Isolation of Extensively Drug Resistant (XDR) Tuberculosis Patients

Tuberculosis (TB) has been a scourge for the human society since time immemorial. In recent decades, the disease has gained significance as a public health problem in USA; increased incidence of TB has been reported owing to the HIV epidemic. Public health system has responded by isolating patients when they are infective and ensuring their proper and complete treatment. Completing treatment is vital to prevent latent infection and to decrease the development of resistant strains. The recent emergence of extensively drug resistant tuberculosis (XDR-TB) has posed a new challenge for public health. XDR-TB is highly fatal with only 30% clinical cure rate being reported. The routine public health response to TB cannot be justified for XDR-TB, particularly as treatment has a high failure rate; isolation of infective patients remains the only other viable option. The present paper addresses isolation as a strategy for containing XDR-TB infection in USA and analyzes its ethical justification.

TB is a public health threat as most Americans have never been exposed to the disease and run the risk of getting infected if exposed, which is higher in immune deficient states like that of an AIDS patient. But unlike other highly contagious respiratory infections like influenza, TB requires a close contact for a relatively long term for transmission (Victorian Health Government Information, 2008). XDR-TB strain of mycobacteria tuberculosis has a higher resistance to medication, but it is not a more virulent strain. The concern in spread of XDR-TB is that the disease is highly fatal (Singh, 2007). Prevention of disease, rather than treatment, takes precedence and thus, isolation of infective XDR-TB cases is necessary (Childress, 2007).

Isolation is a time tested strategy for preventing the spread of TB. A patient is isolated particularly when he is infective, which is defined as the presence of mycobacterium bacilli in the sputum of the patient. Isolation could be voluntary on part of the XDR-TB patient or be enforced if he/she were to not comply with directives. When enforced, isolation would infringe upon the right of freedom of an individual, yet he would be a threat to public health if not isolated. The 'harm' principle proposed by John Mill ethically justifies isolation (Parmet, 2008). He believed that limiting the liberty of an individual is justified if it is done in order to prevent the person from harming others. Professor Lawrence Gostin has stated:

Classic liberal philosophers from John Stuart Mill to Joel Feinberg, argue that,

while individual freedom to engage in self-regarding behavior is near absolute,

"other-regarding" behaviors have distinct limits. (Gostin, 2003).

If the individual is infective and knows the risk he poses to others, then he should choose to isolate himself or can be forced into isolation (Ergo, 2007). However, the use of force is justified only if the person acts as a threat and not if he is only a risk to public health. The distinction between threat and risk has to be elaborated here—a person is a risk if he has a contagious infection but is a threat if he knows this fact and makes a deliberate or negligent act of infecting others. Knowledge of disease status and the level of risk posed to public health are necessary before a XDR-TB patient can be coerced into isolation.

Mill also argued that although harm principle provides a necessary justification for limiting a person's liberty, yet it was not sufficient enough (Parmet, 2008). Thus, even if isolation were to reduce the risk of harming others, it may be unjustified. Infectivity in XDR-TB varies along a spectrum from highly infective patients with mycobacteria in the sputum to minimal infectivity seen in people with latent infection and suspected exposure to XDR-TB (Selgelid, 2008). Isolation can be justified for highly infectious patients who are a public heath risk but not for people with latent infection or suspected exposure. Defenders of isolation would argue that even a minimal risk of spread of XDR-TB should be countered and even people with latent infection should be isolated. However, individuals with latent XDR-TB infection can be compared to people with HIV- both carry a minimal, yet possible risk of spread of a fatal disease. Restriction of individual liberty in this scenario is not in proportion to the potential harm that can be caused to others (DuBois). Provided that people with latent infection take regular treatment and those with suspected exposure use a face mask until a confirmatory diagnosis is reached, none of them should be isolated.

In case of TB, isolation is limited for a period of time of infectivity which may last from 2 weeks to 2 months, yet it is a comparatively short period of time. In XDR-TB the period of infectivity may last for months to years, sometimes until death. Consequently, isolation would be required for life for some XDR-TB cases. This may not resonate well with the moral norms of most people and lesser restrictive alternatives may be sought. The use of face masks by the infective individual would serve the same purpose of isolation and is not as restrictive. Yet, this strategy may be fraught with a higher risk of spread of XDR-TB if not properly used. Nevertheless it is a viable solution which should be considered as an alternative strategy for preventing spread of XDR-TB. An infective XDR-TB case may be isolated in a hospital or at his home. Clearly, isolating him at his home than at a hospital would be less restrictive and hence, more justified. For a homeless person, isolation in hospital may be the only possible alternative, yet the environment should be such that it favors treatment of the individual like an improved ventilation system.

Conclusion:
XDR-TB is a highly fatal disease and isolation of XDR-TB patient is ethically justified. Yet isolation is highly restrictive and should be limited to infective XDR-TB cases, with use of face masks favored wherever possible. When required, isolation should be enforced only after informing the person of his diagnosis and explanation of potential threat to public health. Home isolation should be preferred to hospital isolation.

References:

Childress, J.D., et al (2002). "Public Health Ethics: Mapping the Terrain," Journal of Law, Medicine and Ethics, 30(2), 170-178.
DuBois, J. "Justifying Decision When Values Clash", www.emhr.net
DuBois, J. "Framework for Analyzing Ethics Cases", www.emhr.net
Ergo. "Medical Ethics and Moral Dilemmas." Leitmotif- Reason as the Leading Motive. 15 Dec. 2007. 01 Dec. 2008
Gostin, L. O. (2003). Dunwoody Distinguished Lecture in Law, When Terrorism Threatens Health: How Far are Limitations on Personal and Economic Liberties Justified? Florida Law Review, 55, 1105–1170.
Parmet, W.E. "J. S. Mill and the American Law of Quarantine." Public Health Ethics Advance Access published on November 1, 2008, DOI 10.1093/phe/phn029. Public Health Ethics 1: 210-222.
Selgelid, M. J. (2008). Ethics, Tuberculosis and Globalization. Public Health Ethics, 1(1), 10-20.
Singh, J. A., Upshur, R., & Padayatchi, N. (Jan 2007). XDR-TB in South Africa: No Time for Denial or Complacency. PLOS Medicine, 4(1), 19-25.
Victorian Government Health Information. "Tuberculosis - air travel for patients with TB - guidelines." 15 Jan. 2008. State Government of Australia. 02 Dec. 2008.