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Silva DS, Citro B, Volchenkov G, Gonzalez-Angulo L. Ethics and human rights considerations regarding involuntary isolation of people with TB. Int J Tuberc Lung Dis 2021; 24:15-20. [PMID: 32553038 DOI: 10.5588/ijtld.17.0879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Involuntary isolation of people with tuberculosis is rarely medically required, ethically permitted or justified on the ground of human rights law. The rare circumstances that do call for involuntary isolation must only occur once a number of conditions are met. These include just procedural protections and ensuring that all other options have been exhausted before resorting to involuntary isolation. This article is intended to outline for healthcare workers, policy makers and advocates the ethical reasoning behind isolation and involuntary isolation, as well as describing the requisite human rights laws that impinge on the topic. Finally, we present a list of conditions that must be met to justify involuntary isolation on the grounds of both ethics and human rights.
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Affiliation(s)
- D S Silva
- Sydney Health Ethics, Sydney School of Public Health, Marie Bashir Institute of Infectious Diseases, University of Sydney, Sydney, NSW, Australia
| | - B Citro
- Northwestern Pritzker School of Law, Chicago, IL, USA
| | - G Volchenkov
- Vladimir Regional TB Control Center, Vladimir, Russia
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Kendall EA, Shrestha S, Cohen T, Nuermberger E, Dooley KE, Gonzalez-Angulo L, Churchyard GJ, Nahid P, Rich ML, Bansbach C, Forissier T, Lienhardt C, Dowdy DW. Priority-Setting for Novel Drug Regimens to Treat Tuberculosis: An Epidemiologic Model. PLoS Med 2017; 14:e1002202. [PMID: 28045934 PMCID: PMC5207633 DOI: 10.1371/journal.pmed.1002202] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 11/16/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Novel drug regimens are needed for tuberculosis (TB) treatment. New regimens aim to improve on characteristics such as duration, efficacy, and safety profile, but no single regimen is likely to be ideal in all respects. By linking these regimen characteristics to a novel regimen's ability to reduce TB incidence and mortality, we sought to prioritize regimen characteristics from a population-level perspective. METHODS AND FINDINGS We developed a dynamic transmission model of multi-strain TB epidemics in hypothetical populations reflective of the epidemiological situations in India (primary analysis), South Africa, the Philippines, and Brazil. We modeled the introduction of various novel rifampicin-susceptible (RS) or rifampicin-resistant (RR) TB regimens that differed on six characteristics, identified in consultation with a team of global experts: (1) efficacy, (2) duration, (3) ease of adherence, (4) medical contraindications, (5) barrier to resistance, and (6) baseline prevalence of resistance to the novel regimen. We compared scale-up of these regimens to a baseline reflective of continued standard of care. For our primary analysis situated in India, our model generated baseline TB incidence and mortality of 157 (95% uncertainty range [UR]: 113-187) and 16 (95% UR: 9-23) per 100,000 per year at the time of novel regimen introduction and RR TB incidence and mortality of 6 (95% UR: 4-10) and 0.6 (95% UR: 0.3-1.1) per 100,000 per year. An optimal RS TB regimen was projected to reduce 10-y TB incidence and mortality in the India-like scenario by 12% (95% UR: 6%-20%) and 11% (95% UR: 6%-20%), respectively, compared to current-care projections. An optimal RR TB regimen reduced RR TB incidence by an estimated 32% (95% UR: 18%-46%) and RR TB mortality by 30% (95% UR: 18%-44%). Efficacy was the greatest determinant of impact; compared to a novel regimen meeting all minimal targets only, increasing RS TB treatment efficacy from 94% to 99% reduced TB mortality by 6% (95% UR: 1%-13%, half the impact of a fully optimized regimen), and increasing the efficacy against RR TB from 76% to 94% lowered RR TB mortality by 13% (95% UR: 6%-23%). Reducing treatment duration or improving ease of adherence had smaller but still substantial impact: shortening RS TB treatment duration from 6 to 2 mo lowered TB mortality by 3% (95% UR: 1%-6%), and shortening RR TB treatment from 20 to 6 mo reduced RR TB mortality by 8% (95% UR: 4%-13%), while reducing nonadherence to the corresponding regimens by 50% reduced TB and RR TB mortality by 2% (95% UR: 1%-4%) and 6% (95% UR: 3%-10%), respectively. Limitations include sparse data on key model parameters and necessary simplifications to model structure and outcomes. CONCLUSIONS In designing clinical trials of novel TB regimens, investigators should consider that even small changes in treatment efficacy may have considerable impact on TB-related incidence and mortality. Other regimen improvements may still have important benefits for resource allocation and outcomes such as patient quality of life.
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Affiliation(s)
- Emily A. Kendall
- Johns Hopkins University School of Medicine, Division of Infectious Diseases, Baltimore, Maryland, United States of America
- * E-mail:
| | - Sourya Shrestha
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland, United States of America
| | - Ted Cohen
- Yale School of Public Health, Department of Epidemiology of Microbial Diseases, New Haven, Connecticut, United States of America
| | - Eric Nuermberger
- Johns Hopkins University School of Medicine, Division of Infectious Diseases, Baltimore, Maryland, United States of America
| | - Kelly E. Dooley
- Johns Hopkins University School of Medicine, Division of Infectious Diseases, Baltimore, Maryland, United States of America
- Johns Hopkins University School of Medicine, Division of Clinical Pharmacology, Baltimore, Maryland, United States of America
| | | | | | - Payam Nahid
- University of California San Francisco, Division of Pulmonary and Critical Care Medicine, San Francisco, California, United States of America
| | - Michael L. Rich
- Partners In Health, Boston, Massachusetts, United States of America
- Brigham and Women's Hospital, Division of Global Health Equity, Boston, Massachusetts, United States of America
| | - Cathy Bansbach
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Thomas Forissier
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | | | - David W. Dowdy
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland, United States of America
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