XDR-TB patients should be isolated in order to prevent spread, medical ethicists urge

South Africa’s public health officials should be more aggressive in using the law to detain people with MDR-TB and XDR-TB in order to limit their spread, three doctors and medical ethicists argue in an article published by PLoS Medicine this week.

They say that isolation ought to be used to protect the wider population, and argue that it is ethical to detain people who fail to comply with treatment or who have XDR TB.

Jerome Amir Singh of the Centre of AIDS Programme Research in South Africa (CAPRISA) (also a bioethicist at the University of Toronto), Ross Upshur and Nesri Padayatchi write: “We believe that the forced isolation and confinement of individuals infected with XDR-TB and selected MDR-TB may be an appropriate and proportionate response…less severe measures may be insufficient to safeguard public interest.”

“We would not argue for forcible treatment of patients with MDR-TB or XDR-TB, simply restriction of mobility rights for such individuals.”

WHO currently recommends that people with suspected MDR TB should avoid mixing with others while waiting for results of drug susceptibility tests, but XDR TB shows that this approach has not worked, say the authors.

However, more than half the people diagnosed with XDR TB in the first outbreak had never been treated for TB before and almost certainly acquired their infection at the local hospital in Tugela Ferry, suggesting that widespread non-compliance with treatment was not the root cause of the outbreak.

Contact tracing identified no cases in the local community; instead, genetic fingerprinting of the TB isolates revealed a very close match between 85% of the isolates, suggesting one or two sources - probably health care workers at the local hospital, as reported in November at an international TB conference.

Lack of infection control within hospitals has been highlighted by other public health specialists as a major risk for dissemination of MDR and XDR TB, and the authors address this problem by arguing that XDR TB poses such a high risk to the community and to global public health that XDR and MDR TB patients should be prioritised for hospitalisation over patients with AIDS-related opportunistic infections due to the risk they pose to AIDS patients in hospital. Furthermore, XDR TB patients should be housed separately from MDR patients, they say.

They also highlight the way in which South African welfare policy is inadvertently contributing to the emergence of MDR TB. Currently anyone in receipt of welfare grants (around ten million South African citizens) who receives free medical treatment due to lack of insurance will lose their welfare grants during their period in hospital, For anyone whose household is partly dependent on their social welfare grant, this is a powerful disincentive to stay in hospital, especially for someone with MDR-TB.

The South African government should re-think this policy, they say, and also offer welfare benefits to employed people diagnosed with TB in order to lure them into the health care system.

Finally they point out that if global agencies like the World Health Organization truly believe that XDR TB should be given the same priority as bird flu and SARS, new diagnostic tests and better treatment regimens are urgently needed.

“All reasonable attempts must be made to accommodate the interests of infected patients in a sensitive and humane manner, although, if necessary, the government must adopt a more robust approach towards uncooperative patients with MDR-TB and XDR-TB.”