DETENTION UNTIL CURE AS A LAST RESORT - NEW-YORK-CITY EXPERIENCE WITHINVOLUNTARY 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 bet ween September 9, 1993, and September 9, 1994., All 46 detained patien ts were members of minority groups, more than 90% were substance abuse rs, nearly half had been perviously incarcerated, 70% had been homeles s at some point prior to detention, and 54% were HIV infected, The med ian 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-resis tant tuberculosis (MDR-TB). Thirty-seven patients (80%) completed trea tment with only 1 reported relapse (median follow-up of 30 months, ran ge I to 38 months), Two (4%) patients were persistently culture negati ve and still on treatment 42 months after the start of the study perio d, Six patients with MDR-TB died of AIDS during detention and a sevent h died of tuberculosis, Eleven (24%) of the 46 patients completed trea tment as outpatients. All patients achieved initial culture conversion to negative, Five (29.4%) of 17 patients with MDR-TB became culture p ositive again after initial culture conversion to negative despite tre atment 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 co mpletion 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 negati ve sputum cultures after 6 weeks of detention (P<0.03) than the patien ts with rifampin-resistant isolates who remained culture negative thro ughout treatment, No patient was lost to follow-up.