News of the quarantine of a Georgia man with an extremely drug-resistant strain of tuberculosis (XDR TB) has heightened our concern and raised many questions. Andrew Speaker — the first governmentordered quarantine case in the United States since 1963 — traveled on two trans-Atlantic flights and potentially exposed other travelers to the serious disease. Recent articles report XDR TB from areas of Asia, South Africa and the former Soviet states.

With the number of travelers coming through our Islands and our geographic isolation, how prepared are we to handle similar situations?

First, understanding is key.

Tuberculosis is a common respiratory ailment that has plagued mankind

through the ages. It afflicted Europe and continues to plague Asia and sub-Saharan Africa today. In Hawai'i, tuberculosis is thought to have been introduced to Kaua'i in 1778. During a survey for bubonic plague at the turn of the century, health authorities found abundant tuberculosis in Honolulu. Sanatoriums, such as Leahi, began to quarantine TB patients in the early 1900s before the antibiotic streptomycin was developed during World War II.

Considered the most common infection in the world, one-third of the world's population is estimated to be infected with Mycobacterium tuberculosis, the bacterium that causes TB. Tuberculosis can be spread through the air when someone with active TB talks or coughs in close proximity to others. Hawai'i continues to have one of the highest rates of active TB in the nation: Hawai'i's rate is 8.9 per 100,000 compared with the national rate of 4.6 per 100,000 .

However, Speaker's XDR TB is not the typical tuberculosis; his is an extensively drug-resistant TB that is difficult to treat and can be passed through the air. Fortunately, Speaker is thought to be minimally contagious.

The Hawai'i's Administrative Rules, which are currently being revised, mandate who needs TB clearance in Hawai'i. Students, immigrants and food handlers are among those currently required to have screenings. Suggested revisions include adopting a risk assessment to screen only those at highest risk for developing TB and inclusion of new blood tests for TB infection. Some in Hawai'i believe we should reduce the amount of mandated screening; however, this controversial issue must be further discussed in light of this recent XDR TB case.

Prior to entering the United States, some immigrants are required to have medical evaluations in their countries of origin that include an X-ray to examine for tuberculosis. Working with the Honolulu Quarantine Station, the Hawai'i TB Control Program re-screens approximately 95 percent of the recently arrived immigrants who have abnormal X-rays. Other high-risk communities in Hawai'i include immigrants, workers and students from TB-endemic areas of the world — particularly Asia and the Pacific Islands.

TB control is a complex strategy that aims to promptly identify an active TB case, isolate the patient if infectious, initiate medications and reduce transmission to close contacts. For a TB case, it is imperative to have directly observed therapy to ensure that medications are taken, as prescribed, to minimize drug resistance.

The Speaker case raises the stakes. The fact that he readily traveled through several countries illustrates the need for us to review our international, national and local policies to ensure they are stringent enough to protect public health. Locally we need to review our current practices to further reduce any loopholes in our surveillance and renew our vigilance. That means reviewing our strategies for finding cases, tracking those who might have had contact with an infected patient, and reviewing our infection control, isolation and quarantine regulations for drug-resistant TB cases. Since 80 percent of the TB cases in Hawai'i are among non-U.S. born, importation of TB remains the most common method of introducing TB to Hawai'i.

In April, we conducted a large investigation of a TB case from a ship in Hawai'i, rapidly and aggressively screening more than 200 contacts within a one-month period. In a close collaboration with the Honolulu Quarantine staff, the Hawai'i TB Control Program was able to detain a second patient with early-stage active TB. We were informed of the abnormal lab tests at 8 p.m. the previous evening. By 11 a.m. the following morning, the patient was barred from leaving Hawai'i, as he prepared to board a 10-hour flight to Asia. He remained in Honolulu on medical parole and was required to take medications under our supervision. Both these cases were typical tuberculosis cases, not XDR TB. Still, they reflect our most recent test of the system, and, fortunately, the system responded well.

As with most prevention strategies, there is room for improvement. For example, diagnostic tests to detect drug resistance more rapidly are needed. We also need better medications and strategies to handle multi-drug resistant TB and XDR TB; newer medications and regimens to reduce the six-month course of treatment; and improved continuity of care, including being able to coordinate TB care internationally.

It is encouraging to see new blood tests, new drug regimens and new vaccines being actively researched. New blood tests are on the horizon, pending approval from the U.S. Food and Drug Administration. Still, TB control programs across the nation are in dire need of more support for fundamental prevention and control programs and effective research — especially now that XDR TB has penetrated our airspace and may represent the most significant, recent challenge to our public's safety.

Thus far, XDR TB has been reported in more than 30 countries, and in 15 percent of the lab samples in Korea. With millions of domestic and international visitors arriving in Hawai'i each year, we would expect to see XDR TB in Hawai'i in the future. How we prepare now will determine how we fare when the real challenge is upon us.

Dr. Jessie Wing is a medical officer for the Centers for Disease Control assigned as chief of the Hawai'i State TB Control Program and a captain in the U.S. Public Health Service. She wrote this commentary for The Advertiser.