Detention to prevent transmission of tuberculosis: a proportionate public health response?

Case study Trevor (not his real name) was a homeless man in his late 40s habituated to heroin and alcohol who presented to a hospital in Sydney with cough and shortness of breath in June 2009. A chest X-ray showed upper lobe changes and computed tomography (CT) scanning revealed a cavity in his left lung apex; his sputum smear was positive for acid fast bacilli (a marker of infectiousness). It was presumed and later proven that he had tuberculosis (drug sensitive) and he was started on standard four-drug therapy. These medications need to be taken for at least 6months to ensure cure. With regular meals and effective therapy, including daily methadone for opiate dependence, his health improved fairly quickly and he discharged himself 3 weeks after admission (without a plan for further treatment in place).