Publication Date: 
Sunday, July 12, 2009

The Problem: Tuberculosis is a classic public health scourge. Globally, there are over 9 million new cases of TB each year. World Health Organization: Tuberculosis Fact Sheet. The risks associated with TB have increased with the emergence of more virulent and drug-resistant strains of the disease. In the United States, the rate of TB incidence and associated mortality declined precipitously for most of the 20th century. In 1900 TB was the second leading cause of mortality accounting for over 10% of deaths; by 1980s deaths attributed to TB were in the hundreds. CDC: MMWR: Achievements in Public Health: Infectious Disease. In the early 1990s, however, incidence of TB began to increase again due to the HIV/AIDS epidemic and the synergistic risks of co-infection. Although these increases appear to have leveled off in the last few years, the risks associated with drug resistant strains continue to make TB an important public health challenge. CDC: MMWR: Trends in Tuberculosis.

The Law: There are numerous legal measures for controlling the spread of TB. Law authorizes surveillance and specifies treatment requirements like Directly Observed Therapy (DOT). The most extreme and controversial legal measures involve the involuntary detention of individuals who are suspected or known to have infectious TB. In the United States, state statutes (Ca. Health & Safety Code § 121366) and regulations (New Jersey, N.J. Admin. Code § 8:57-5.7 et seq) define the procedural and substantive requirements for detaining an individual who presents a putative risk to the community as the carrier of an infectious disease. A sizable body of case law has also developed providing guidance about how and when an individual can be detained against their will to protect the public from disease. One of the seminal cases interpreting state power over coercive tuberculosis control measures is Green v. Edwards, 263 S.E. 2d 661 (1980).

The Evidence: Coker systematically reviewed studies assessing the effect of detention of individuals with TB on public health. R.J. Coker. Public Health Impact of Detention of Individuals with Tuberculosis: Systematic Literature Review. Public Health (2003) 117, 281–287. Twenty-two studies fit the inclusion criteria. One of the studies employed a molecular finger printing design and found evidence that removing some infected individuals from the population would significantly decrease population incidence. Other modeling studies, however, suggested that the presence of coercive measures might increase transmission by decreasing the proportion of infected individuals that seek treatment. Observational and case control studies were few and small. According to Coker, there is insufficient evidence to sustain inferences about the effects of detention on population health.

The Bottom Line: According to the author of a peer-reviewed systematic review, there is insufficient evidence at this time to conclude that detention of individuals with infectious tuberculosis improves population health.

Impact: Uncertain