MDR-TB and its RELATIONSHIP TO QUARANTINE LAWS by Gerald Roger Clough
Tuberculosis is a severe disease caused by the bacilla mycobacterium tuberculosis humanis . The bacteria is slow moving and measures 1/25,000 of an inch. While the bacteria can live in the kidneys, the bones or the brain, it prefers to settle in the lung. The bacillis is inhaled in a droplet of liquid and eventually breeds.
Unlike AIDS, TB can be spread through what is commonly termed casual contact ( ie ., coughs and sneezes); it is important to note, however, that the most likely way for TB to spread is through what health experts term close and prolonged contact.
While it is theoretically possible to be infected with a sneeze , it is through the close and prolonged contact through which the germ is usually spread. Close and prolonged contact is considered to be six to eight hours a day for six months . This can be, as one can imagine, a particularly vexing problem in crowded, poorly ventilated areas.
Worldwide three million people die annually from TB. Like many causes of death that have virtually disappeared via medical technology in the developed countries TB, as evidenced by the above statistic does most of its damage in the third world where life can be more crowded and less ventilated.
In 1991, there were 26,000 cases of active TB reported in this country. There are varying estimates as to the numbers of people in this country who might be carrying around the bacteria that cause TB. Depending on who is asked, the number of carriers range from 10 to 15 to 30 million people.
Worldwide, according the World Health Organization (WHO), nearly two billion people carry the infection with 20 million active cases. In most all cases, the disease lies dormant, held in check by the body's immune system; for the ten percent who develop the active disease and allow it to go untreated the symptoms are: coughs, fever, weight loss and blood spitting; people in the United States used to fear TB like they now do cancer , heart disease and AIDS.
Then after the years of terror, in 1943 came the antibiotics that doctors found effective in treating TB and thanks to a massive medical effort, the disease was on the run.
The medical community began to focus its attention to chronic conditions such as heart disease and cancer. By the mid 1960s, it appeared that the medical community had all but abolished TB due primarily to a combination of three antibiotics. Santitariums were closing. In 1984, the United States recorded its lowest TB rates in history.
It was in 1990 that the CDC renamed its "TB Control Division" to the "TB Elimination Division; then a couple years later—almost out of nowhere like the plagues of yesteryear, a May 1992 New York Times article reported that CDC officials said that TB was out of control in the United States.
TODAY'S TB
Probably the most startling development in TB's recent resurgence is the emergence of a distinct and far more troublesome form of the disease, termed Multi-Drug Resistant TB (MDR-TB). Health experts say that drug resistant TB has been
around at very low levels for decades but the strains were
considered so rare that it was, statistically speaking, ignored until recently. The well known--or traditionally examined-- form of TB is now normally relatively simple to diagnose and treat.
Most patients can be made non infectious after a few weeks and a complete cure consists of strictly following a regimen of antibiotics from anywhere from six months to two years.
Many people begin feeling better after a few weeks of medication . And it is true that these people are most likely non infectious at this point. What happens is the TB patient begins treatment , feels better—becomes non infectious after a couple of weeks then ceases the medication.
Some suggest the cessation of treatment is almost logical because of the prevalence of unpleasant side effects. The most common side effect is nausea which, according to Dr. Michael Iseman , Chief of TB Services at Denver 's National Jewish Hospital, makes the cure appear worse than the disease.
The current epidemic is primarily ravaging poor, primarily inner city areas (very similarly to the 19th century epidemic) it hits people who are less likely to be given the proper medical advice regarding the disease which grows invisible after a few weeks of medication.
As Dr. Jordan Glaser of the Staten Island University Hospital said on a recent CNN HealthWeek program, "for the homeless, it's not as if they pick up their cellular phones and call and tell me 'Hey, Doc, I have a problem.'"
A study of patients at New York ' Harlem Hospital found that 90% of patients hospitalized for TB did not finish their treatments . In Houston , seven to 10 percent of TB cases are drug resistant. In 1991, the CDC estimated that 14.1 percent of new TB cases were drug resistant to one drug and 3.3 percent were resistant to two or more.
In New York one in three cases of TB were resistant to one drug and one in five resistant to many antibiotics.
One of the more chilling aspects to these numbers besides the relative ease with which TB can be spread is the fact that a person with a contagious form of MDR-TB infects the next person with a form of MDR-TB and not just the original, more easily treatable TB. It is generally agreed that each infectious person has "strong chance of infecting anywhere from eight to 12 people. There is a case out of rural Maine where a shipyard worker infected 412 of his co-workers.
It is difficult to imagine another health problem that poses as serious a public health threat than the current form of MDR-TB. The TB bacteria which are exposed to insufficent or incomplete doses of antibiotic develop defenses to that antibiotic
Until the early 1980s, one will find newspaper and magazine stories that treated TB like it was some sort of extinct malady like polio. There is a story of a street preacher who claimed God had cured her (1982); there is a New York Times piece dealing with TB ravages inside Alaskan Native villages (1983); a story about a 79 year old man who had been resisting treatment for the disease since 1969, finally agreeing to treatment in 1987. Then there was what appeared to be an isolated outbreak in an Alabama prison in what we will see was a grim foretelling of what was to come. In 1988, New York City based Newsday ran this headline:
An Old Killer Stalks City : Tuberculosis, Once Nearly Extinct Resurges.
In December of the same year, The Washington Post reported that a TB related quarantine was being lifted in an Alexandria jail. It was in November of 1991, that a Gannet News Service story reported on what is probably the most infamous of MDR-TB outbreaks. The headline:
Untreatable TB Strain Kills 13 in N.Y. Prisons. Eventually 13 prisoners and one guard would die as a result of the drug resistant TB. According to reports, all the victims had compromised immune systems of an unspecified nature. According to the same New York Times report, sources said all 12 inmates had tested HIV positive; the guard's immune system, the sources said, was compromised because he was suffering from cancer. When a thirteenth inmate died soon after the initial report, Federal Health Officials confirmed that it was a single strain of MDR-TB that caused all of the deaths.
This was particularly bad news because eight of the deaths occurred in New York City and the other six were in upstate New York . This meant the strain was apparently spread between widely separated points in the correctional system.
The empirical evidence that these deaths were the result of single type of bacteria came from the CDC . James Flateau , a spokesman for the State Department of Correctional Services, said that a records check of those who died showed that both groups of victims had never come in contact with each other in the prison system. That suggested , he said, that other inmates infected with the new strain had carried it between the prisons, and perhaps to other prisons as well.
Studies have shown that TB rates run as much as three times higher in NY prisons than on its streets. One study has shown that approximately 24 percent of inmates are at least TB carriers .
The 1991 Alabama outbreak is probably the incident that epidemiologists will point to as the one which reawakened America 's consciousness to a disease that was resurging with a vengeance . While the numbers of health officials who say that the resurgent epidemic was "completely avoidable" are legion, it is apparent that medical officials are again hard at work fighting MDR-TB.
Ironically (and maybe logically), it is in the very places that allow TB to fester and spread that control and eradication is the easiest: prisons.
Because of the lack of mobility of the inmates, coupled with reduced standing for most civil liberty claims and the huge amounts of discretion left to correctional facilities regarding health and safety matters, it is likely that prison outbreaks can be effectively checked.
For instance, in Illinois every person booked into the Cook County Jail is given an X-ray and those who test positive are given the further test of a chest X-ray; a September 1992 article reported that 20 percent of Cook County inmates were infected with TB.
In California officials had tried to perform wide scale testing in the past but were frustrated by the constant movement of the prisoners within the system. In early 1993, though, the state halted movement of the 117,000 person population for an entire weekend. During this hiatus, all prisoners were tested and no one was allowed to move until their TB status was determined. Six infectious cases were discovered. "We're going to control it in the prisons... [b] ut the real question is how are you going to control it now that it is established in the community?" asked one prison official.
Because TB once killed thousands—mostly in crowded slums-- that concern is not a mild one, particularly when one remembers the 26,000 or so cases reported in the U.S. in 1991.
There is a general medical consensus that a single infected person can infect, on average, anywhere from eight to 12 people during the disease's infectious stage. That does not take into account the possibilities of passing on MDR-TB during a separate and later re-infectious stage.
One must remember, of course, the vast majority of ordinary citizens who may be at risk while living in the crowded conditions of the inner cities.
To get an idea of how this disease is affecting the so called marginal members of society, it may be helpful to' examine a recent incident in Ventura County , California . Headline of the August 24, 1993 Los Angeles Times:
"Countywide Focus: Help is Sought in Finding Infected ,Man ."
August 25 Headline: "Transient with Contagious TB Shows up at Hospital."
The man sought was a 34 year old homeless man who was wanted for violating a quarantine order. The man ignored the qurantine order, issued by the Ventura County Health Department and had been missing for two months. Just how dangerous a person walking around a city carrying TB for two months is not agreed upon. But it is generally agreed that people with normal immune systems are unlikely to be infected by transient exposure such as will occur while on a bus or subway. (NY TIMES; Nov. 16, 91 ).
Tuberculosis is much easier spread between those who, live or work closely together.
This is particularly so when ventilation is poor. Homeless shelters are also shelters for TB bacteria; in New York City shelters, for instance, as high as 43 percent of occupants are estimated to be infected.
It is HIV patients who, according to a Houston Chronicle report , account for 90 percent of the modern MDR-TB cases.
These patients develop a, "virulent, almost immediately active disease that is deadly in 70 percent to 90 percent of cases." Reporting on the World Congress on Tuberculosis (held in November 1992) Aids Weekly quoted Dr. David Rogers, a professor of medicine at Cornell and the then vice chairman of the National Commission on AIDS.
Rogers said that society must protect itself from those who are infected with TB and who are non compliant in their treatment.
"In situations where compliance is uncertain," Rogers said, "directly observed therapy must be employed and mechanisms must be in place to contain or quarantine the occasional bad actor who refuses treatment."
~ In December 1992, the American Lung Association ( ALA ) released a report in response to the growing problem entitled, "Control of Tuberculosis in the United States ."
Included in the recommended procedures is a "network of health care workers who would actually watch people taking their anti-TB drugs, an idea called 'observed therapy.'"
This is the same as the aformentioned directly observed therapy. Whatever the name, the idea is to use some force to insure patients take their medications-but stop far short of an actual quarantine.
The report also discusses the more drastic measure of quarantine .
The ALA considers quarantine a last resort, but sometimes necessary. . "The issue'becomes protecting people," said ALA President Dr. Lee Reichman , "the right to protect people supersedes an individual's rights. You have the right to breathe smoke-free air--you should have the right to breathe healthy air ."
As of this writing, it appears that public health officials and the politicians of the country have recognized that this resurgence of TB needs to be addressed fully and vigorously.
It is therefore helpful to survey what medical measures are currently being undertaken. As we have seen transmission is a huge concern to the medical community. Transmission, coupled with the fact that those who cease their medications too early are at risk of developing and then spreading the MDR-TB has led to what some are calling "draconian" measures to prevent further spread of MDR-TB.
Quarantine laws are nothing new to this country, nor is there much chance of them being struck down on Constitutional grounds due to a combination of stare decisis and strong health and safety grounds which create a very compelling state interest.
Before recently, however, these laws were written in a manner that have tied the hands of health officials who are now trying to do something about the modern strain of MDR-TB.
The major problem with many of these laws was that a person could only be held against his or will--after refusing treatment--if they were actually infectious at the time the health department wanted to quarantine them. A sample of a growing number of public health laws reveals that stricter handling of TB cases is the current and likely near future norm.
In July 1993, ' Maryland moved to toughen laws in effect to insure the curbing of the drug resistant TB which can occur if a person stops the treatment prematurely.
Typically, what happens is that the infectious patient begins treatment but then stops .. when he or she begins to feel better. This is usually after a few weeks. The problem is that the complete cure "takes at least six months."
This beginning of treatment that ceases allows the still present TB germ to become "smarter"-- ie ., develop drug resistance . A big problem with the medications taken to cure the disease is their side effects, most notably nausea. According to medical experts, "the cure soon seems worse than the disease ."
The Maryland Department of Health and Mental Hygiene recently issued new regulations that deal with the problems that a recalcitrant MDR-TB patient can pose.
The new regulations recognize that the person who becomes non contagious while taking the requisite medication may become contagious again--this time passing on MDR-TB.
The 1993 regulations, according to Ebenezer Israel , Maryland 's Director of Disease Control and Epidemology , allow medical supervision until the patient is completely cured. Israel also stated that quarantine will be used in only the most stubborn cases. "The very fact that we have the authority makes a lot of people come into compliance," Israel said, "I would not hesitate to use it, but I would only use it as a last resort."
New York , the epicenter of the modern TB epidemic, has also recently amended its well established police power which gives it the power to quarantine in the name of public health. The regulations went into effect in April after being passed in March after approximately a year of debate between civil libertarians and public health officials.
The new regulations allow the City Health Commissioner to detain, for as long as two years, patients who are no longer infectious and appear to pose no danger of immediate transmission.
It appears to be generally accepted that the new rules have introduced notions of due process into the health and safety field , a place that has traditionally allowed the state to significantly undercut civil liberties when public health is at stake .
The new rules, according to New York City Health Commissioner Dr. Margaret A. Hamburg are important adavances because they establish two critical goals. "One," she said, "is to introduce due process into detention, and the other is to clarify the circumstances in which detention is appropriate."
"The Health Department deserves real praise," said Robert M. Levy, Senior Staff Attorney at the New York Civil Liberties Union after the passage of New York 's updated quarantine laws. Levy was one of the key players in the updating process.
Some highlights of the legal machinations at work in the new quarantine regulations:
1) In order to confine, the health commissioner must show, by clear and convincing evidence, that voluntary compliance efforts have failed.
2) If a patient is to be detained for a "long term detention", he or she has a right to request release.
3) Within 72 hours of the request, the commissioner must get a court order authorizing continued confinement.
4) If this court order is denied, be held for only five days.
5) If the patient/detainee does not ask to be set free, they can be detained for 60 days before the commissioner has to go to court.
6) Judicial review of the detention is to be conducted every 90 days.
7) TB patients who are to detained are to be advised of their right to representation, if necessary at the city's expense.
8) Because legal counsel is provided and periodical review occurs, immediate appeal is unavailable.
While there are many who are applauding these new due process conscious quarantine laws, there is another school of thought whose members think that the most humane and cost efficient way to go is a mixture of almost directly observed therapy that works because it induces--rather than coerces- patients into being treated.
Among the incentive advocates is Tom Privett , program administrator for the Virginia Bureau of TB Control who says, "The key to beating TB is not isolation laws. The key is to come up with incentives that give a person some reason to comply with treatment."
In Virginia , for instance, the TB infected homeless are given housing during their treament . Dr. Paul Davidson, Los Angeles ' TB Control Officer, credits a patient incentive program with drastically reducing the number of people who must be confined in order for them to be treated. The incentive program uses a community health worker who goes to places where the homeless gather.
The health worker then offers them food and lodging vouchers as long as they go to a clinic and get treatment.
This program has been credited with increasing the treatment rate from 50 to 90 percent.
Another incentive success story can be found in Denver . Dr.John Sharbaro , formerly Denver 's Director of TB Control, has been a voice advocating incentive programs to bolster treatment compliance.
As a result, Denver has apparently been spared the TB resurgence. The CDC and the American Thoracic Society have issued their opinions as to how this problem should be addressed in a recent Journal of the American Medical Association and goes as follows: "CDC and the American Thoracic Society recommend that consideration be given to treating all TB patients with DOT [Directly Observed Therapy]. Commitment for inpatient management is indicated for patients who, after receiving a range of less restrictive treatment options, remain nonadherent and who pose a substantial efficient way to go is a mixture of almost directly observed therapy that works because it induces--rather than coerces- patients into being treated.
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