Public health impact of detention of individuals with tuberculosis: systematic literature review

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.

Tuberculosis control in big cities and urban risk groups in the European Union: a consensus statement

In low-incidence countries in the European Union (EU), tuberculosis (TB) is concentrated in big cities, especially among certain urban high-risk groups including immigrants from TB high-incidence countries, homeless people, and those with a history of drug and alcohol misuse. Elimination of TB in European big cities requires control measures focused on multiple layers of the urban population. The particular complexities of major EU metropolises, for example high population density and social structure, create specific opportunities for transmission, but also enable targeted TB control interventions, not efficient in the general population, to be effective or cost effective. Lessons can be learnt from across the EU and this consensus statement on TB control in big cities and urban risk groups was prepared by a working group representing various EU big cities, brought together on the initiative of the European Centre for Disease Prevention and Control. The consensus statement describes general and specific social, educational, operational, organisational, legal and monitoring TB control interventions in EU big cities, as well as providing recommendations for big city TB control, based upon a conceptual TB transmission and control model.

Discovery and development of SQ109: a new antitubercular drug with a novel mechanism of action

Existing drugs have limited efficacy against the rising threat of drug-resistant TB, have significant side effects, and must be given in combinations of four to six drugs for at least 6 months for drug-sensitive TB and up to 24 months for drug-resistant TB. The long treatment duration has led to increased patient noncompliance with therapy. This, in turn, drives the development of additional drug resistance in a spiral that has resulted in some forms of TB being currently untreatable by existing drugs. New antitubercular drugs in development, particularly those with mechanisms of action that are different from existing first- and second-line TB drugs, are anticipated to be effective against both drug-sensitive and drug-resistant TB. SQ109 is a new TB drug candidate with a novel mechanism of action that was safe and well tolerated in Phase I and early Phase II clinical trials. We describe herein the identification, development and characterization of SQ109 as a promising new antitubercular drug.

Public health law and tuberculosis control in Europe

BACKGROUND

Tuberculosis control is an important public health challenge in many European countries. Law is an important tool that policy-makers can draw upon to support control efforts and, according to the World Health Organization, represents a tangible expression of political commitment and will. Despite this, little national research, and even less cross-national comparative research, has been conducted to describe and analyse legislative approaches to tuberculosis control.

METHODS

We conducted a survey of 14 European countries to identify, describe, map and analyse legislative tools used to support tuberculosis control.

RESULTS

We found a wide range of legislative models. Legal measures available to nation states, such as compulsory examination, compulsory screening, compulsory detention, compulsory treatment and compulsory vaccination, vary widely in both scope and number. We identified a typology of legal frameworks, from the most authoritarian to the least restrictive. It seems likely that the application of some laws might not withstand scrutiny under the European Convention for the Protection of Human Rights and Fundamental Freedoms.

CONCLUSIONS

Harmonization of legislative response to infectious diseases, based upon sound evidence, may be necessary if collaborative efforts in support of infectious disease control, as envisaged in the new International Health Regulations, are to be most effective and are to reflect more appropriately a globalized 21st century world.

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.

Compulsory detention of recalcitrant tuberculosis patients in the context of a new tuberculosis control programme in Israel

OBJECTIVE

To analyse the use of compulsory detention in the context of a new national tuberculosis (TB) control programme launched in 1997.

METHODS

A retrospective review was made of the use of compulsory detention in the management of infectious TB before and after the initiation of a new TB control programme, using data from the central TB registry in the Ministry of Health and the charts of each patient.

RESULTS

Between 1994 and 2001, 13 recalcitrant patients out of 3056 (0.43%) cases of pulmonary TB were brought to trial. Eleven patients were detained. All were either hospitalized under a court order and, when failing to comply with the order, hospitalized in prison, or referred directly to a prison hospital. Twelve of 13 (92%) patients were new immigrants. After the new programme was launched, proportionately fewer patients were brought to trial [6/943 (0.64%) in 1994-1996 compared with 7/2113 (0.33%) in 1997-2001].

CONCLUSION

The reduction in the number of individuals detained could be viewed as an improvement in TB control due to the new TB control programme. It remains to be shown whether these individuals, most of whom had drug-resistant strains of TB, posed a sufficient threat to public health to justify detention.