How to handle Index MDR and XDR TB cases

Dr K K Aggarwal

Atlanta attorney Andrew Speaker’s case has started the debate on the role of compulsory isolation and quarantine in TB control.

In May, after being diagnosed with a drug-resistant TB he flew to Europe for his wedding.  While he was there, lab test at CDC indicated that he was suffering from XDR- TB.

CDC contacted  and asked him to stay in Italy. Fearing isolation in an Italian hospital, he flew to Prague and then Montreal, bypassing his inclusion on the federal no-fly list, which doesn’t apply to flights outside the United States. In Montreal he rented a car; then he drove into the United States.

Weeks later, while he was being treated at the National Jewish Medical and Research Center in Denver, laboratory tests revealed that he did not have XDR tuberculosis but instead had multidrug-resistant (MDR) tuberculosis. MDR tuberculosis is resistant to the first-line drugs isoniazid and rifampin. XDR tuberculosis is also resistant to a quinolone and to an injectable second-line drug.

Speaker’s case provoked a flurry of media attention and public outrage.

1.    MDR and XDR TB are a threaten the nation.

2.    These patients must be put on isolation and quarantine.

3.     Isolation applies to someone who is known to be contagious, and quarantine applies to not-yet-ill people who or goods that may have been exposed to a disease.

4.     Isolation and quarantine may be voluntary or compelled by law.

5.     TB is more commonly addressed by isolation than by quarantine

6.      Both the states and the central government have the authority, in appropriate cases, to compel isolation and quarantine.

7.     TB and influenza with pandemic potential are among the listed diseases.

8.     Patients who are isolated by law have right to counsel and a hearing before an independent decision maker.

9.      In TB courts have upheld detention when a patient has failed to follow medical advice.

10.   During the 1990s TB epidemic, New York City did not rely only on isolation orders; it increased funding for TB control and directly observed therapy.  Courts have pointed to the failure of particular patients to comply with directly observed therapy as a justification for detention.


1.     MDR and XDR should be isolated (voluntary) till they are non-infective on directly observed drugs.

2.     MDR and XDR should be isolated (legally) if they deny treatment.

3.     Rs 500 per month is given to all TB patients for nutrition. All XDR and MDR patients should be paid extra to cover the loss of wages during the period they become non-infective.

4.     Rs 1000 is given to doctors for completing a TB treatment case and Rs 10,000 should be given after fully treating an XDR or MDR case.

5.     Each XDR and MDR patient should be treated as an index case and mandatory testing of contacts should be done

6.     Open MDR and XDR patients should not be allowed to travel by public transport or visit public places till they are negative.

7.      MDR and XDR TB cases should be given job immunity. Like HIV AIDS such cases should not be discriminated in the jobs

8.     Newer MDR/ XDR drugs should be introduced in the country at the earliest.

9.     There should be designated centres in the country to treat MDR and XDR TB cases

10.  Admissions, all investigations and all related treatments costs should be born by the government

Dr K K Aggarwal

Recipient of Padma Shri, Vishwa Hindi Samman, National Science Communication Award and Dr B C Roy National Award. Gold Medallist Nagpur University. Limca Book of Record Holder in CPR 10

Vice President Confederation of Medical Associations of Asia and Oceania

President Heart Care Foundation of India

Group Editor in Chief IJCP Group & eMedinewS

Immediate Past National President IMA