Dr. Katkowsky was NOT informed that the meeting was being tape-recorded by the elder Mr. Speaker. The beleaguered Dr. Katkowsky states there is a legal Catch-22 about restricting TB patients against their will. "A patient has to be non-compliant before you can intervene..."
• Fulton County Department of Health officials notified the Georgia Division of Public Health who in turn notified the CDC.
  
• May 12, 2007 Mr. Speaker flew from Atlanta, Georgia, USA to Paris, France
  
• May 14, 2007 Mr. Speaker flew from Paris to Athens, Greece
• May 16, 2007 Mr. Speaker flew from Athens, Greece to Thira Island, Greece. He claims to have gotten married there, but the Mayor of Santorini, Angelos Roussos, disputes this, stating the necessary paperwork for a civil ceremony was never obtained. Mr. Speaker did not contact the municipality prior to making his travel plans to get his paper work in order for his wedding...(hmmm...does he have issues with authority or something?)
  
• May 17, 2007: Georgia State Public Health officials learned Mr. Speaker had flown overseas.
• May 18, 2007: CDC learned Mr. Speaker was in Europe
  
• May 21, 2007 Mr. Speaker flew from Mykonos, Island to Athens, Greece then onto Rome, Italy
  

ANYONE WHO TRAVELED ON THESE FLIGHTS CALL 1-800 CDC INFO. The link for the actual flight details is on the CDC Website.

• At some point, a representative of the CDC in Rome called Mr. Speaker in Rome and told him he could not fly back to the US unless he chartered a plane ($100,000) and that he should check into a local hospital in Italy. He was told he would be placed on a no-fly list to restrict his movement. His parents say they "are not rich" and could not afford to charter a plane. Hmmm? Not rich? A month-long honeymoon in Europe...the dollar is so weak against the euro right now, my friends & I can't even consider a summer trip to "the continent".
• May 22, 2007: CDC determined Mr. Speaker has XDR-TB, or XDBTB (extensively drug-resistant strain)
  
• Question? How long does it take to test a sample of sputum to determine the strain of TB? I really do not know the answer and I am hoping some of our microbiologist readers can help us out.
• Question? When did Georgia Public Health officials notify CDC that Mr. Speaker had TB? ( was it May, January or some time in between?)
  
• Question? When did they begin testing the sample?
• The CDC notified Homeland Security through the regional office of Customs and Border Patrol (CBP) in Atlanta vs. the Washington headquarters.
  
• The CDC did not immediately inform Italian health officials, but waited for them to insist on the information.
  
• May 24, 2007 Mr. Speaker flew from Rome, Italy to Prague, Czech Republic. He deliberately changed his departure date and destination to elude authorities, slipping into the US via rental car. Mr. Speaker told Diane Sawyer in a TV interview that he was afraid of getting stuck in Italy so he made a decision to fly back to North America.
  
• The World Health Organization (WHO) and Italian Health authorities were notified that an XDR-TB infected US citizen had been at large in Europe.
• CDC & CBP alerted the Transportation Security Administration and DHS to place Mr. Speaker on a no-fly list.
• DHS wants to know why the alert was shared with field offices only
• they want to know why CDC did not notify DHS's National Operations Center so that agencies from the TSA to the Coast Guard to state partners could be alerted.
• Both the CDC and FBI resisted divulging Mr. Speaker's name and targeting an individual for public health reasons.
  
• May 25, 2007: The Greek Health Ministry was notified that an XDR-TB infected US citizen had been at large in their country
  
• An alert had been attached to his passport to warn customs agents to detain Mr. Speaker but the border guard waved him through. The warning was pretty explicit: "Hold traveler...don a protective mask...call health authorities....".
  
• May 25, 2007 Mr. Speaker was ordered into quarantine in Atlanta, GA by health officials. This is the first federal isolation order in 34 years.
• June 1, 2007 Mr. Speaker was flown to Denver from Atlanta under watch of federal marshals for specialized treatment.
  
• June 2, 2007, the New York Times reported that "...opportunities to head off...an international public health emergency were lost because of restrictive regulations, poor communication and questionable judgment..."
• The CDC withdraws the federal isolation order because the Denver, CO health agency order to detain him at the hospital "...is sufficient to protect public health."
  
• June 4, 2007: Homeland Security officials briefed Congress on how Mr. Speaker was able to elude CDC, border, transportation security and counterterrorism agencies despite the fact that they knew his name, passport number and whereabouts.
  
• So now Dr. Cooksey is being investigated, the border guard is being investigated, how many other lives will be hurt in the fall-out? What about the maids, the porters in the hotels, restaurants where the honeymooners stayed? We have another international public relations disaster with another US public agency so everyone will hate us even more than they already do.
• Per the CDC, this is the first investigation of a case of XDR-TB during air travel. The CDC urges all passengers on these flights to receive evaluation, testing, and follow-up. Your health provider can use this XDR-TB Investigation Form and contact your state TB officials.
  

My own personal tips for airline travel:

1. Always travel with a large headscarf (yes, even guys) and don't be embarrassed to wrap it around your ears, over your mouth and nose.
   
2. Take a mask and if someone near you is coughing or sneezing, put it on.
3. Take some hand wipes and use them every time you touch anything public, especially the bathroom.
4. Stay hydrated with bottled, non-alcoholic beverages.
5. Walk around and stretch out frequently to prevent deep vein thrombosis.

Finally, use common sense, concern for others and compassion when making plans. If you have an illness that is contagious and may infect others, just stay home. One sneeze can infect anyone five rows in front of you and two rows back on an airplane.

Thank you, purevizhun for use of runaway_groom.

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