Chest X-ray of a patient suffering from tuberculosis

Chest X-ray of a patient suffering from tuberculosis

10/24/2007

Disease Lockdown

by Iris Tse

When Mary Mallon returned to cooking in 1914, under the alias of Mary Brown, she did, in her mind, the only thing a poor Irish immigrant of her skills could do to earn a living in New York City. She appeared to be healthy to her employers. Little did they know she spent three years in a mandatory quarantine for unwittingly infecting 22 people with a deadly disease. She was eventually forced into quarantine again in 1915 when she infected 25 more people while working as a cook at New York's Sloan Hospital. There, she stayed for the next 23 years, until her death.

History remembers Mallon as “Typhoid Mary,” a women whose vehement denial of her illness and stubbornness resulted in 51 infected people, three of whom died. But Mallon deserved some sympathy—after all, she was involuntarily held in quarantine, twice. She was told she was a carrier of a disease, yet she didn’t display any symptoms. Health officials who struggled to control the spread of typhoid fever amongst the population paid little attention to Mallon’s nebulous knowledge of how she spread typhoid fever to those around her.

 

Nearly 100 years have passed since Mallon’s first quarantine, yet mandatory isolation is once again creating headlines. The disease that ignited the latest round of debate is the extensively drug-resistant tuberculosis (XDR-TB). Not only is XDR-TB very contagious—aerosol droplets transmit the disease when infected patients cough and sneeze—it also cannot be effectively treated with most first and second-line tuberculosis drugs. Some doctors consider it virtually incurable. Because of the severity of the infection, a group of Canadian and African scientists have suggested that people infected with this extremely virulent form of tuberculosis should be isolated—against their will, if necessary—to prevent the further spread of the disease.

“Restricting freedoms sounds unpleasant, but so is letting a highly fatal disease spread within populations with high HIV rates,” said Dr Ross Upshur of the University of Toronto Joint Centre for Bioethics. In an article that appeared in the January issue of Public Library of Science Medicine, he and his co-author stressed that this is no time for denial or complacency.

“The option of doing nothing is ridiculous. But we must recognize that we have been slow to develop effective TB drugs in the past 40 years. And vaccines for TB hasn’t been particularly effective either.”

The major concern surrounding XDR-TB is that it has a very high mortality rate within a very short period of time. Of the 53 XDR-TB patients diagnosed in one of the initial outbreaks in May 2005, 52 died, on average, within 25 days, including those benefiting from antiretroviral drugs. In total, more than 350 cases of XDR-TB have been identified across South Africa and Mozambique since that first outbreak in a KwaZulu-Natal hamlet called Tugela Ferry. According to the World Health Organization, of the 424,000 multidrug-resistant tuberculosis (MDR-TB) cases that occur in the world each year, 25,000 are XDR. Therefore swift, decisive actions must be taken in order to halt the disease from spreading wildly in the general population. Even if health officials choose not to institute mandatory isolation, some other plan should be in place.

 

Quarantine is an archaic disease control strategy with roots going as far back as the Black Plague. In 1348, Venice established the world's first institutionalized system of quarantine, detaining ships, cargoes, and individuals in the Venetian lagoon for up to 40 days—the word “quarantine” evolved from the Italian words for 40 days, quaranta giorni. However, medical advances during the 20th century had reduced the need for quarantine. The advent of antibiotics in the early 1940s and its widespread use staunched the spread of many contagious diseases such as leprosy. Other diseases, such as poliomyelitis, became preventable through vaccination. Quick access to medication, better diagnosis and treatment resulted in shorter supervised care and hospital stays.

Despite that, mandated quarantine measures still have a modern role in controlling unexpected outbreaks of severe diseases. During the 2003 SARS outbreak in Toronto, 27 people were confined to their homes by court order and travel warnings discouraged tourists from visiting other affected cities such as Singapore and Hong Kong. New York City also used strong measures to control MDR-TB during the 1990s. More than 200 people who refused voluntary treatment were detained in secured wards for about six months. Many epidemiologists agree that these measures were effective in containing the spread of the disease. They demonstrate that despite the intrusion on individual rights, quarantine and travel restrictions are useful to halt the spread of isolated outbreaks.

Unlike in Mallon’s time, the public is now more aware of their individual rights and public health officials are under increasing pressure to balance individual rights and public safety. Some fear that the suggested isolation measures in South Africa is just a new variation of the old leper colonies. Beyond the loss of individual rights, quarantine also causes incredible stress. Retrospective studies done after the SARS outbreak in Toronto observed posttraumatic stress disorders and symptoms of depression in more than a quarter of the citizens placed under voluntarily or mandatory quarantine. Many public health officials believe that in order to make mandatory isolation palatable for the patients, they must educate them on the severity of the disease and placate their concerns.

“The first thing that any government has to do is to guarantee that all its citizens have access to the best possible care for TB,” said Dr Mario Raviglione, the Director of the World Health Organization’s Stop TB Department.

“Once this is guaranteed, there may be the exceptional case where patients refuse to adhere to basic public health recommendations that prevents spread of a fatal disease like XDR-TB. In this situation, all possible efforts must be made and all possible measures must be exhausted before considering compulsory isolation and coercive treatment.”

 

Most public health experts agree that mandatory isolation is epidemiologically the best way of handling a contagious disease with no vaccine or therapeutic remedies. In the case of the emerging H5N1 avian flu, the virus doesn’t commonly infect humans. Therefore, the global human population has little or no immune protection against the virus and would be vulnerable in the event of an influenza pandemic. In April 2005, President Bush added H5N1 to the list of quarantinable diseases, which already includes SARS, Cholera, Diphtheria, infectious Tuberculosis, Plague, Smallpox and Yellow fever.

While public health officials in Hong Kong, Canada, and Singapore demonstrated during the SARS outbreaks that they will not shy from exercising mandatory isolation, poorer countries may not have the resources to do the same thing. Experts point out that, realistically, South Africa does not have the adequate resources or isolation facilities to handle large numbers of XDR-TB patients. For example, the only hospital capable of treating XDR-TB patients in KwaZulu-Natal’s major city, Durban, has only 11 beds.

“There is now increased attention and priority in upgrading dedicated facilities for XDR-TB. Still, most public health facilities in South Africa do not have appropriate airborne infection control measures in place,” said Dr Karin Weyer, the director of tuberculosis programs for South Africa’s Medical Research Council (SAMRC), a semiofficial research arm of the government, in an e-mail correspondence.

The lack of funding also affects the quality of care. Upshur suggested that mandatory isolation facilities could double as palliative facilities, providing comfort and dignified care for the incurable XDR-TB patients. But the existing facilities in South Africa paint a far different picture.

“You’re looking at social and economic isolation, separation from families, friends, work and poor treatment in these institutions. Few are comfortable and the staffs are stressed and miserable and probably irritable,” said Dr Mary Edington of the Wits School of Public Health in Johannesburg, South Africa. “It must be unbelievably dreadful to endure that while feeling very ill too.”

"And have you seen some of the South African MDR-TB hospitals? They are disgusting and depressing,” she said.

 

South Africa’s reaction to XDR-TB will be closely watched by its neighbouring countries. The WHO estimates that two thirds of South African TB sufferers are HIV-positive. Since the disease thrives best in people whose immune systems are weakened by HIV, many fear that if XDR-TB isn’t carefully controlled and monitored in the five million HIV-positive patients in South Africa, it can easily spread to tens of millions more throughout sub-Saharan Africa. Countries that share borders and migrant workers with South Africa, specifically Lesotho, Swaziland and Mozambique, will be severely affected if South Africa failed to control the spread of XDR-TB.

With today’s ease of inter-continental travels, physical geological distances no longer define the actual gaps between countries. Any actions taken by the South African government will reverberate in different corners of the world and provide a snapshot of success or failure at confining a rapidly spreading disease. Similarly, reactions from patients and the general public will determine mandatory quarantine’s role in our society.

Our health care system is now confronted by a two-pronged attack
coming from antibiotic-resistant strains of old diseases, such as XDR-TB, and emerging new diseases, such as the H5N1 avian flu. Mandatory isolation might be one of the few choices we have left to swiftly confront these diseases. While it’s too late to for Mary Mallon to shed her unsavory moniker, with better sensitivity and allocation of resources, hopefully mandatory quarantine in the 21st Century will be less miserable than the ones that Mallon endured.