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In England and Wales the power to detain individuals with tuberculosis who pose a threat to public health lies principally in sections 37 and 38 of the Public Health Act 1984.1 Section 37 authorises a local authority officer to remove an individual to a suitable hospital and section 38 authorises the “detention for a period specified in the order”. By way of the Public Health (Infectious Diseases) Regulations 1988, in addition to the five notifiable diseases (cholera, plague, relapsing fever, smallpox, typhus), these sections currently apply to tuberculosis of the respiratory tract in an infectious state (although the term “infectious” is not defined by law).
Because central records are not kept, it has been unclear how many individuals are detained each year under legislation.2 No research has been conducted in Britain to determine trends in the use of detention as a public health tool in the control of tuberculosis, although a survey conducted in the early 1990s of consultants in communicable disease control/medical officers of environmental health (CCDC/MOEH) reported the issuance of six orders, “equivalent to less than one use of the sections for every hundred years of CCDC/MOEH experience”.3
A brief structured postal questionnaire was sent to consultants in communicable disease control in all 99 health authorities in England and Wales in February 2000 requesting information on whether any detention orders (section 38 of the 1984 Public Health Act) for individuals with tuberculosis had been issued in the health authority to which the letter had been sent since 1993. Information was received from consultants in 97 of the health authorities.
Thirty detention orders were issued during the 6 years surveyed; the year of issuance was given for 29. There was no apparent clustering in any health authority although 13 orders (43%) were issued in London. The duration of the period of the detention orders varied from 3 days (n=1) to 6 months (n=6) with a median of 3 months.
The number of detention orders being issued for individuals with tuberculosis since 1994 has increased significantly (p<0.005). By 1999 0.2% of individuals notified with pulmonary tuberculosis were issued with detention orders. Regression analysis, taking account of health authority response rates and notification rates for pulmonary tuberculosis, shows a significant increase in the issuance of detention orders since 1994 (b=1.8283,r 2=0.9; fig 1).
The reasons for the increase in numbers of detention orders being issued are unclear. Increases in the incidence of tuberculosis outbreaks in healthcare settings and the scourge of drug resistant and multidrug resistant strains have, over the past decade, perhaps concentrated the minds of clinicians and public health physicians on ensuring that patients comply with treatment, and this may be playing a part. Elsewhere, notably in New York but also in Europe, consideration of the legal and ethical aspects of contemporary control measures has resulted in legislative amendments to public health laws which have enabled public health authorities to detain, for prolonged periods, patients with tuberculosis who will not or cannot comply with treatment.4-7 Failures in tuberculosis control allied to insufficient resources to facilitate patients' adherence to treatment, particularly in London, may also be contributing to the use of more restrictive measures by the authorities.8 9 An alternative explanation may be that, because of drug resistance and associated HIV infection, the treatment of tuberculosis is becoming increasingly complex, demanding greater commitment from patients and clinicians. This survey suggests that there is a need to monitor formally, in an ongoing fashion, trends in the issuance of detention orders for individuals with tuberculosis.
I thank the consultants in communicable disease control in England and Wales for assisting with this research and the Communicable Disease Surveillance Centre for providing the data on pulmonary tuberculosis notifications.
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