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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: 257
2. 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): 680-3
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
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): 2711-7
2. 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)
Public Health Images Library (PHIL)
id#131 Source: CDC/Barbra Rice
• Currently no immunity in
population
• Vaccination would be of
unknown efficacy
Barbara J, et al. JAMA. 2001; 286(21): 2711-7.
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
outcomes
Weiss S, et al. NEJM 1994; 330(17): 1179-84.
Compliance of TB Therapy
• 18% are non-compliant on DOT therapy
• Epidemiology studies indicates noncompliant 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)
Personal communication: Robert Longfield,
MD, David Griffith, MD, and Jim Elkins.
http://www.dshs.state.tx.us/tcid/
• Only 1 of 3 hospitals in the
U.S.
• In 2007, TCID admitted 101
patients, 19 under court
order
• Length of stay varies from 624 months length of stay
• Non-compliant patients
need a court order prior to
admission
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/4
10003.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