Chest
Volume 145, Issue 1, January 2014, Pages 95-100
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Original Research
Chest Infections
Risk Factors for and Outcomes of Detention of Patients With TB in New York City: An Update: 2002-2009

https://doi.org/10.1378/chest.13-0324Get rights and content

Background

One of the most controversial aspects of New York City’s highly effective TB control program is the use of public health law and court-ordered detention to treat persistently recalcitrant patients with active TB. We now report on characteristics and outcomes of patients undergoing detention for completion of TB treatment due to nonadherence in New York City from 2002 through 2009.

Methods

A retrospective cohort study was designed to compare patients undergoing court-ordered detention (n = 79) and time-matched control subjects undergoing TB treatment in outpatient directly observed therapy (DOT) at Bellevue Hospital in New York City.

Results

From January 1, 2002, through December 31, 2009, 79 patients underwent court-ordered detention for TB treatment. Compared with patients completing treatment in DOT, univariate analysis found that detainees were younger; more likely to be of minority race/ethnicity; to have a history of substance abuse, tobacco use, homelessness, incarceration, HIV infection; and to be born in the United States. Multivariate analysis adjusting for other variables found smear positivity (OR = 3.93; 95% CI, 1.05-14.75; P = .04), mental illness (OR = 5.80; 95% CI, 1.18-28.51; P = .03), and substance abuse (OR = 9.25; 95% CI, 2.81-30.39; P < .01) to be the strongest independent predictors of likelihood of detention. Of those initially detained, 46 (58%) completed treatment during inpatient detention, 29(37%) completed treatment under outpatient court-ordered DOT, and four died during their hospitalization.

Conclusions

The majority of patients undergoing court-ordered detention for TB treatment (95%) successfully completed therapy. Likelihood of detention was most strongly associated with factors expected to be associated with poor adherence, including mental illness and substance abuse.

Section snippets

Detention Policy

Patients with suspected or proven active pulmonary TB and either prior nonadherence or who overtly decline to protect the public may be subject to regulatory action. Before regulatory action, patients are counseled in their language about TB, how it is transmitted and treated, and how to protect the public and themselves. Criteria for regulatory action include7 sputum culture positive for Mycobacterium tuberculosis during the past year3; no evidence of treatment completion8 history and/or risk

Results

Characteristics of 79 patients detained for TB from January 1, 2002, through December 31, 2009, were compared with 70 time-matched control subjects undergoing outpatient DOT treatment of TB at Bellevue Hospital Center (Table 1). The mean age of detainees was 42 years (range, 18-69 years), and mean duration of hospitalization/detention was 4.7 months (range, 1-18 months). The majority of detainees were men (65%) and of minority race/ethnicity (47% black and 32% Hispanic). Substance abuse was

Discussion

Involuntary detention of patients with TB who are nonadherent to treatment is a last-resort option in NYC. We chose to review this experience as we approach 2 decades of its use in our city and since it has controversially been used to argue for involuntary detention policies to control extensively drug-resistant TB.11, 12, 13 We felt that a follow-up of how this policy has been used over time would inform this debate.

When controlling for other variables, age, positive acid-fast bacilli sputum

Acknowledgments

Author contributions: Dr Rogers had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Pursnani: contributed to the study concept and design; data acquisition, analysis, and interpretation; statistical analysis; critical revision of the manuscript for important intellectual content; and served as principal author.

Mr Srivastava: contributed to data analysis, statistical analysis, and critical revision of the

References (0)

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A preliminary analysis of these data were presented at the American Thoracic Society International Conference, May 14-19, 2010, New Orleans, LA (Abstract 386).

Funding/Support: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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