The World Health Organization has issued new guidance on the treatment of patients with extensively drug resistant tuberculosis (XDR-TB), after it was suggested that people may need to be involuntarily detained to prevent a virtually untreatable disease from emerging.
Writing in the latest edition of PLoS Medicine (2007;4:e50, doi: 10.1371/journal.pmed.0040050), Jerome Singh, from South Africa's Centre for the Aids Programme of Research, recommends that the South African government follow the example of New York state in the 1990s, where forced confinement was used successfully to contain an outbreak of multiple drug resistant tuberculosis.
The outbreak of XDR-TB in South Africa (BMJ 2006;333:566, 16 Sep) has so far caused 74 deaths, predominantly among people with AIDS. Its virulent nature and mortality of nearly 100% is starting to cause panic in southern Africa. Doctors in the region fear that it threatens to overwhelm Africa's fragile health systems, which already face the world's highest AIDS burden.
Dr Singh writes: “XDR-TB represents a major threat to public health. If the only way to manage it is to forcibly confine then it needs to be done. Ultimately in such crises, the interests of public health must prevail over the rights of the individual.”
But Peter Davies, a cardiothoracic consultant at the Cardiothoracic Centre (NHS) Trust, Liverpool, and at University Hospital Aintree and secretary of the advocacy group TB Alert, disagreed. He said, “We're not in the business of locking up patients,” and he stressed that resistance to treatment was generally the fault of health systems rather than patients.
Professor Davies said, “Drug resistance is not unprecedented—there's no need to get into a flap about it. The one good aspect of the scare is that it will hopefully kickstart finance for new TB drug research. With sufficient funding we could probably get a treatment for XDR-TB within five years, but at the rate we're currently going we're not going to be there in 20 [years].”
WHO insists that XDR-TB should be given the same priority as avian flu and severe acute respiratory syndrome, and it recommends that any form of involuntary confinement “must be viewed as a last resort, and justified only after all voluntary measures to isolate such a patient have failed.”
WHO recommends: “Governments must ensure, as their top priority, that every patient has access to high quality TB diagnosis and treatment for TB and drug-resistant forms of TB.”
However, it adds: “If a patient wilfully refuses treatment and, as a result, is a danger to the public, the serious threat posed by XDR-TB means that limiting that individual's human rights may be necessary to protect the wider public. Therefore, interference with freedom of movement when instituting quarantine or isolation for a communicable disease such as MDR-TB [multiple drug resistant tuberculosis] and XDR-TB may be necessary for the public good, and could be considered legitimate under international human rights law.”
Paul Thorn, who underwent months of isolation after contracting multiple drug resistant tuberculosis while undergoing treatment for AIDS in the UK and who wrote the Tuberculosis Survival Handbook (under the name Paul Mayho), said, “It's a difficult decision: patients have rights, but they also have a greater responsibility not to infect the public. It would be catastrophic if this new strain of XDR-TB got into general circulation.”