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Local Health Authority’s Role in Texas

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

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Local Health Authority’s Role in Texas

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  1. Local Health Authority’s Role in Texas John T. Carlo, MD, MSE Medical Director/Health Authority Dallas County Health & Human Services

  2. 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

  3. History of Quarantine • References in the Old Testament • Quarantino, derived from quaranta meaning “forty” Sehdev, PS. CID. 2002; 35: 1071

  4. 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

  5. Santa Barbara TB Sanatarium 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 • Gensini FG, Yacoub MH, Conti AA. J Infection. 2004; 49: 257 • Executive Orders: 12452, 13295, 13375

  6. 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.

  7. 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

  8. Civil Liberties? “Quarantine and isolation must be the last resorts that are employed and failed*” ABC News Website *ACLU Issued Statement: 5/30/2007

  9. 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 • CDC. MMWR 2003; 52(43): 1038-40. • CDC. MMWR 2003: 52(29): 680-3 • 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

  10. Quarantine and Bioterrorism • Anthrax: no valid scientific evidence which justifies quarantine may be used1 • 30,000 individuals were given prophylaxis2 • Facility was quarantined • Barbara J, et al. JAMA. 2001; 286(21): 2711-7 • MMWR. August 26, 2005. 54(Suppl); 163-7.

  11. 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 Public Health Images Library (PHIL) id#131 Source: CDC/Barbra Rice Barbara J, et al. JAMA. 2001; 286(21): 2711-7.

  12. 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.

  13. 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 outcomes Weiss S, et al. NEJM 1994; 330(17): 1179-84.

  14. 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

  15. 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.

  16. Court-ordered treatment in TexasMission: 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/

  17. 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

  18. 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

  19. 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

  20. Local Case 1 • Attempted to change flight reservations • Was observed in an area hospital without mask

  21. 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.

  22. 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

  23. 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

  24. Local Case 2 47 year old male repeatedly named by females who were newly diagnosed with HIV disease as a sexual contact

  25. 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

  26. 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

  27. 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

  28. 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

  29. What is “other corrective action?”

  30. 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?

  31. 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

  32. 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

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