Health Management Tuberculosis (TB)

Locking up XDR TB patients is ‘€˜extreme’€™

The detention of patients with extremely drug resistant (XDR) TB should only be considered as a last resort when all other voluntary measures have failed, according to the South African health department. By Chris Makhaye & Kerry Cullinan.

This week it was reported that XDR TB patient Robert Daniels from Phoenix, Arizona, has been kept in isolation in a US hospital ward since July last year after he failed to wear a face mask in public.

Daniels, 27, was ordered to wear a protective mask in public after he was diagnosed with XDR TB, which he contracted while living in Russia.

After discovering he was not complying with the order, the Arizona health authorities obtained a court order to lock him up because he was a danger to public health, according to Associated Press.

Daniels also had his radio, personal computer, cellphone and televisions removed by Phoenix county sheriffs.

He complained that he is effectively in solitary confinement and is only visited by masked medical personnel who ensure he takes his medication.
The Phoenix city health authorities wanted to keep Daniels in the facility for the rest of his life as they believed that XDR TB was incurable, reported AP.

Since the emergence of XDR TB in the Msinga area of KwaZulu-Natal over a year ago, 352 South Africans have been diagnosed with the deadly TB strain and 237 of these have already died.

Media reports about XDR TB have caused panic at some hospitals with calls for XDR patients to be kept in isolation.

Dr Ross Upshur, director of the Joint Centre for Bioethics at the University of Toronto, said authorities should detain people with drug-resistant tuberculosis if they were unco-operative.

‘€œWe’re on the verge of taking what was a curable disease, one of the best-known diseases in human endeavours, and making it incurable,’€ said Upshur.

Upshur warned that if XDR TB patients were not detained in a medical facility, they may spread their infection and soon Complete Drug Resistant TB (CDR TB) would develop.

However, health ministry special advisor Professor Ronald Green Thompson said that ‘€œnone of the XDR TB patients have declined treatment after appropriate counselling’€.

‘€œEnforced hospitalisation or quarantine of patients with XDR-TB is only justifiable as a last resort within a human rights framework after all reasonable voluntary measures to isolate individual patients have failed,’€ said Green Thompson.

AIDS Law Project head Mark Heywood said his organisation was against ‘€œany type of coercion of people with MDR and XDR TB’€ and that no reasonable person should oppose being treated for TB, even if this meant temporary seclusion so that they didn’€™t infect others.

But, added Heywood: ‘€œIn circumstances where patients with MDR or XDR TB refuse treatment, it may be justifiable to detain them as long as they are infectious. They should not be permitted to put others at risk, especially in the context of our severe HIV epidemic.’€

Heywood said the main problem in this country was not that people were refusing treatment but that many people were unaware that they had TB.

‘€œPublic health messages promoting TB literacy, and encouraging people to seek TB diagnosis and treatment are simply not being put out in South Africa,’€ said Heywood.

However, Green Thompson said that his department was working on improving ‘€œsocial mobilisation’€ about TB, as well as improving the TB treatment programme. Drug resistant TB has been caused by people not finishing their TB treatment, thus allowing the TB bacilli to mutate.

‘€œMDR-TB Units are being renovated to further strengthen infection control measures and increase bed capacity to accommodate XDR-TB patients,’€ added Green Thompson.

The World Health Organisation (WHO) said it noted the Daniels detention case with interest.

WHO’€™s Stop TB head, Dr Mario Raviglione, said that while his organisation was ‘€œdeeply concerned about the growing rate of drug-resistant TB, especially in South Africa’€, isolating XDR TB patients should be the prerogative of an individual state or country.

‘€œOur position is that all available measures should be exhausted before people are isolated,’€ Raviglione said.

A high-level delegation of WHO TB experts is in South Africa to offer assistance in control, detecting and surveillance of XDR TB cases.

‘€œI think the (South African) government is moving in the right direction in the fight against the epidemic and we are going to give all the support that is required,’€ said Raviglione.

The majority of the country’€™s XDR TB cases are still confined to Msinga, and all the relatives and close contacts of those with the TB strain have been traced and tested, according to Bruce Margot, head of TB control in KwaZulu-Natal.

‘€œAt first, 12 families absolutely refused to have anything to do with us. Because of the mass hysteria in the media, they were afraid that they would be persecuted. But they have since been persuaded to be tested,’€ said Margot.

Margot said the provincial health department was making a huge effort to contain those with MDR and XDR TB.

Until now, there have not been enough beds in the province for patients with drug-resistant TB, which has meant that infectious patients have had to wait at home until a bed becomes available. In addition, King George V Hospital in Durban was the only hospital dealing with drug-resistant TB, which meant patients had to travel long distances to get treatment.

By August, the province’€™s bed capacity for MDR and XDR TB will have increased from 240 to 703 beds decentralised throughout the province, said Margot.

About the author

Kerry Cullinan

Kerry Cullinan is the Managing Editor at Health-e News Service. Follow her on Twitter @kerrycullinan11