Isolation urged
for South Africans with drug-resistant tuberculosis

Doctors have recommended forcibly detaining people in South Africa who refuse treatment for a drug-resistant form of tuberculosis, an extreme measure meant to keep the infected away from others to curb the spread of the disease, according to a paper published Monday in an international medical journal. Since detecting extensively drug-resistant tuberculosis, also known as XDR-TB, in South Africa last year, health officials have called for increased measures to combat the strains, including better surveillance, diagnostics, and drugs.

In their paper in the PLoS [Public Library of Science] Medicine journal, physicians Jerome Amir Singh, Ross Upshur, and Nesri Padayatchi propose that XDR-TB patients who refuse treatment be involuntarily detained in hospitals or other health care facilities. Singh and Padayatchi are at the Centre for AIDS Programme of Research in South Africa, and Upshur is the director of the Joint Centre for Bioethics at the University of Toronto.

Ronnie Green-Thompson, an adviser to the South African Department of Health, said the idea had been discussed by health experts in South Africa and elsewhere and was a possibility. ''Holding the patient against their will is not ideal but may have to be considered in the interest of the public,'' Green-Thompson said in a statement issued by the South African Department of Health. ''Legal opinion and comment as well as...the opinion of human rights groups is important."

In the 1990s, New York City health authorities authorized the forcible detention of people who rejected TB treatment, some for as long as two years, ultimately leading to a significant dip in cases. The detainees were held in Bellevue or Goldwater hospitals.

Last September, the World Health Organization announced there were 53 confirmed XDR-TB cases in South Africa, of which 52 were fatal. Most of the patients were also HIV-positive. To date, more than 300 cases have been identified, and at least 30 more are added each month.

In their paper the doctors recommend that XDR-TB patients be paid while being detained. ''This isn't a carte blanche to public health authorities to start locking people up,'' Upshur said. ''If we ask individuals to forgo their rights, they need to be supported.''

Some public health experts say South Africa and the international community haven't taken basic outbreak response steps, such as drafting an emergency plan, conducting a proper investigation, and reinforcing surveillance. WHO and its partners have held a flurry of international meetings since XDR-TB in South Africa was identified, but little has changed for patients there.

''The government hasn't yet done the most obvious things to shut down transmission,'' said Mark Harrington, executive director of the Treatment Action Group, a health advocacy group. ''Starting to imprison patients is a step very far downstream from where we are now.''

Green-Thompson, the South African Department of Health adviser, said all measures were being considered and that early diagnosis and treatment were ''of paramount importance.'' Others worry that involuntarily detaining people would result in ''driving patients underground,'' said Dr. Tido von Schoen-Angerer of Medecins Sans Frontieres, the international medical aid group.

Though extensively drug-resistant tuberculosis exists worldwide, including in eastern Europe, Russia, and the United States, Africa's high number of HIV and AIDS patients makes it particularly worrying. Not only does HIV fuel the spread of tuberculosis, but infection with both HIV and XDR-TB means almost certain death. (AP)