Detention of persistently nonadherent patients with tuberculosis
T. Oscherwitz, J. P. Tulsky, S. Roger, S. Sciortino, A. Alpers, S. Royce and B. Lo
Program in Medical Ethics, University of California, San Francisco, USA.
CONTEXT: Patients with tuberculosis (TB) who are persistently nonadherent
to treatment present a public health risk. In 1993, California created a
new civil detention process and allowed detention of noninfectious but
persistently nonadherent patients. OBJECTIVES: To determine (1) which
patients TB controllers attempt to detain, (2) how often and where patients
are detained, and (3) how many of these patients complete TB treatment.
DESIGN: Case series with cross-sectional comparison to other adult TB
patients in the study counties. SETTING: Twelve California counties with
the largest number of new TB cases reported in 1994. SUBJECTS: All patients
whom TB controllers sought to detain during 1994 and 1995 because of
persistent nonadherence to treatment. DATA SOURCES: Public health records,
interviews with county TB officials, and Reports of Verified Cases of
Tuberculosis to the California Tuberculosis Control Branch. RESULTS:
Tuberculosis controllers sought the civil detention or arrest of 67
patients during the study period (1.3% of adult TB patients with the same
disease sites). Forty-six percent of these patients were homeless, 81% had
drug or alcohol abuse, and 28% had mental illness. Tuberculosis controllers
sought civil detention of 15 patients. Fourteen patients were detained
(median length of detention, 14.5 days). Tuberculosis controllers sought to
arrest 62 patients during the study period. Fifty-three patients were
arrested (median time in jail, 83 days). In 10 cases, both civil and
criminal detention were attempted. We analyzed completion of therapy after
excluding patients who were not detained or who died or moved. Overall, 41
(84%) of the remaining 49 detained patients completed therapy. Of the
patients who completed therapy, only 17 were detained until treatment was
completed. Compared with other TB patients in these counties, detained
patients had 4 times the proportion lost to follow-up and half the
proportion completing therapy within 12 months. CONCLUSION: Further
improvements in the care of persistently nonadherent patients may require
more psychosocial services, appropriate facilities for civil detention, and
detaining patients long enough to assure completion of treatment.
