WHO Guidance on human rights and

involuntary detention for xdr-tb control

WHO/P. Virot

24 January 2007. WHO places prevention and care of XDR-TB as a priority through the strengthening of basic TB control and the necessary interventions to cure existing cases. This includes strengthening political will throughout affected countries to reduce the burden of TB, rapid accurate bacteriological diagnosis, a secure supply of high quality drugs, supervised and standardised treatment, and recording of the outcome of every single patient at the end of treatment. It also includes ensuring that the capacity to identify and treat drug-resistant TB is in place, with a secure supply of second-line anti-TB drugs required for treating multidrug-resistant TB obtained through the Green Light Committee (in resource-limited settings) (1), as well as implementing good infection control procedures.

These measures are currently the best approach to the prevention and care of XDR-TB and were listed among the recommendations supported by international health experts at the first meeting of the WHO Global Task Force on XDR-TB in October 2006 (2).

WHO's position with respect to the legal and ethical issues surrounding compulsory TB treatment was published in 2001 (3) with the specific purpose of ensuring prevention and control is strengthened within a legal and human rights' framework. The publication of a PLoS Medicine journal report (4) has highlighted again the issues around compulsory treatment, particularly in relation to drug-resistant TB.

WHO strongly recommends that governments must ensure, as their top priority, that every patient has access to high quality TB diagnosis and treatment for TB and drug-resistant forms of TB. It also fully supports the rights and responsibilities of TB patients as recommended in the Patients' Charter for TB Care (5).

In this regard, if a patient wilfully refuses treatment and, as a result, is a danger to the public, the serious threat posed by XDR-TB means that limiting that individual's human rights may be necessary to protect the wider public. Therefore, interference with freedom of movement when instituting quarantine or isolation for a communicable disease such as MDR-TB and XDR-TB may be necessary for the public good, and could be considered legitimate under international human rights law.

This must be viewed as a last resort, and justified only after all voluntary measures to isolate such a patient have failed.

A key factor in determining if the necessary protections exist when rights are restricted is that each one of the five criteria of the Siracusa Principles (6) must be met, but should be of a limited duration and subject to review and appeal. The Siracusa principles are:

The restriction is provided for and carried out in accordance with the law;

The restriction is in the interest of a legitimate objective of general interest;

The restriction is strictly necessary in a democratic society to achieve the objective;

There are no less intrusive and restrictive means available to reach the same objective;

The restriction is based on scientific evidence and not drafted or imposed arbitrarily i.e. in an unreasonable or otherwise discriminatory manner.

Responsibilities of TB treatment-providers to their patients are detailed in The International Standards for Tuberculosis Care (7).