Local Health Authority’s Role in Texas

John T. Carlo, MD, MSE

Medical Director/Health Authority

Dallas County Health & Human Services

Objectives• Discuss examples of past practice in

quarantine and isolation• Review diseases which potentially call

for medical orders and quarantine• Provide real-world examples where

public health laws are being used• Understand the ethical problems

associated with the implementation of medical quarantine and isolation

History of Quarantine

• References in the Old Testament

• Quarantino, derived from quaranta meaning “forty”

Sehdev, PS. CID. 2002; 35: 1071

History of Quarantine

• 1744: Sir Richard Mead’s Short Discourse Concerning Pestilential Contagion, and the Methods to be Used to Prevent It.

• Muncie, Indiana: 1893 outbreak of smallpox led to violence including shootings of several public health officials

• 1900: San Francisco: Plague epidemic causes widespread quarantine in Chinatown

• 1913: William Head, B.C. 379 Passengers, 290 were Chinese were detained

Quarantine in the 20th Century

• Preventive-therapeutic practice1

• International quarantine: Cholera, diphtheria, plague, infectious TB, yellow fever, smallpox, VHF, SARS, novel influenza virus with pandemic potential2

Santa Barbara TB Sanatarium

1. Gensini FG, Yacoub MH, Conti AA. J Infection. 2004; 49: 2572. Executive Orders: 12452, 13295, 13375

Where is Public Health Law in

the Constitution?

• “Nothing in the language of the Due Process Clause requires the State to protect the life, liberty, and property of its citizens…”

• Defensive document mainly addresses the limits of government authority

Gostin, Lawrence O. Public Health Theory and Practice in the Constitutional Design. Health Matrix. 2001; 11: 265-325.

Public Health Practice and the Texas Legal System

• Communicable Disease Prevention and Control Act

• § 81.002. “The state has a duty to protect the public health.”

• Responsibility is with everyone

Available: http://tlo2.tlc.state.tx.us/statutes/hs.toc.htm

Civil Liberties?“Quarantine and isolation must be the last

resorts that are employed and failed*”

ABC News Website

*ACLU Issued Statement: 5/30/2007

SARS (Severe Acute Respiratory Distress

Syndrome)• China: ~30,000 residents in Beijing were

quarantined. 2.3% of these cases developed SARS1

• Taiwan: ~131,000; (0.09%) developed SARS2

• Toronto: 13,000-30,000 individuals were isolated or quarantined, 27 legal orders issued3

1. CDC. MMWR 2003; 52(43): 1038-40.2. CDC. MMWR 2003: 52(29): 680-33. DiGiovanni, C. et al. Biosecurity and Bioterrorism: Biodefense Strategy,

Practice, and Science. 2004; 2(4)1-8 and Warner JE and Loehr M. 2004. available: http://bt.naccho.org/E-newsletter-archive/April-IQ-Article.htm

Quarantine and Bioterrorism

• Anthrax: no valid scientific evidence which justifies quarantine may be used1

• 30,000 individuals were given prophylaxis2

• Facility was quarantined

1. Barbara J, et al. JAMA. 2001; 286(21): 2711-72. MMWR. August 26, 2005. 54(Suppl); 163-7.

Smallpox• Historically, quarantine and

isolation have been successful control measures– Illness is readily identifiable– Long incubation period (10-17

days)

• Currently no immunity in population

• Vaccination would be of unknown efficacy

Barbara J, et al. JAMA. 2001; 286(21): 2711-7.

Public Health Images Library (PHIL) id#131 Source: CDC/Barbra Rice

Tuberculosis• Ancient disease: Found in the spines of

Egyptian mummies• Rates declined throughout the 20th

century due to identification, treatment, and isolation

• Incidence increased beginning in 1985• Rates are increasing 1.8% per year

worldwide

Woo G and Carlo J. Dallas Medical Journal. 2007; 93(7): 254-5.

Principles of TB therapy• Patients require multiple drugs for months

(standard therapy for at least 6-9 months in HIV negative patients; longer for HIV infected)

• Compliance is often a problem; patients stop therapy when they “feel” better

• Cure requires multiple drugs• Directly observed therapy (DOT) is

recommended for patients who demonstrate non compliance and can improve treatment outcomesWeiss S, et al. NEJM 1994; 330(17): 1179-84.

Compliance of TB Therapy

• 18% are non-compliant on DOT therapy

• Epidemiology studies indicates non-compliant patients significantly spread disease

• Incomplete treatment leads to resistance.

Burman WJ, et al. Chest. 1997; 112: 57-62

Detention Practices for TB

• Forcible isolation is only employed for only 1.3-6.2% of patients in the United States

• Reported treatment completion rates are 83-97%

Lerner BH. Chest. 1999: 115: 236-41.

Court-ordered treatment in Texas

Mission: Provide care to 4-5% of TB cases

• Available beds:– 9 Isolation rooms– 20-75 Non-isolation beds– U.T. Tyler: 7 Isolation

beds, (no court managed patients)

• Only 1 of 3 hospitals in the U.S.

• In 2007, TCID admitted 101 patients, 19 under court order

• Length of stay varies from 6-24 months length of stay

• Non-compliant patients need a court order prior to admission

Personal communication: Robert Longfield, MD, David Griffith, MD, and Jim Elkins. http://www.dshs.state.tx.us/tcid/

Local Case 1• 23 year old male from India, here on

business, presents to County-area emergency room with symptoms of:– Fever– Productive Cough– Weight loss– Night sweats

• 2-3 month duration

Local Case 1

• Chest X-ray, abnormal, cavitary lesions

• Smear-positive for AFB• Started on INH, RIF, PZA, EMB, B6• Discharged from hospital after 3

days

Local Case 1• Presented to TB Clinic the following day• Smear +AFB and confirmed by PCR

detection for Mycobacteria tuberculosis• Medical Order issued, DOT initiated,

Consent to treat form signed• Attempted to change flight reservations• Was observed in an area hospital without

mask

Local Case 1• Attempted to change flight

reservations• Was observed in an area hospital

without mask

Local Case 1• Request made by Local Health Authority to

place individual on the Department of Homeland Security’s “no fly list”

• Request processed and completed within 8 hours

• Counseled patient concerning the need to be compliant

• Discussed case with District Attorney.

Local Case 1• Verizon provided for individual’s housing,

food, and basic needs• After 20 days of therapy and demonstration of

drug-sensitive TB, he was released• No fly restrictions were removed within 8

hours• 151 persons were investigated as contacts• CDC Contact investigation continues

Conclusions, Local Case 1

• In Texas, the Medical Order must be issued and violation of medical order must be demonstrated in order for court mandated detention and/or treatment to take place

• The “no fly list” while implemented may have unnecessarily infringed on individual’s civil liberties

• New procedures by the CDC Division of Global Migration and Quarantine are in place

http://www.cdc.gov/ncidod/dq/quarantine_stations.htm

Local Case 2

47 year old male repeatedly named by females who were newly

diagnosed with HIV disease as a sexual contact

Local Case 2• Further investigation revealed 25

sexual partners by the index case within the last year

• 8 of these tested positive for HIV disease

Local Case 2

• Records indicate index case was diagnosed with HIV disease in 2005

• Post test counseling was noted by the physician conducting the testing

• Health Department unable to contact index case during this time

Local Case 2• Medical Order was issued and delivered

by the local health authority with police escort

• Several days after the medical order, another case presented who indicated she had sexual intercourse with index patient the night before without him disclosing his status or using a condom

Accelerated HIV Intervention Program: Policy No. 410.003• Recalcitrance: continues to engage in

behaviors known to transmit HIV despite intensive behavioral counseling

• Must be thoroughly documented• Procedures are followed as outlined in

Chapter 81• Available:

http://www.dshs.state.tx.us/hivstd/policy/pdf/410003.pdf

What is “other

corrective action?”

Issues, Case 2

• HIV is not a curable disease (how do you implement control measures?)

• Entities wish to prosecute for criminal charges. Is this allowed under State Law?

• What is the effect this case will have on the ability to promote future testing?

Conclusions

• The Local Health Authority practice, like the practice of medicine is based on technique but also is a craft

• Public Health threats are real, diseases requiring legal control exist

• Ethical challenges are significant in the practice of public health

Acknowledgements• James Zoretic, DSHS Regional

Medical Director• Texas Center for Infectious Disease• DFW DGMQ Quarantine Station• Mr. Zachary Thompson, Dr. Garry

Woo and staff at DCHHS