Public health law and tuberculosis control in Europe

Preventing Occupational Tuberculosis in Health Workers: An Analysis of State Responsibilities and Worker Rights in Mozambique

Given the very high incidence of tuberculosis (TB) among health workers in Mozambique, a low-income country in Southern Africa, implementation of measures to protect health workers from occupational TB remains a major challenge. This study explores how Mozambique's legal framework and health system governance facilitate-or hinder-implementation of protective measures in its public (state-provided) healthcare sector. Using a mixed-methods approach, we examined international, constitutional, regulatory, and policy frameworks. We also recorded and analysed the content of a workshop and policy discussion group on the topic to elicit the perspectives of health workers and of officials responsible for implementing workplace TB policies. We found that despite a well-developed legal framework and national infection prevention and control policy, a number of implementation barrier persisted: lack of legal codification of TB as an occupational disease; absence of regulations assigning specific responsibilities to employers; failure to deal with privacy and stigma fears among health workers; and limited awareness among health workers of their legal rights, including that of collective action. While all these elements require attention to protect health workers from occupational TB, a stronger emphasis on their human and labour rights is needed alongside their perceived responsibilities as caregivers.

The first 5 years of Part 2A Orders: the use of powers from court applications to protect public health in England 2010-15

BACKGROUND

Part 2A Orders are the legal means which allow local authorities (LAs), upon application to court, to exercise powers over persons, things or premises to protect public health.

METHODS

We surveyed lead professionals involved in applications to understand the use and utility of such Orders since their inception in April 2010 to July 2015.

RESULTS

All applications for Orders were granted; 29 for persons (28 for tuberculosis, 1 for HIV); these were renewed in 18 (18/25, 72%) cases up to seven times; 23 applications related to things (tattoo and piercing equipment); and three applications related to 'premises' (Escherichia coli 0137 on farm, faecal contamination). Use of the Orders against things occurred where there was failure of the Health and Safety Executive to transfer powers to LAs. Orders against persons were used as a last resort and renewed until treatment completion in the minority of cases (n = 3). One patient was detained under quarantine powers while assessing infectiousness. Significant difficulties in implementing the Part 2A Orders due to lack of resources, facilities and interagency collaboration were reported.

CONCLUSIONS

Part 2A Orders are used as a last resort but improved facilities for safe and secure isolation would help improve implementation.

Difficulty of confining recalcitrant tuberculosis patients in isolation wards in Japan, 2013-2014

OBJECTIVES

In Japan, approximately 7000 smear-positive tuberculosis (TB) cases were reported in 2014. According to the law, such patients must be isolated in a TB ward until they become at least sputum smear-negative. However, there are some recalcitrant patients who are difficult to isolate because of problematic behaviors. This study was conducted to characterize recalcitrant TB patients and determine why they left the hospitals and how they were followed up after they left.

STUDY DESIGN

Cross-sectional study.

METHODS

We sent a self-administered questionnaire to the hospitals in Japan with over 11 TB isolation beds, asking about recalcitrant TB inpatients from April 2013 through March 2014, in terms of demographic information, the reasons why they left, and how they were followed up.

RESULTS

A total of 38 recalcitrant patients were reported, of whom 15 (39.5%) self-discharged, eight (21.0%) were discharged, and 15 (39.5%) were transferred. Thirty-three (86.8%) were males. The main reason (52.6%) why the patients were considered recalcitrant was related to psychiatric problems. However, nine (23.6%) patients physically assaulted or insulted the staff members. Thirty-six (94.7%) were able to continue anti-TB treatment after they left the original hospital.

CONCLUSION

Although the number of recalcitrant TB patients who were abusive was small, there should be TB facilities with law enforcement officials readily available to enforce isolation.

Implementing International Health Regulation (2005) in the Brazilian legal-administrative system

The scope of this study was to analyze how the International Sanitary Regulation (ISR 2005)has been incorporated into the Brazilian legal-administrative system, in relation to sanitary control measures involving freight, means of transportation and travelers and possible alterations to health surveillance activities, competencies and procedures. This case study has been undertaken using a qualitative approach, of a descriptive and exploratory nature, using institutional data sources and interviews with key-informants involved in implementing ISR (2005). Alterations to the Brazilian legal-administrative system resulting from ISR (2005) were identified, in relation to standards, special competencies and procedures relating to sanitary controls for freight, modes of transportation and travelers. In its present form, the International Sanitary Regulation is an instrument that, in addition to introducing new international and national sanitary control concepts and elements, also helps to clarify questions that are helpful on a national level, relating to the specific competencies and procedures which will, to a certain extent, put pressure on administrative structures in the areas of sanitary control and surveillance.

The role of the law in reducing tuberculosis transmission in Botswana, South Africa and Zambia

OBJECTIVE

To determine whether laws and regulations in Botswana, South Africa and Zambia - three countries with a high tuberculosis and HIV infection burden - address elements of the World Health Organization (WHO) policy on tuberculosis infection control.

METHODS

An online desk review of laws and regulations that address six selected elements of the WHO policy on tuberculosis infection control in the three countries was conducted in November 2015 using publicly available domestic legal databases. The six elements covered: (i) national policy and legal framework; (ii) health facility design, construction and use; (iii) tuberculosis disease surveillance among health workers; (iv) patients' and health workers' rights; (v) monitoring of infection control measures; and (vi) relevant research.

FINDINGS

The six elements were found to be adequately addressed in the three countries' laws and regulations. In all three, tuberculosis case-reporting is required, as is tuberculosis surveillance among health workers. Each country's legal and regulatory framework also addresses the need to respect individuals' rights and privacy while safeguarding public health. These laws and regulations create a strong foundation for tuberculosis infection control. Although the legal and regulatory frameworks thoroughly address tuberculosis infection control, their dissemination, implementation and enforcement were not assessed, nor was their impact on public health.

CONCLUSION

Laws and regulations in Botswana, South Africa and Zambia address all six selected elements of the WHO policy on tuberculosis infection control. However, the lack of data on their implementation is a limitation. Future research should assess the implementation and public health impact of laws and regulations.

Political commitment to tuberculosis control in Ghana

As part of expanding and sustaining tuberculosis (TB) control, the Stop TB Partnership of the World Health Organization initiative has called for strong political commitment to TB control, particularly in developing countries. Framing political commitment within the theoretical imperatives of the political economy of health, this study explores the existing and the expected dimensions of political commitment to TB control in Ghana. Semi-structured in-depth interviews were conducted with 29 purposively selected staff members of the Ghana Health Service and some political officeholders. In addition, the study analysed laws, policies and regulations relevant to TB control. Four dimensions of political commitment emerged from the interviews: provision of adequate resources (financial, human and infrastructural); political authorities' participation in advocacy for TB; laws and policies' promulgation and social protection interventions. Particularly in respect to financial resources, donors such as the Global Fund to Fight AIDS, Tuberculosis and Malaria presently give more than 60% of the working budget of the programme. The documentary review showed that laws, policies and regulations existed that were relevant to TB control, albeit they were not clearly linked.

Public health policy and law for pandemic influenza: a case for European harmonization?

This article provides a critical portrait of the current state of public health policies and laws governing pandemic influenza prevention and control in Europe. It examines the role of and relationship between national public health policy and national communicable disease legislation as tools for the prevention and control of pandemic influenza, the role of Europe in pandemic disease preparedness, and the concept of harmonization across European states, including an overview of supranational initiatives and powers created to enhance harmonization of national pandemic disease policy. Short case studies epitomize important concerns around harmonization in Europe. The article considers opportunities and impediments to further harmonization. Particular attention is paid to the essential role of law as a tool to underpin and implement preparedness policies and to protect individual rights against unjustified state intervention.

Humiliation or care? A qualitative study of patients' and health professionals' experiences with tuberculosis treatment in Norway

AIM

Directly observed treatment (DOT) has been implemented globally as a strategy in treatment of tuberculosis. Studies from high-endemic settings show that DOT involves social and economical burdens for patients, but little is known about experiences with practicing DOT in low-endemic settings. The present study explores patients' and health professionals' views and experiences with DOT in Norway.

METHOD

In-depth interviews were conducted with 22 patients originating from Somalia and Ethiopia and with 20 health professionals. Data from the interviews were analysed using systematic text condensation.

FINDINGS

We found that there was little room for patients to negotiate whether or not to consent to the organization of treatment (DOT). Patients told that it was difficult to question the way treatment was organized, as they got the impression that there was no other way of gaining access to medication. Both patients and health professionals reported that persuasion based on authority and subtle threats was used as means to facilitate patients' acceptance of DOT. A majority of patients experienced DOT as humiliating and discriminating, while some had the experience of being cared for. Patients who attended school or had occupational obligations reported high social costs related to the treatment. Patients with positive experiences told that they had been given an opportunity to negotiate flexible treatment schedules and emphasized the importance of continuity among health professionals. Health professionals had divergent views and practices. Some argued that patients should be treated equally, while others argued for an individualized and flexible approach.

CONCLUSION

The practice of DOT reflects societal power structures that influence the clinical interactions between health professionals and patients. To avoid experiences of disempowerment and humiliation among patients, treatment and care should be organized in a way that safeguards patients' right to consent to treatment and that allows patients to negotiate an individualized treatment schedule.

Legal aspects of public health: how law frames communicable disease control in Greece

We reviewed Greek law (legislation, historic Royal Decrees, and modern Presidential ones, 1833-2010) pertinent to control of communicable diseases and compared this body of Greek law with the revised International Health Regulations. Greece authorizes and regulates communicable disease control commensurate with public health risks, and integrates the principles of equality, objectivity, and respect for human rights. Despite strength at the level of principles, Greek law lacks coherence, clarity, and systematization. An inadequate body of regulations means legislation falls short of adequate implementing authority and guidelines; public health authorities often cannot find or understand the laws, nor are they certain about allocation of jurisdictional authority. We identified areas for improvement.

Planning for pandemic: a new model for governing public health emergencies

Imagine the following scenario:

Tuberculosis and air travel: a systematic review and analysis of policy

WHO international guidelines for the control of tuberculosis in relation to air travel require-after a risk assessment-tracing of passengers who sat for longer than 8 h in rows adjacent to people with pulmonary tuberculosis who are smear positive or smear negative. A further recommendation is that all commercial air travel should be prohibited until the person has two consecutive negative sputum smears for drug-susceptible tuberculosis or two consecutive cultures for multidrug-resistant tuberculosis. In this Review I examine the evidence put forward to support these recommendations and assess whether such an approach is justifiable. A systematic review identified 39 studies of which 13 were included. The majority of studies found no evidence of transmission. Only two studies reported reliable evidence of transmission. The analysis suggests that there is reason to doubt the value of actively screening air passengers for infection with Mycobacterium tuberculosis and that the resources used might be better spent addressing other priorities for the control of tuberculosis.

The role of law in pandemic influenza preparedness in Europe

The European Union (EU) is composed of 27 states with widely varying histories, economies, cultures, legal systems, medical systems and approaches to the balance between public good and private right. The individual nation states within Europe are signatories to the International Health Regulations 2005, but the capacity of states to undertake measures to control communicable disease is constrained by their obligations to comply with EU law. Some but not all states are signatories to the Schengen Agreement that provides further constraints on disease control measures. The porous nature of borders between EU states, and of their borders with other non-EU states, limits the extent to which states are able to protect their populations in a disease pandemic. This paper considers the role that public health laws can play in the control of pandemic disease in Europe.

The power of detention in the management of non-compliance with tuberculosis treatment: a survey of Irish practitioners and analysis of potential legal liability

Objectives

The detention of patients infected with tuberculosis has recently been the subject of significant professional and public interest. In Ireland, the power to detain and isolate probable sources of infectious disease is found in the Health Act 1947. The objective of this study was to describe the use of the power to detain, and to examine relevant legal implications.

Study design

Cohort survey.

Methods

Respiratory and infectious disease physicians practising in the public sector were invited to complete a self-administered postal questionnaire.

Results

Of the 44 clinicians surveyed, 33 responded, representing a total of 356 years of specialist practice (mean 10.8 years). Although 70% of respondents had made use of threats of formal detention in dealing with non-compliant patients, only one formal detention under statutory powers was identified. Infrastructural and legal concerns with the use of detention were common. There was widespread support for a broadening of the range of additional public health powers, including a power of prolonged detention in the setting of multi-drug-resistant tuberculosis.

Conclusion

Detention and isolation of non-compliant tuberculosis patients remains in active use. Physicians detaining, or threatening to detain, patients continue to expose themselves to legal liability because of the outdated legal framework underlying those powers.

Detention and the evolving threat of tuberculosis: evidence, ethics, and law

The issue of detention as a public health control measure has attracted attention recently. This is because the threat of strains of tuberculosis that are resistant to a wider range of drugs has been identified, and there is renewed concern that public health is threatened. This paper considers whether involuntary detention is justified where voluntary measures have failed or where a patient poses a danger, albeit uncertain, to the public. We discuss the need for strengthening evidence-based assessments of public health risk and suggest that we should reflect more profoundly on the philosophical foundations upon which our policies and practices are grounded.