Struggling to keep a resurgent epidemic under control, state health officials announced new rules yesterday that strengthen their authority to quarantine tuberculosis patients who refuse to take their medicine.
The new regulations, which took effect last week, also require doctors to offer tuberculosis skin-testing to all patients who carry the human immunodeficiency virus, which causes AIDS.
Health Secretary Nelson J. Sabatini, who announced the new rules yesterday, said he was particularly concerned about diagnosing tuberculosis among people with HIV infection because their suppressed immune systems make them highly vulnerable.
The quarantines and skin-testing are seen as necessary to keep tuberculosis from exploding into a public health crisis, as it has in New York and other large metropolitan areas.
Officials said they wanted to make sure that Maryland remained relatively free of TB strains that are resistant to conventional drugs. Those strains, known as multidrug-resistant tuberculosis, tend to develop in patients who stop taking their pills before completing treatment.
The strains are deadlier than the common ones and require more expensive antibiotics to treat.
Tuberculosis is a disease of the lungs that is spread through the air, usually when an infectious person coughs or sneezes. It can also affect other parts of the body, such as the brain, kidneys or spine.
Dr. Ebenezer Israel, director of epidemiology and disease control for the state Department of Health and Mental Hygiene, said quarantines will be used only as a last resort. If a patient does not consent, he said, a court order will be sought.
Officials take the step of quarantining about once a year. Quarantined patients are confined in hospitals to limit their contacts with others.
"We want to kill every single TB germ in the body," Dr. Israel said. Patients are generally expected to take antibiotics for six months, a regimen that even the most willing patients may find difficult to follow. Compliance is more demanding for people infected with HIV, who must continue the routine for a year.
Many patients stop taking their pills once they start feeling better, which may happen only a few weeks into treatment. However, stopping treatment gives the remaining bacteria a chance to mutate into resistant strains. The patient can become contagious again and pose a more dangerous health threat.
In the past, health officials have had the authority to quarantine people only if they are contagious. Now, uncooperative patients may be quarantined whether or not they are contagious.
Dr. Israel said doctors and public health officers are usually successful in getting patients to adhere to medication schedules.
In Maryland, there were 451 cases of tuberculosis in 1991 and 442 in 1992. So far, there have been three cases of multidrug-resistant TB -- but none this year.
Dr. Israel credited the relatively low number of resistant cases to a vigorous program of tuberculosis control, pioneered by Baltimore and later copied by surrounding counties.
In this program, public health nurses deliver medication to patients at their homes and watch them swallow their pills. This is widely considered the only way to make sure people take their pills for the entire length of therapy.