11 December 2008

Why quarantine may backfire

XDR-TB patients are being kept behind fences. Is this sensible, or a crucial error in the fight against the epidemic?

Recently a patient was shot and a guard stabbed when XDR-TB patients were protesting at the Sizwe hospital in Edenvale. According to reports the patients were unhappy with some of the medicines they were receiving and wanted passes allowing them to leave the hospital.

The incident illustrates some of the difficulties regarding enforced isolation of XDR-TB patients and is symbolic of what some critics consider to be the department of health's harsh response to the threat posed by XDR-TB.

In fact, at some sessions at the recent 38th Union World Conference on Lung Health the general feeling seemed to be that forced isolation is not the most effective way to face the threat of XDR-TB.

According to Nathan Geffen, spokesperson for the Treatment Action Campaign, incarceration is a bad idea for various reasons, which he lists as follows:

  • Most XDR infections are taking place at hospitals and clinics.
  • It can never be done on a scale that would make a significant difference to the epidemic.
  • It scares people off getting screened for TB and therefore might have a very deleterious effect on managing the epidemic.
  • People who get locked up without having committed a crime realise their human rights are being breached. Sometimes they riot, as happened at Sizwe hospital. It's particularly cruel to incarcerate people with fatal diseases for six months or more, especially children.

In a statement on the issue, the South African Medical Research Council warns that, "Public anxiety coupled with the risk that XDR-TB may rise to epidemic levels in SA is putting increased pressure on government and public health authorities for quarantine of patients and coercive measures to curtail the spread of XDR-TB. The dual stigma associated with TB and HIV, now compounded by XDR-TB, poses a real risk of driving the XDR-TB problem underground, especially if isolation measures are coercive. This is a situation that SA can ill afford."

Perspective on the disease
According to Judy Seidman, writing in the Mail and Guardian, quarantine of actively infectious people forms a standard part of the medical response to drug-resistant TB. The emphasis here is very strongly on "actively infectious."

She points out that, "many people with TB (and even XDR-TB) are not infectious. Patients who do not cough do not spread infection through the air. Patients who respond to treatment are no longer infectious after the drugs take effect. Patients need to be quarantined only until the drugs start to work - for days, not weeks or months."

On a similar note, much of the societal concern with drug-resistant forms of TB seems to be based on misconceptions regarding the disease.

According to the World Health Organization (WHO), drug-resistant forms of TB are not more infectious than strains that are not drug-resistant. In fact since they are less prevalent, the risk of being infected is much lower.

According to the WHO, "the majority of healthy people with normal immunity may never become ill with TB, unless they are heavily exposed to infectious cases who are not treated or who have been on treatment for less than about one week. Even then, 90% of people infected with TB bacteria never develop TB disease. This applies to XDR-TB as well as to ‘ordinary’ TB."

Why HIV ups the risk
Thus, unless your immunity is compromised and you are in relatively close contact with an infected person in a closed space, the risk of infection is very low. This is why there is a particularly high risk of drug-resistant forms of TB spreading in hospitals. The compromised immunity is also what places HIV-infected people at a higher risk.

The WHO writes that, "People with HIV infection, however, in close contact with a TB patient, are more likely to catch TB and fall ill. The TB patients whom they meet should be encouraged to follow good cough hygiene, for example, covering their mouths with a handkerchief when they cough, or even, in the early stages of treatment, using a surgical mask, especially in closed environments with poor ventilation."

The way forward
Voices at the conference generally seemed to be in favour of a decentralised, community-based model in the fight against drug-resistant TB.

According to Geffen, "What we've got to do is improve infection control in health facilities."

"XDR patients should be educated on infection control measures (e.g. cough etiquette, maybe wearing masks and a few other simple measures) that can reduce the risk of them passing on the disease," he said.

Government not budging
The department of health, however, seems very much to be keeping the focus on the isolation of infected persons.

Presenting South Africa's new plan to fight TB, the director general of the department of health, Thami Mseleku, said the department is looking for ways to make it easier to commit people with drug-resistant tuberculosis to treatment facilities against their will.

Until now, health authorities had to get a high court order every time they wanted to commit someone who posed a danger to the community.

"We're still exploring the alternatives," he said. The department was looking for clauses in existing legislation that would allow "a general approach to the matter".

On the legality of enforced isolation, the Medical Research Council (MRC) writes that, "current health legislation in SA empowers authorities to detain patients with infectious diseases until the disease no longer poses a public health threat, thereby allowing quarantine restrictions to be enforced for a limited period. Herein lies the dilemma: many XDR-TB patients may have untreatable disease and confinement would have to be until death or, conceivably, could be indefinite. From a human rights perspective prolonged isolation could, without sufficient procedural safeguards, violate several SA Constitutional rights and international human rights law."

According to Seidman, the media's response, like that of the government, has been rather one-dimensional. She writes, " These articles present arguments saying we should protect ourselves by harsh “control” of sick people, even where this negates their human - and constitutionally guaranteed - rights. This theme has become our most common response to XDR-TB."

False sense of security
In the New England Journal of Medicine, researchers write that, "excessive reliance on compulsory measures can lull the public into a false sense of security and at the same time prompt people who are at risk to do exactly what Speaker did — run." (Andrew Speaker is an American man who fled from authorities after being diagnosed with drug-resistant TB.)

They continue writing that, "fortunately, most persons infected with tuberculosis want treatment and have no desire to infect others. When clinicians and health officials work with patients and have their trust, most will co-operate. By ensuring that coercion is used only when less restrictive alternatives will not work and with due regard for the rights of those detained, the law can foster public trust, minimising the need for compulsion and laying the groundwork for the comprehensive and costly control programs needed to prevent the spread of XDR tuberculosis and other contagious pathogens."

- (Marcus Low, Health24)

World Health Organization FAQ on XDR-TB
Legal Power and Legal Rights — Isolation and Quarantine in the Case of Drug-Resistant Tuberculosis - New England Journal of Medicine.
A response from hell - Mail and Guardian.
SAMRC position statement on the detention of XDR-TB patients - South African Medical Research Counsel

Read more:
The quarantine controversy
Multi-drug resistant TB
SA in deadly TB fight

November 2007


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