Louisiana Administrative Code
Title 51 - PUBLIC HEALTH-SANITARY CODE
Part II - The Control of Diseases
Chapter 1 - Disease Reporting Requirements
Section II-121 - Special Tuberculosis Control Measures [formerly paragraph 2:014-1 and Appendix A]

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).

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:

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:

M. Tuberculosis Control Form 3 is an attachment to Form 2 to be hand delivered to the patient.

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:

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:

P. TB Control Form 5 is a statement of intention to comply with the state health officer's quarantine order for hospitalization.

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, 40:4 A(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:

S. TB Control Form 6 (continued)

T. TB Control Form 6 (continued)

U. TB Control Form 6 Instructions

SUBSTITUTE FOR NUMBERS IN ABOVE FORM

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.