An American man with a highly dangerous form of tuberculosis is under guard in an Atlanta hospital while health officials in many countries try to track down people he may have exposed to the disease on his way to Europe and back.
The dramatic episode represents the first time in more than four decades that the United States has invoked its authority to isolate and quarantine people with certain infectious diseases. Health officials and experts say it also exposes serious gaps in that authority.
In an hourlong conference call with reporters Wednesday, officials at the Centers for Disease Control and Prevention were beset by questions of what went wrong. In particular, how the unnamed man with extensively drug-resistant TB could have been allowed to leave the United States for a European wedding and honeymoon, and how he could have then flown back from Prague to Montreal despite stern official warnings not to travel on commercial aircraft.
"We did everything we could by reaching out to the various systems and tools that we had," says Dr. Martin Cetron, chief of the CDC's global migration and quarantine division.
He says the case was a breakdown of the usual measures, which rely on moral suasion.
"This is a cooperation of public good, public trust," Cetron says, "and we need to rely on people to do the right thing and we don't move quickly to compulsory orders for isolation or quarantine, and we take the use of those quite seriously."
But experts say it also points out that compulsory orders, when the government resorts to them, are really a paper tiger.
Dr. Mario Raviglione heads the World Health Organization's "Stop TB" program. He says laws barring potentially infectious people from traveling only work if they're uniform among nations.
"If that is not uniform — at the moment it is not —- then there is very little you can do, frankly," Raviglione says.
The best approach, of course, is to prevent someone with a potentially dangerous infection from traveling.
"That's the first thing to be done. And the most important lesson really is how we prevent these type of episodes from happening again in the future," Raviglione says.
But this case reveals that preventing someone from traveling is not easy to do. By the emerging accounts, county public-health authorities in Georgia were apparently reluctant, uncertain and unclear about when and how to stop someone with a particularly dangerous infection from traveling. They advised the TB patient not to travel, but CDC officials say the man left before they could put it in writing.
Once such a person has boarded a commercial aircraft, there's no law that says airlines have to tell public authorities who else was on the flight who might have been exposed.
Raviglione says that in the past, not all airlines have cooperated with releasing that information. Part of the reason is concern over confidentiality. Part of the reason is the cost of keeping track.
Officials are well aware of the gaps in their legal authority. A year ago, the CDC proposed regulations modernizing its authority to isolate and quarantine those with infectious diseases. Those regulations have gotten bogged down in controversy.
Lawrence Gostin of Georgetown University Law School thought of those regulations when he heard about this week's case.
"My first reaction was, 'Well, here is another case where we have a potentially serious infectious disease that could affect the United States, and we still don't have the legal tools to make sure that we do it properly and constitutionally," Gostin says.
Gostin says he can sympathize with the TB patient's decision to come back to the United States for treatment, no matter what officials were telling him.
"Most American citizens would want to come immediately back to the United States for treatment," Gostin says. "That's the right instinct. Unfortunately, if you've got a highly infectious disease — you have to resist that impulse. And if the person doesn't resist that impulse, you have to have some form of legal authority to make sure that they're not infectious during their travel back to the United States."
Gostin hopes this case will finally break the logjam on updating the nation's quarantine laws, and that other countries will follow suit.
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