LEGAL ASPECTS OF TUBERCULOSIS

Transcription

1 TB Nurse Case Management Arlington, Texas July 14-16, 2009 Legal Aspects of Tuberculosis Melanie Barton, JD July 16, 2009 LEGAL ASPECTS OF TUBERCULOSIS Melanie Barton Assistant District Attorney Dallas County, Texas 1

2 Quarantine and Isolation Primary responsibility for public health matters within their borders rests with state and local governments. Quarantine Isolation YALE JOURNAL OF BIOLOGY AND MEDICINE 78 (2005), pp Copyright Quarantine is the restriction of persons who are presumed to have been exposed to a contagious disease but are not ill. (i) It may be applied at the individual, group, or community level; (ii) usually involves restriction to the home or designated facility. (iii) Quarantine may be voluntary or mandatory. Isolation is the separation of ill persons with contagious diseases. It may be applied at the individual, group, or community level. YALE JOURNAL OF BIOLOGY AND MEDICINE 78 (2005), pp Copyright

3 The HHS plan states that: The goal of quarantine is to protect the public by separating those exposed to dangerous communicable disease from the general population. It represents collective action for the common good that is predicated on aiding individuals who are already infected or exposed and protecting others from inadvertent exposure. Inmates Quarantined in Chickenpox Scare In November 2008, the Harris County Jail quarantined 22 prisoners in a cell block for three weeks. Routine medical test showed a new inmate may have been exposed to the chickenpox virus. No visits and no recreation outside the cell block. Quarantined inmates who completed their sentences were permitted to leave. 3

4 Swine Flu SAN ANTONIO April 2009, a family in Schertz was quarantined for 10 days after high school son was confirmed to have contracted swine flu. Family given Tamiflu and directed to take for two weeks. June 2009, the mayor of New Orleans was quarantined in China after possible exposure to the H1N1 virus. On the plane, he sat beside a passenger who was being treated for symptoms suspected to be from the virus. Nagin, his wife and a member of his security detail were quarantined for several days in Shanghai, China, though all three were symptom free. 4

5 Farming Quarantine In July 2001, Karnal bunt, a fungal disease of wheat, was identified in three counties in Texas. The counties were placed under quarantine to prevent spread of the disease and to prevent infected wheat from entering the export market. Quarantines remain in effect for five years. All elevators have to be tested for presence of the disease. All wheat harvested must be checked for presence of the disease before hauling to an elevator or out of the county. All harvest and tillage equipment is subjected to steam cleaning prior to movement from the regulated area. Every wheat farmer, whether his fields tested positive or not, must have his wheat tested and certified before he can move the crop out of the county. Texas Health & Safety Code Chapter 81 5

6 Administration of Control Measures Section permits the Health Authority to impose control measures when there is an outbreak of a communicable disease. Control measures include: Immunization Detention Restriction Disinfection Decontamination Isolation Quarantine Health & Safety Code Section Application of Control Measures to Individual. (a) Any person, including a physician, who examines or treats an individual who has a communicable disease shall instruct the individual about: (1) measures for preventing reinfection and spread of the disease; and (2) the necessity for treatment until the individual is cured or free from the infection. (b) If the department or a health authority has reasonable cause to believe that an individual is ill with, has been exposed to, or is the carrier of a communicable disease, the department or health authority may order the individual, or the individual's parent, legal guardian, or managing conservator if the individual is a minor, to implement control measures that are reasonable and necessary to prevent the introduction, transmission, and spread of the disease in this state. 6

7 Written Order Agreeing to Control Measures Signed by Patient c) An order under this section must be in writing and be delivered personally or by registered or certified mail to the individual or to the individual's parent, legal guardian, or managing conservator if the individual is a minor. (d) An order under this section is effective until the individual is no longer infected with a communicable disease or, in the case of a suspected disease, expiration of the longest usual incubation period for the disease. Tex. Health & Safety Code

8 Violation of Written Order for Control Measures (e) An individual may be subject to court orders under Subchapter G if the individual is infected or is reasonably suspected of being infected with a communicable disease that presents an immediate threat to the public health and: (1) the individual, or the individual's parent, legal guardian, or managing conservator if the individual is a minor, does not comply with the written orders of the department or a health authority under this section; or (2) a public health disaster exists, regardless of whether the department or health authority has issued a written order and the individual has indicated that the individual will not voluntarily comply with control measures. Tex. Health & Safety Code Criminal Penalty for Violation Section If a person knowingly refuses to perform or allow the performance of certain control measures ordered by the Health Authority, he may be charged with a Class B misdemeanor. 8

9 Court Orders for Management of Persons with Communicable Diseases Application for Court Order (a) At the request of the health authority, a municipal, county, or district attorney shall file a sworn written application for a court order for the management of a person with a communicable disease. (b) The application must be filed with the district court in the county in which the person: (1) resides; (2) is found; or (3) is receiving court-ordered health services. (c).... (d) A copy of written orders made under Section , if applicable, and a medical evaluation must be filed with the application, except that a copy of the written orders need not be filed with an application for outpatient treatment. Criteria for Application Section The Application is styled using the person s initials. Application may be for temporary or extended management. Statement that the person is infected with or is reasonably suspected of being infected with a communicable disease that presents a threat to public health. Statement that the person fails to comply with written orders. 9

10 Appointment of Attorney Section The judge will appoint an attorney to represent the person within 24 hours of the application being filed. The attorney will receive all records and papers in case and have access to all medical records. Setting on Application Section The judge shall set a date for a hearing to be held within 14 days after the filing of the application. 10

11 Affidavit of Medical Evaluation Section An affidavit of medical evaluation must be dated and signed. Usually provided by the Health Authority. Attached to Application. (Written Orders also attached) The affidavit must specify which criteria is met. If the Health Authority is seeking an extended commitment, a statement that the condition is expected to continue for more than 90 days. Order of Protective Custody Person will be placed under an Order of Protective Custody. Not permitted to leave hospital. Usually receives treatment pending the court hearing. 11

12 Probable Cause Hearing Within 72 hours of the Order of Protective Custody being issued, a probable cause hearing must be held to determine if: (i) the person presents a substantial risk of serious harm to himself or others to the extent that the person cannot be at liberty pending the court hearing. (ii) the Health Authority has stated a detailed basis for its opinion that the person is infected with a communicable disease and presents an immediate threat to public health. Right to Jury Trial A hearing on a temporary management order (90 days) will be held before a judge, unless the person requests a jury trial. A hearing on an extended management order (12 months) will be held before a jury, unless the person waives the right to a jury trial. 12

13 Designation of Facility The Commissioner of Health shall designate a facility to provide the treatment. We have two options in Texas: (i) Tyler (ii) San Antonio Texas Center for Infectious Diseases Tyler Campus Available beds: 9 Isolation rooms Non-isolation beds U.T. Tyler: 7 Isolation beds, (no court managed patients) Only 1 of 3 hospitals in the U.S. Length of stay varies from 6-24 months length of stay. Non-compliant patients need a court order prior to admission. 13

14 San Antonio Campus Texas Center for Infectious Disease 2303 SE Military Drive, San Antonio, Texas Switchboard: (210) TB Consultations: (800) TEX-LUNG ( ) Inpatient services of 72 beds are available for patients admitted by court order or on referral for tuberculosis or other infectious, contagious diseases where hospitalization is appropriate. Physician examination and support services for specialty consultation in tuberculosis, Hansen's disease, and other infectious diseases are funded through the DSHS Infectious Disease Control Unit, Intervention and Control Branch. 14

15 Ward Activities Video tapes and movies Computer literacy Religious Studies Computer-based reading literacy Computer games Reading Pool tables (on two wards) Puzzles Assorted board games cards Recreation Room Activities Leather work Plaster art Plastic stain glass art Sewing Music therapy Wood art Beading art Yarn art Video games 15

16 Outdoor Activities Volleyball Basketball Gardening Badminton Croquet Ping Pong Bingo Horseshoe toss 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):

17 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: Detention Practices for TB Forcible isolation is employed for only % of patients in the United States Reported treatment completion rates are 83-97% Lerner BH. Chest. 1999: 115: