Public Health Act – Challenges & Successes with TB

1
Public Health Act Challenges Successes with
TB

• 2010 TB Conference

Evalina Der, RN Edmonton TB Clinic Marcia M.
Johnson, MD Acting MOH Edmonton Zone
2
Topics

• Case A
• Case B
• What is an MOH Order?
• Who do those MOHs think they are?
• Ethical considerations of MOH orders
• Challenges
• Successes

3
Case A

• 30 years old female, immigrated to Canada 1990s,
  lived in Northwest Territories for 4 years before
  settled in Edmonton
• Married and worked full-time, had no medical risk
  factors
• Presented to a medi-centre with 2 months history
  of nonproductive cough, fever, weight loss and
  general malaise
• Chest x-ray demonstrated nodular consolidation
  within the left upper lobe and lingula

4
Case A (contd)

• Sputum AFB was smear-positive and subsequent
  PCR was positive for mycobacterium tuberculosis
• Admitted to TB ward for isolation and treatment
  initiation
• Drug susceptibility confirmed sensitivity to all
  first line TB medications
• Upon sputum conversion, client was discharged
  from hospital, arrangements were made for her to
  be followed through the TB clinic for ongoing
  outpatient management of her tuberculosis

5
Case A (contd)

• Compliance was perfect initially but started to
  decline 4 months into treatment
• indicated that the medications made her feel
  tired and seemed to cause a reaction in her skin
• was reluctant to continue TB therapy
• Case manager attempted to reach client were
  unsuccessful (would not return phone messages or
  respond to letters)

6
Case A (contd)

• Failure to comply with treatment persisted in
  spite of being informed about continual missing
  medications would result in hospitalization under
  Public Health Act

7
Case A (contd)

• Treatment had been interrupted for 11 weeks, an
  MOH Order under the Public Health Act was issued
• Client was located and brought to TB ward for
  isolation
• Chest x ray and sputa were performed to assure
  that her pulmonary TB had not been reactivated
  and become contagious again

Admission Date Admission Type Institute Discharge Date Discharge Type
Dec 20 FIRST WALTER C MACKENZIE CENTRE Jan 02 MEDICAL ADVICE
Aug 14 MOH ORDER WALTER C MACKENZIE CENTRE Aug 20 MEDICAL ADVICE
8
Case A (contd)

• Proper TB treatment was re-established
• Directly observed therapy was again arranged in
  the community upon discharge from hospital
• Treatment was completed without further
  complication

9
Case B

• a female in her late 20s, identified as non
  household but frequent contact of an infectious
  pulmonary case (diagnosed in February)
• single-parent of 3 young children aged between 8
  months to 4 years
• contact investigation done in March, tuberculin
  skin test was positive, chest x ray normal
• treatment for latent TB infection was offered but
  declined

10
Case B (contd)

• in late April, noted presence of tender and
  swollen lymph node at left supraclavicular fossa
• in May, visited emergency x 3 for pain and
  increased fatigue
• fine needle aspiration performed, the
  Ziehl-Neelsen (ZN) stained slide showed acid-fast
  bacilli consistent with mycobacterium
  tuberculosis
• referred to TB clinic for assessment, subsequent
  lymph node biopsy confirmed TB lymphadenitis by
  smear and culture, susceptible to all first line
  anti-tuberculous agents

11
TB Lymphadenitis

• a common form of extrapulmonary TB
• non infectious
• has a peak age onset of 20 to 40 years
• when treatment is interrupted,
• the affected lymph node may suppurate and form a
  draining sinus
• the risk of disseminated disease may evolve
  (and/or progress to infectious pulmonary TB)
• drug resistance TB may emerge

12
Case B (contd)

• TB treatment initiated in June, compliance had
  not been great took 2 weeks of treatment in 10
  weeks

13
Case B (contd)

• client was reminded numerous time to go for
  directly observed therapy, informed about Public
  Health Act (by verbal and written notification)
  and the possible consequence (detention at TB
  ward)
• when clients treatment could not be managed
  effectively in the community, the act was
  enforced

14
Case B (contd)

• An MOH order under the Public Health Act was
  issued on Aug 7, renewed weekly x 2 before client
  was located and sent to TB ward Aug 28
• TB treatment was re-established after one week
  of hospitalization, client was discharged with
  the understanding that she would be compliant in
  the community
• 2 months after discharge, compliance became
  infrequent again

15
Case B (contd)

• 6 months since initiation of anti-TB medications,
  client had only completed 2 months of TB
  treatment

16
Case B (contd)

• Child Intervention Service was involved as her
  children did not get contact follow up completed
  when she was diagnosed with active TB
• Medical Officer of Health Order (authority in PH
  Act) issued again Dec 1, client got picked up
  promptly (admitted to TB ward Dec 3) to establish
  proper treatment

Admission Date Admission Type Institute Discharge Date Discharge Type
Aug 28 MOH ORDER WALTER C MACKENZIE CENTRE Sep 02 MEDICAL ADVICE
Dec 03 MOH ORDER WALTER C MACKENZIE CENTRE Dec 10 MEDICAL ADVICE
17
Case B (contd)

• Since discharge after the second public health
  warrant, compliance had been much improved

18
Incentives to Improve Compliance

• taxi rides to and from home and health centres
  for directly observed therapy
• regular phone call contacts with client from same
  case manager to offer consistent care plan
• case mangers empathy, flexibility and
  persistence to accommodate or co-ordinate
  clients social issues such as childcare, finance
  assistance, housing problems
• lymph node was again enlarged due to treatment
  interruptions, clients gradual realization that
  proper healing would not occur until treatment
  was more regular

19
MOHs get to order people around? Really?

• Yes, actually.
• Each province has a Public Health Act
• Each PH Act confers significant power to Medical
  Officers of Health
• to be informed of the occurrence of infectious
  diseases and other nuisances.
• To undertake action required to protect the
  health of the population in the given
  jurisdiction.

20
The fine print

• WHEREAS pursuant to the provisions of Section
  29(1) of the Public Health Act being Chapter P-37
  of the Revised Statutes of Alberta, 2002 a
  medical officer of health who knows of or has
  reason to suspect the existence of a communicable
  disease within the boundaries of the health
  region in which he has jurisdiction may
• (a) initiate an investigation to determine
  whether any action is necessary to protect the
  public health, and
• (b) where the presence of a communicable
  disease is confirmed, carry out any measures
  prescribed in the regulations in respect of that
  communicable disease.

21
More fine print

• AND WHEREAS pursuant to the provisions of
  Section 8(2)(a)(b) of the Communicable Diseases
  Regulation made under the Public Health Act,
• (a) a medical officer of health shall take
  whatever steps are reasonably possible
• (i) to suppress disease in those who may already
  have been infected with communicable disease,
• (ii) to protect those who have not already been
  exposed,
• (iii) to break the chain of transmission and
  prevent spread of the disease, and
• (iv) to remove the source of infection,
• Includes isolation, quarantine, and exclusion
  from work, enter a place with warrant, etc.

22
Quarantine

• Restriction of people who feel well but who were
  exposed to an infectious disease of concern.
• usually for duration of incubation period
• Remain well release
• Become ill - isolation

23
Isolation
Separation or segregation of people who are ill
with a communicable disease in order to contain
transmission protect the public. Lasts for the
duration of the period of communicability
24
Exclusion

• Typically restriction of workers or others who
  are ill with an communicable disease of interest
  from a work or school environment which either
• presents increased risk for transmission
• or contains a high level of vulnerable people
• e.g. food handlers with food borne illnesses
• healthcare and daycare workers

25
More fine print

• Paramountcy of Public Health Act
• 75 Except for the Alberta Bill of Human
  Rights, this Act prevails over any enactment that
  it conflicts with including the Health
  Information Act, and a regulation under this Act
  prevails over any other bylaw, rule, order or
  regulation with which it conflicts.

26
Who are these MOHs?

• Alberta Health Wellness
• Chief MOH and 2 deputies
• Alberta Health Services
• Senior MOH
• Zone MOHs and Associate MOHs
• FNIH
• TB Provincial Medical Lead
• STD Provincial Medical Lead
• All have to be officially appointed.

27
Ethical Considerations
Protection of the public (public good)
Patient autonomy and civil liberties
28
General Approach

• Restriction of individual rights in the interest
  of public health is justifiable when
• Risks posed are medically-based
• Restrictive measures are targeted to avoid undue
  burdens to the individual
• A safe environment is provided
• The least restrictive possible means of achieving
  the desired public health outcomes are used

29
Challenges requirement for PH orders

• Underlying need for PH Restrictions
• Mistrust/misunderstanding of Medicine and
  medical instructions
• Difficulty placing good of others before ones
  own
• Difficulty admitting to friends and family one
  has a problem
• Financial implications of complying with
  recommended care
• At time chaotic life styles
• Addictions etc.,

30
Challenges After order is written

• Person flees or cant be found
• Logistics of making sure police are able to take
  patient to place ready to handle the situation
• i.e. Friday p.m. never works well
• Patient tries to flee once detained
• Security, re-apprehension
• Treatment fails or takes longer than expected.

Andrew Speaker March 2010
31
Challenges HIV

• In HIV patients are informed by various HCWs and
  occasionally ordered by the MOHs to refrain from
  unsafe sex with partners to whom they have not
  disclosed their status
• If unwilling or unable to comply occasionally
  they have been placed in secure settings under PH
  orders
• What is the end point as there is no cure?
• Reorganization of AHS and future re-writing of PH
  Act

32
Successes

• Restrictive orders are only one strategy and
  usually the last strategy.
• Cases presented are examples of successes
• Restrictive orders are only one strategy and
  usually the last strategy.
• Great to have if nothing else works.

Questions