March 29, 2017
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Passenger with XDR-TB dies on 3-hour flight from Turkey to Germany

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A passenger with extensively drug-resistant tuberculosis, or XDR-TB, collapsed and died during a 3-hour flight from Turkey to Germany, touching off an unusual investigation to determine whether any of the other 162 passengers and crewmembers on board the plane were infected.

The incident, which happened in July 2013, was recently detailed in a Eurosurveillance report.

The unidentified patient died of infectious cavitary pulmonary TB while receiving first aid from three crew members and two passengers in the back of the plane near the cabin bathroom area, according to Maria an der Heiden, DVM, infectious disease epidemiologist at the Robert Koch Institute in Berlin, and colleagues.

Some passengers reported seeing the patient moving around the plane and coughing up blood, causing concern of widespread infection. But their recollections were disputed by all three crew members and one of the passengers who rendered first aid, and the investigators found only one other person on the plane — a passenger sitting in the last row — who was “probably” infected during the event.

The investigators agreed with those rendering first aid, concluding that an acute massive hemoptysis event happened in the last 30 minutes of the flight in the back of the plane.

An der Heiden told Infectious Disease News that cleaning personnel found blood only in the back part of the plane, not on the seats.

“Maybe the initial information that indicated that the patient had moved about the aircraft coughing blood was more a rumor than the reality,” an der Heiden said.

Privacy concerns prevented the investigators from disclosing certain information about the patient who died, including his or her gender and nationality. According to the investigation, the patient was flying alone after arriving in Turkey on an earlier flight from a country in Eastern Europe that is on WHO’s list of places with a heavy burden of multidrug-resistant TB (MDR-TB), raising suspicion that the patient might have a drug-resistant infection.

Fifteen of the 27 countries on WHO’s list of countries with a heavy MDR-TB burden are in Eastern Europe, but an der Heiden would not even note the prevalence of MDR-TB in the patient’s home country for fear it would give away his or her nationality. “The patient was a resident in the country of origin” of the first flight, an der Heiden said. (The investigators said they did not know if any attempt was made to contact passengers and crew on the earlier flight.)

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Despite little evidence that there is a risk for acquiring TB during air travel, the investigators attempted to contact and test all 155 passengers and seven crew members on the Turkey-to-Germany flight. Because of the severity of the patient’s symptoms, reports of the patient moving around the cabin, and the high rate of MDR-TB in the patient’s home country, the investigators considered the event a “public health threat” and went beyond European guidelines, which generally call for contact tracing only on flights that are 8 hours or longer.

Testing eventually confirmed that the patient’s TB strain was resistant to isoniazid, rifampicin, prothionamide, pyrazinamide, ethambutol, streptomycin, ofloxacin, moxifloxacin, amikacin, capreomycin and rifabutin, and was sensitive only to linezolid.

The passengers and crew members on the affected flight were of 17 different nationalities, but most were German. Investigators asked health authorities in the different countries to test them at least twice: once as soon as possible and once at least 8 weeks later. In all, 112 people from the flight were tested at least once for TB infection, including all seven passengers considered at high risk for exposure: the three crew members and two passengers who rendered first aid, and two passengers who sat near the patient. (An der Heiden and colleagues said those who rendered first aid were aware of the patient’s TB diagnosis because the patient had told another passenger about the condition.)

Evidence of “probable” transmission was found in only one passenger, a young Turkish adult who was sitting in the last row close to where the patient collapsed. The passenger reported receiving a Bacillus Calmette–Guérin vaccine for TB. In 14 other LTBI cases, including one person who rendered first aid, recent transmission could not be ruled out.

An der Heiden and colleagues said no secondary active TB cases related to the event had been reported as of this month. One of the biggest challenges of their investigation, they said, was the lack of a fast and reliable testing method for detection of a recent TB infection.

“The yield of the investigation strongly depends on the performance of the diagnostic test and an applicable test strategy,” they concluded. “Further efforts are needed to develop eligible tests that allow the detection of a newly acquired TB infection and that indicate the risk of progression of TB infection to active TB.” – by Gerard Gallagher

Disclosure: The researchers report no relevant financial disclosures.