Detention until cure as a last resort: New York city's experience with involuntary in-hospital civil detention of persistently nonadherent tuberculosis patients

Patients with active pulmonary tuberculosis were civilly detained in a secured 29-bed unit in a long-term care facility in New York City between September 9, 1993, and September 9, 1994. All 46 detained patients were members of minority groups, more than 90% were substance abusers, nearly half had been previously incarcerated, 70% had been homeless at some point prior to detention, and 54% were HIV infected. The median time from TB diagnosis to detention was 19 months (range 4 to 77). The median length of stay for all study patients was 186 days (range 44 to 654). Seventeen patients (37%) were admitted with multidrug-resistant tuberculosis (MDR-TB). Thirty-seven patients (80%) completed treatment with only I reported relapse (median follow-up of 80 months, range 1 to 38 months). Two (4%) patients were persistently culture negative and still on treatment 42 months after the start of the study period. Six patients with MDR-TB died of AIDS during detention and a seventh died of tuberculosis. Eleven (24%) of the 46 patients completed treatment as outpatients. All patients achieved initial culture conversion to negative. Five (29.4%) of 17 patients with MDR-TB became culture positive again after initial culture conversion to negative despite treatment under detention: all 5 became culture negative once again with intensified treatment, but 1 of these 5 patients failed treatment yet again and died of TB. A sixth patient relapsed soon after treatment completion and died of AIDS and TB. These six patients were more likely to have advanced disease (P <0.04) and to have failed to achieve negative sputum cultures after 6 weeks of detention (P < 0.03) than the patients with rifampin- resistant isolates who remained culture negative throughout treatment. No patient was lost to follow-up.