More programs incarcerating patients

73% have done so in last five years

A wide majority of TB control programs in the country are resorting to incarcerating noncompliant patients when necessary, a recent study found. Among the programs surveyed, 73% have incarcerated TB patients who have proven severely noncompliant, says William J. Burman, MD, attending physician at the Denver Public Health Department.

"It used to be that when you said you incarcerated people, you got this horrified look," Burman says. "But my sense is that there's been a change. TB controllers are more willing to incarcerate now, perhaps because of the evidence that a few people can cause a large number of cases."

Burman, like most TB controllers, has a story or two about severely noncompliant patients who have stretched his patience to the breaking point. "We had a guy who was smear-positive for eight years, who was treated in seven states, never completed a program, and - so far as we can tell - was infectious the entire time."

In what is probably the best-known example of how noncompliance can affect a TB control program, researchers in San Francisco found that two patients accounted for clusters amounting to a third of all cases in a year.

Now, new published evidence shows that severely noncompliant patients with a taste for the open road have spread contagion on an interstate scale, Burman says.

Burman's survey went out to administrators in all 50 states, nine territories, and 41 large cities. Responses came from jurisdictions accounting for 96.5% of all TB cases.

Most jurisdictions equipped with the means to incarcerate people have done so, Burman found. Seventy-nine percent of his respondents say they have access to a place of incarceration, and 88% say they have a legal mechanism for incarceration.

Lack of one or the other generally explains why the remainder of programs haven't resorted to incarceration. In some cases, Burman adds, administrators who think they don't have a law on the books ought to check; sometimes the law exists, but TB controllers aren't aware of it.

Alcohol, drug abuse are top risk factors

Survey respondents put the frequency of severe noncompliance at about 5%, the median response. (The range spanned from 0 to a sobering 40%.) Risk factors closely associated with severe noncompliance won't surprise anyone: Respondents say the top risk factor is alcohol abuse, followed by substance abuse and homelessness.

The duration of incarceration ranges from less than two months (for about a third of respondents), up to six months (for about half of respondents).

The shift in how people view the issue is especially evident in jurisdictions with lots of patients or problems. "In New York City, for example, they never used to incarcerate," Burman says. "California is another place where they almost never resorted to it." Now, both places do.

In New York City, which was plagued earlier in the decade with outbreaks of multidrug-resistant TB, severely noncompliant patients with MDR-TB can expect especially firm treatment, Burman says. "There, if you're noncompliant and have MDR-TB, you're in for the duration," he says.

Genne D, Siegrist HH. Tuberculosis of the thumb following a needlestick injury. Clin Infect Dis 1998; 26:210.

Describing a rare case of transmission of localized TB via needlestick, the authors stress the need for infection control in lab settings. A technician received a cervical lymph node for microbiological analysis from an HIV-positive, severely immunocompromised patient with active pulmonary TB. A mycobacterial culture was requested. While trying to insert the needle through the membrane of the bottle, the technician stuck it deeply into the tip of his left thumb, touching the bone. He accidentally injected a bolus of the liquid deeply into his finger. Ten days later, the technician felt numbness at the wound site. The acid-fast bacilli in the lymph node were identified as M. tuberculosis. Susceptibility tests showed the organisms were susceptible to the four principal anti-TB drugs: isoniazid, rifampin, ethambutol, and pyrazinamide.

Infection with TB by direct injection is rare. The skin is naturally resistant to TB, so a breach of the cutaneous barrier is needed to provoke infection. This can occur after circumcision, tattooing, intramuscular injection, or mouth-to-mouth resuscitation, the authors note.

"To our knowledge, only one [previous] case has been described where a syringe used on an HIV-positive patient with tuberculosis caused an accidental infection," they conclude. "In that case, a nurse injured herself with the needle of a catheter removed from an HIV-positive patient with pulmonary tuberculosis."

The technician's thumb improved slowly while he was treated with 300 mg of isoniazid and 600 mg of rifampin daily for six months. The pain progressively disappeared, and no bone involvement was seen. Complete recovery took more than a year.