Detention Until Cure as a Last Resort: New York City's Experience with Involuntary In-Hospital Civil Detention of Persistently Nonadherent Tuberculosis Patients

Gabriel Feldman; Prem Srivastava; Edward Eden; Thomas R. Frieden

doi:10.1055/s-2007-1009364

Seminars in Respiratory and Critical Care Medicine, Table of Contents

Semin Respir Crit Care Med 1997; 18(5): 493-501
DOI: 10.1055/s-2007-1009364

Detention Until Cure as a Last Resort: New York City's Experience with Involuntary In-Hospital Civil Detention of Persistently Nonadherent Tuberculosis Patients

Gabriel Feldman^* , Prem Srivastava^† , Edward Eden^† ^‡ , Thomas R. Frieden^* ^§

*New York City Department of Health, Bureau of Tuberculosis Control, New York, York;
†Goldwater Memorial Hospital, Roosevelt Island, New York;
‡St. Luke's/Roosevelt Hospital Center, New York, New York;
§Division of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia

Abstract

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Abstract

Patients with active pulmonary tuberculosis were civilly detained in a secured 29-bed unit in a long-term care facility in New York City between September 9, 1993, and September 9, 1994. All 46 detained patients were members of minority groups, more than 90% were substance abusers, nearly half had been previously incarcerated, 70% had been homeless at some point prior to detention, and 54% were HIV infected. The median time from TB diagnosis to detention was 19 months (range 4 to 77). The median length of stay for all study patients was 186 days (range 44 to 654). Seventeen patients (37%) were admitted with multidrug-resistant tuberculosis (MDR-TB). Thirty-seven patients (80%) completed treatment with only 1 reported relapse (median follow-up of 30 months, range 1 to 38 months). Two (4%) patients were persistently culture negative and still on treatment 42 months after the start of the study period. Six patients with MDR-TB died of AIDS during detention and a seventh died of tuberculosis. Eleven (24%) of the 46 patients completed treatment as outpatients. All patients achieved initial culture conversion to negative. Five (29.4%) of 17 patients with MDR-TB became culture positive again after initial culture conversion to negative despite treatment under detention; all 5 became culture negative once again with intensified treatment, but 1 of these 5 patients failed treatment yet again and died of TB. A sixth patient relapsed soon after treatment completion and died of AIDS and TB. These six patients were more likely to have advanced disease (P <0.04) and to have failed to achieve negative sputum cultures after 6 weeks of detention (P <0.03) than the patients with rifampin-resistant isolates who remained culture negative throughout treatment. No patient was lost to follow-up.

Key Words:

Detention - New York City - tuberculosis

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