A. Louisiana is changing its method of treating tuberculosis due to recent recommendations of the federal Centers for Disease Control and Prevention as set forth in its Morbidity and Mortality Weekly Report, Volume 42, Issue RR-7, dated May 21, 1993. These new and revised recommendations have become necessary because the majority of tuberculosis patients on daily self-administered medications do not comply with a full course of therapy which leads to drug resistance and secondary spread of the disease.B. This Section contains a step-wise approach for encouraging compliance with treatment and for managing the non-compliant patient. The steps in the process begin with a voluntary patient compliance agreement, meant to spell out the time and place of directly-observed therapy negotiated between the healthcare provider and the patient and to inform the patient of the possible consequences of non-compliance with the course of therapy.C. If the patient does not comply with the terms of this agreement, a quarantine order for directly-observed therapy follows. This order from the state health officer or his designee reinforces the need for compliance with therapy.D. If the patient continues to be uncooperative, the state health officer or his designee may issue a formal quarantine order for hospitalization. This assigns the patient to a specific hospital facility for care of tuberculosis as an inpatient, with detailed warning of the consequences of non-compliance with therapy. It is to be noted that the patient must agree to be transported to the selected hospital facility, and to further comply with the quarantine order to remain in the hospital until his/her condition improves, and the patient may be discharged and placed under a new quarantine order for continued directly observed therapy treatment, as needed, outside of the hospital facility's restrictive environment.E. In certain cases, where the OPH disease intervention specialist and supervisor anticipate that a given uncooperative patient will refuse to be voluntarily transported to a hospital facility under a formal quarantine order for hospitalization, the state health officer may authorize and instruct the OPH disease intervention specialist supervisor or other appropriate OPH official, to fill out a request for a court order for hospitalization, and present it to the district attorney in the parish wherein the patient is known to be situated. (In rare instances, the district attorney may see that criminal charges for violation(s) of the quarantine order for directly observed therapy are filed at this point, instead of the OPH requested civil court order).F. It is hoped that in most instances of initial non-compliance with the required treatment, an uncooperative patient will agree to be transported to a specific hospital facility for inpatient care under a formal quarantine order issued by the state health officer or his designee, without court intervention.G. In the event a patient under a formal quarantine order for hospital care becomes uncooperative within the hospital facility's restrictive environment, or a patient continues to be non-compliant with therapy after isolation/quarantine by a civil court order, the hospital facility or state health officer may seek to have criminal charges filed pursuant to R.S. 40:6.B, and upon conviction, the patient may be sentenced to the hospital unit of a state prison and placed in the custody of the Department of Corrections.H. This Section contains suggested forms with instructions for the steps prior to the filing of criminal charges.I. Louisiana is following the recommendations of the federal Centers for Disease Control and Prevention by placing all tuberculosis patients initially under a voluntary program of "Directly Observed Therapy" pursuant to a "Patient Compliance Agreement" signed by the patient. A sample "Patient Compliance Agreement" form follows:J. Tuberculosis Control Sample Form 1 VOLUNTARY PATIENT COMPLIANCE AGREEMENT
Plan of therapy for______________________________________
Full Name
Date of birth_________ Social Security #____________________
Whose residence is__________________________
Parish _______________ Date this regimen begins______________
For the Patient: NOTE: All statements are to be read to patient (or patient may read).
1. You are being treated for suspected tuberculosis; therefore, it is essential that you take your medication.2. To avoid long-term isolation or quarantine, you will be expected to follow your drug therapy schedule. No dose of medication is to be missed.3. State law requires that the Office of Public Health assist you in controlling your disease. The only way to cure your disease is by regular use of drug therapy.4. The following therapy schedule requires that you report to __________________________________________________ on _______, at ________o'clock to receive your medications under supervision. The staff will work with you in arranging special schedules for your therapy as necessary. You will be expected to call and report any difficulties in keeping your appointments.5. Failure to comply with these guidelines may result in quarantine, involuntary confinement to a hospital or possible criminal charges for violations of quarantine. (If patient states any barriers to compliance, list them here.)
I agree that I understand the above therapy schedule and will make every effort to comply with the full course of my therapy.
Patient's Signature_______________________________________
Date__________
Public Health Nurse or Disease Inter. Spec.
Copy received by patient _____________________
Patient Initials
SCHEDULE CHANGES
New schedule __________________________________________
Medical Reason/Other ___________________________________
Patient Signature_________________________ Date __________
__________________________________________________
Signature Public Health Nurse or Disease Intervention Specialist
Copy to patient______________
Patient Initials
K. In the event a particular tuberculosis patient fails to cooperate, as evidenced (for example) by failing to voluntarily appear timely at the place that was agreed upon in the patient compliance agreement to take the required drugs, or otherwise interrupts and/or stops taking the anti-tuberculosis medication as prescribed, it may become necessary to issue a formal public health isolation or quarantine order to "Directly Observed Therapy" (DOT) means drugs taken in the presence of a designated health care provider at a specified place. In such cases, the patient is fully informed that a violation of the terms of the isolation or quarantine order to DOT may result in orders issued by the state health officer or his designee or agent, or by an order from a Louisiana court of competent jurisdiction, to a more restrictive environment for the management of uncooperative tuberculosis patients. A sample of a public health isolation or quarantine order to DOT follows:L. TB Control Form 2 is a sample letter to hand deliver a quarantine order for directly observed therapy. Date _______________
_____________________
_____________________
________________________, LA 70 __
RE: Quarantine Order for Directly Observed Therapy
Dear ___________________:
This is to inform you that you are under quarantine to prevent the spread of your tuberculosis infection. The circumstances necessitating the specific terms of your quarantine are as follows:
1. You have been diagnosed as having active pulmonary tuberculosis, which could be spread to others when you cough.2. You were diagnosed with pulmonary tuberculosis in ____________________, and had a positive sputum smear and culture for M. tuberculosis, which showed sensitivity to ____________________.3. You have failed voluntary Directly Observed Therapy, as evidenced by ______________________________________________________. In order to protect the public from further unwarranted exposure to your infection, you are required to fully comply with these terms of your quarantine:
1. You will be placed on mandatory Directly Observed Therapy by the regional chest clinician in __________. This regimen will require medications administered at the _________________ Parish Health Unit. This therapy will continue until the state health officer determines that you are no longer likely to transmit your infection to others and have completed an adequate therapy regimen.2. You will comply and cooperate fully with the treatment regimen prescribed for you.3. Failure to comply with mandatory Directly Observed Therapy on an outpatient basis may require subsequent legal action. Failure for the purposes of this quarantine is defined as missing one or more doses of therapy during one month. This order will remain in force until the order is revoked or revised by the authority of the state health officer. In view of the risk to the public health which would result from failure to keep your tuberculosis infection under control, any violation of the specified terms of your quarantine may force us to bring immediate action against you in court.
Please signify your intention to comply with the terms of this order by signing the Statement of Intention which is attached. Return the statement to me through the officer who delivers it to you.
I sincerely hope that you will have a rapid and uneventful recovery and that your tuberculosis can be classed as inactive before very long.
______________________________, M.D.
State Health Officer
M. Tuberculosis Control Form 3 is an attachment to Form 2 to be hand delivered to the patient.STATEMENT OF INTENTION TO COMPLY
I, ____________________________, have read the terms of my quarantine for control of tuberculosis, or have had them read to me. I have had a chance to ask questions about the terms of my quarantine and am satisfied that I understand them. For my own protection and the protection of the public, I agree to comply fully with the specified terms of my quarantine.
_____________________________________________________
(Signature) Date
WITNESSES: _________________ _____________________
(Signature) (Signature)
_______________ _________________________
(Print Name) (Print Name)
cc:
State Health Officer
EXECUTIVE OFFICER, ADMINISTRATION
DHH OFFICE OF PUBLIC HEALTH
TUBERCULOSIS CONTROL SECTION
DHH OFFICE OF PUBLIC HEALTH
BUREAU OF LEGAL SERVICES
DEPARTMENT OF HEALTH AND HOSPITALS
REGION ___DIS SUPERVISOR 1
DHH OFFICE OF PUBLIC HEALTH
_______________________ PARISH HEALTH UNIT
DISTRICT ATTORNEY ___________________ PARISH
SHERIFF,___________________ PARISH
N. A tuberculosis patient with a diagnosis of active tuberculosis who fails to comply with a public health isolation or quarantine order to directly observed therapy may be ordered to a more restrictive environment for the management of uncooperative tuberculosis patients, or by requesting a Louisiana court of competent jurisdiction for the issuance of an order placing the patient in a more restrictive environment. A sample of the state health officer's isolation or quarantine order to a more restrictive environment follows, along with a sample request for a court order.O. TB Control Form 4 is a sample quarantine order (by the state health officer) for hospitalization SAMPLE QUARANTINE ORDER FOR HOSPITALIZATION
Date _______________
_____________________
_____________________
________________________, LA 70 __
RE: Quarantine Order for Directly Observed Therapy
Dear ___________________:
This is to inform you that you are under quarantine to prevent the spread of your tuberculosis infection. The circumstances necessitating the specific terms of your quarantine are as follows:
1. You have been diagnosed as having active pulmonary tuberculosis, which could be spread to others when you cough.2. You were diagnosed with pulmonary tuberculosis on _________________, and had a positive sputum smear and culture for M. tuberculosis, which showed resistance to ________________________.3. You failed to comply with your prescribed therapy and failed mandatory Directly Observed Therapy under quarantine, as evidenced by ____________________________________________________________ . In order to protect the public from further unwarranted exposure to your infection, you are required to fully comply with these terms of your quarantine for hospitalization:
1. You have been placed on treatment for tuberculosis and will remain hospitalized with subsequent transfer to Villa Feliciana Chronic Disease Hospital and Rehabilitation Center.2. You will comply and cooperate fully with the treatment regimen prescribed for you.3. Failure to comply with this order for you to remain hospitalized may result in CRIMINAL CHARGES filed against you and a warrant for your arrest. The CRIMINAL CHARGE would be a violation of your Tuberculosis Quarantine Order, R.S. 40:6.B. Upon trial, if convicted of this charge, you may be sentenced to the hospital unit of a state prison operated by the Department of Corrections. Please be guided accordingly. This formal quarantine order will remain in force until the order is revoked or revised by the state health officer.
In view of the risk to the public health which would result from failure to keep your tuberculosis infection under control, any violation of the specified terms of your quarantine will force us to bring immediate action against you in court.
Please signify your intention to comply with terms of this order by signing the Statement of Intention which is attached. Return the Statement to me through the officer who delivers it to you.
I sincerely hope that you will have a rapid and uneventful recovery and that your tuberculosis can be classed as inactive before very long.
______________________________, M.D.
State Health Officer
P. TB Control Form 5 is a statement of intention to comply with the state health officer's quarantine order for hospitalization.STATEMENT OF INTENTION TO COMPLY
I, _________________________, have read the terms of my quarantine for control of tuberculosis, or have had them read to me. I have had a chance to ask questions about the terms of my quarantine and am satisfied that I understand them. For my own protection and the protection of the public, I agree to comply fully with the specified terms of my quarantine. I also expressly understand that if I violate the terms of this quarantine order, I may be charged with a CRIME and can be SENTENCED TO PRISON.
(Signature) (Date)
_____________________________________________________
(Signature) Date
WITNESSES: _________________ _____________________
(Signature) (Signature)
_______________ __________________________
(Print Name) (Print Name)
cc:
state health officer
EXECUTIVE OFFICER, ADMINISTRATION
DHH OFFICE OF PUBLIC HEALTH
TUBERCULOSIS CONTROL SECTION
DHH OFFICE OF PUBLIC HEALTH
BUREAU OF LEGAL SERVICES
DEPARTMENT OF HEALTH AND HOSPITALS
REGION II DIS SUPERVISOR
DHH OFFICE OF PUBLIC HEALTH
DISTRICT ATTORNEY _____________ PARISH
SHERIFF, _________________ PARISH
L S U UNIT, EARL K. LONG HOSPITAL
_______________________PARISH HEALTH UNIT
Q. The following "format" may be used by the district attorney when the state health officer or his designee or agent requests help in handling an uncooperative person known to have active, infectious tuberculosis. The district attorney may substitute any "format" of his/her preference, however. The general intent here is to provide the OPH disease intervention specialist supervisors (who will be the state health officer's designee in most cases) with an instrument to complete and submit to the district attorney when a particular TB patient shows no intent to cooperate. The "format" of the instrument itself may have to be altered so as to present the facts of a particular case accurately.R. Tuberculosis Control Form 6 SAMPLE REQUEST FOR A COURT ORDER FOR HOSPITALIZATION
IN RE: 1__________________________
NO. 2 __________________________
_________3 JUDICIAL DISTRICT COURT PARISH OF _________4
FILED:_________________5 _____________________________6
DEPUTY
REQUEST FOR AN EMERGENCY PUBLIC HEALTH ORDER TO ISOLATE/QUARANTINE A TUBERCULOSIS PATIENT TO PROTECT THE PUBLIC HEALTH AND THE PATIENT
ON THE MOTION OF ___________________________________, 7
a Disease Intervention Specialist Supervisor employed by the Office of Public Health of the Department of Health and Hospitals of the State of Louisiana and duly designated to act in these premises by the state health officer, appearing herein through the undersigned Assistant District Attorney, and moves pursuant to the provisions of LSA-R.S. 40:3, 40:4A(13), 40:4B(4), 40:5(1), 40:6.C and 40:17, and further pursuant to Sections 117- 119.F of Chapter 1 of Part II of the state sanitary code, and respectfully suggests to the Court that:
I. ___________________________________, 1 to the best of my knowledge and belief is an imminent danger and/or threat to the health and/or lives of individuals in this parish and state and is now in need of immediate medical examination and treatment in a restricted environment in order to protect the individuals of this parish and state as well as the subject individual person from physical harm and/or from spreading active and infectious tuberculosis.
II. ____________________ 1 is known to be located at _________________
_______________________, 8 and has been encouraged to voluntarily submit to necessary medical examination and to seek and receive necessary treatment, but is unwilling and uncooperative in these regards.
III. Mover has contacted ____________________________________________
_________________________________________, 9 concerning the danger and/or imminent threat posed by the subject individual, ___________________________________ 1, and is informed that ________________________________________________________ 9
is prepared to receive the patient and provide housing in a restrictive environment allowing immediate examination and care for tuberculosis and the said facility is further prepared to provide any necessary anti-tuberculosis medication.
IV. Mover asserts that the imminent danger and/or threat to the public health is based on mover's knowledge that ________________________________ 1 is infected with active, infectious tuberculosis as evidenced by _______
______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________
____________________________________________________. 10
WHEREFORE, mover prays that an emergency public health order be issued to locate, detain and transport _____________________________ 1 to _______________________________9 without delay.
Respectfully submitted,
___________________16
Assistant District Attorney
_______3 Judicial District
S. TB Control Form 6 (continued)AFFIDAVIT
STATE OF LOUISIANA
PARISH OF _____________ 4
BEFORE ME, the undersigned authority, personally came and appeared ______________________, 7 who, being first duly sworn, deposed: That ___11 is the Disease Intervention Specialist Supervisor employed by the Office of Public Health of the Department of Health and Hospitals in the regional area including __________________, 4 and ____11 is the mover in the above and foregoing motion, and that all of the allegations of fact made therein are true and correct to the best of mover's knowledge, information and belief.
__________________________________12
SWORN TO AND SUBSCRIBED BEFORE ME
THIS _____ 13 DAY OF ________, 14 20___. 15
_____________________________________ 16
NOTARY PUBLIC
T. TB Control Form 6 (continued)ORDER
IT IS ORDERED, ADJUDGED AND DECREED that ________________1
be detained and placed in the protective custody of a law enforcement officer and transported to the 9 for such medical examinations, testing and treatment for active and infectious tuberculosis and be detained at that facility until the existing imminent danger and/or threat to the public health has subsided.
IT IS FURTHER ORDERED that any law enforcement officer may execute this order by detaining and transporting ___________________________ 1 to the designated treatment facility named above without delay.
JUDGEMENT read, rendered and signed this ________ day of, 20____, at ______ o'clock, at, Louisiana.
________________________________
JUDGE
______ JUDICIAL DISTRICT COURT
PARISH OF _________________
U. TB Control Form 6 Instructions SUBSTITUTE FOR NUMBERS IN ABOVE FORM
1. Name of the person in need of treatment.2. Court personnel will complete this item.3. District Attorney's office will complete this item.4. District Attorney's office will complete this item.5. Court personnel will complete this item.6. Court personnel will complete this item.7. Insert the name of the Disease Intervention Specialist Supervisor who is submitting the matter to the District Attorney's office.8. Insert the person in need of treatment's complete address (which may be in care of a relative's address, or even a "halfway house" or possibly the person may be a patient in a hospital refusing treatment and demanding discharge. Just try to insert sufficient information to enable the deputy sheriff or other law enforcement officer to find and take the party into protective custody, etc.)9. Insert the name of the physician or administrator and the name and address of the designated TB treatment facility. 10. Here it will be necessary for a concise statement of the problem presented by the TB patient whose condition is diagnosed as active and infectious TB.11. Insert "he" or "she."12. The Disease Intervention Specialist Supervisor must sign his or her name exactly as it appears in the form above, and this should be done in the presence of a Notary, who may also be the Assistant District Attorney who will handle the case in court. 13-16 will be completed by the District Attorney's office.
V. A tuberculosis patient who has been ordered to be isolated or quarantined to a more restrictive environment than directly observed therapy and who fails to comply with the express terms and provisions of the isolation/quarantine order to a more restrictive environment issued by the state health officer or his designee, or by the orders of a Louisiana court of competent jurisdiction, shall be considered as having violated the provisions of the state sanitary code and be subject to criminal prosecution pursuant to R.S. 40:6.B, and if so charged and convicted, further subject to being sentenced to the hospital unit of a state prison operated by the Department of Corrections, and to remain so confined so long as the prisoner's tuberculosis condition is active, in order to assure the public is protected from unwarranted exposure to the disease.La. Admin. Code tit. 51, § II-121
Promulgated by the Department of Health and Hospitals, Office of Public Health, LR 28:1215 (June 2002).AUTHORITY NOTE: Promulgated in accordance with the provisions of R.S. 40:4(A)(2)(c)(vii)(aa)-(cc), R.S. 40:5(1) and R.S. 40:1161.