Pierce County TB patient has violated health orders for a year. Could jail be next?

On Monday, the Tacoma-Pierce County Health Department announced it was monitoring a patient with active tuberculosis who had declined treatment.

Court records reveal the woman has not abided by multiple court orders to remain isolated and has declined treatment for more than a year.

The News Tribune discovered the case while researching past TPCHD court action following the Monday announcement.

A health department representative, following multiple rounds of questions from The News Tribune, confirmed that the woman at the center of the court case and the woman described in Monday’s announcement are the same person.

Nigel Turner is division director of Communicable Disease Control for TPCHD. He told The News Tribune in an interview Friday, “We typically don’t announce cases like this.

“In this instance, we’d received some specific inquiries. So we decided that we’d share the information to help provide some context on this in our effort to share information and be as transparent as we can.”

Turner said the department had “to balance the protection of personal health information with protecting the community as well.”

Since January 2022, the Tacoma-Pierce County Health Department has repeatedly sought and received court orders in attempts to isolate the patient to protect the public.

Filings in Pierce County Superior Court show that starting Jan. 18, 2022, the health department sought involuntary isolation orders, contending the woman started, but did not follow through with, prescribed treatment for TB.

The department, in its announcement Monday, stated it was “working with her and her family to try to persuade her to get the treatment she needs to help cure the TB so she can protect herself and others.”

The department added that it had “the legal authority to seek a court order to persuade patients to comply.”

On Thursday, The News Tribune asked the health department if the patient in the ongoing court order and the patient in Monday’s announcement were the same individual.

A media representative for the department confirmed via email, “We are working with one person in Pierce County who is refusing medication for active tuberculosis (TB).”

Turner also confirmed the case and Monday’s release involved the same person.

The Health Department has the legal authority to seek a court order to compel patients “to work with a physician and the Health Department, and in very rare cases, we must take this step to ensure a person does not put others at risk,” TPCHD media representative Kenny Via wrote The News Tribune on Thursday.

“As part of a court order, we may request assistance from local law enforcement if needed to help ensure people take their medication. This step is very rare. In the past 20 years, we’ve requested law enforcement to assist us with three cases.”

The present case has resulted in multiple court orders, but only recently included potential enforcement escalation if orders continue to be violated, including electronic home monitoring and jail time.

Turner told The News Tribune the department sees detention in jail as the last option, and that Pierce County’s Jail booking limitations in 2022 did not play a role in this case.

“We assess that balance between restricting somebody’s liberty and protecting the health of the community,” he said. “We also want to make sure that we have time for the person to comply and try lots of different options that are short of requiring somebody to be detained.”

He added, “Incarceration detention is the very, very last option that we want to take and we don’t do that lightly. But occasionally that becomes necessary if there is a risk to the public.”

Latest order shows how case progressed

On Jan. 20, 2023, Superior Court Judge Philip Sorensen issued an order authorizing involuntary detention, testing and treatment of the woman.

The latest order runs from Feb. 8 to March 25. The patient already was under an involuntary isolation order running from Dec. 25 to Feb. 8.

The department has said in its filings that the patient, after testing positive for TB, “began to undergo treatment, and then ceased treatment before it was complete.”

Court documents show the department’s requests for court-ordered involuntary isolation started in January 2022 and were renewed by the court through the year, with the department saying it had “attempted and failed to obtain voluntary compliance for voluntary isolation and treatment.”

Throughout the filings, the health department noted that the patient could face detention in Pierce County Jail.

Beyond home isolation, locations of agreed upon detention settings as the year unfolded remain sealed. What is clear is court orders were repeatedly violated, according to the filings.

The first court order of Jan. 19, 2022 states, “The Local Health Officer ordered (the patient) to self-isolate and treat; which she declined to do. (The patient) has not complied with such efforts, has discontinued treatment and is unwilling to resume treatment or voluntarily self-isolate.”

It continues: “At this stage, the Local Health Officer seeks an order requiring (the patient) to isolate in her residence, cooperate with testing and treatment as recommended by medical providers. This is less restrictive than a detention facility; however if such measures are not effective, more stringent measures may be requested.”

The patient was ordered to isolate in her home for a set period of time, “unless tests or other information conclusively establishes that Respondent no longer presents a threat to the public health, safety, and welfare, whereupon, Respondent shall be immediately released from detention.”

A similar pattern followed later in the month with another order.

“Federal and State law dictate that Respondent’s identity and the location of isolation or quarantine should be kept confidential to protect health care information under HIPAA,” the Jan. 26 order notes.

The patient was “directed to remain in her residence as identified in the confidential schedule except for purposes of medical treatment. Failure to comply with this order may result in further measures including quarantine.”

On Feb. 14, the department renewed its petition, stating it was “determined that (the patient) has not remained in her residence in accord with the court’s order, nor has she treated or tested to determine the status of her tuberculosis infection.”

It adds, “Active infectious antibiotic-resistant tuberculosis poses a threat to the community.”

Orders were issued Feb. 24 and March 24 for continued involuntary detention for quarantine or isolation. The March order also called for an appointed attorney to represent the patient.

On April 15, the health department’s stated in court filings that the patient had not remained in her residence “in accord with the court’s order.” Another order for continued involuntary detention for quarantine or isolation came on April 19. The evidence it noted was based on regular visits to the patient’s residence and “communications with treating physicians.”

Similar orders came May 17, June 28, July 27, Aug. 25, Sept. 27, Oct. 21, Nov. 18 and Dec. 16, again based on evidence from visits to the patient’s residence and treating physicians. She is directed “to remain in her residence,” except for medical treatment or testing, according to the orders.

January 2023 appeared to have been the tipping point for escalation of court-ordered enforcement in the TB case.

A supplemental petition was filed by TPCHD to the court Jan. 11, 2023. It states that the patient was a passenger in a car involved in a wreck.

The day after the crash, the patient went to an Emergency Department complaining of chest pains. X-rays taken during the visit “demonstrate that she does have tuberculosis and it is progressing,” the petition stated.

“She reported that she was a passenger in a vehicle driven by another. This admission means that she was not in isolation,” the health department’s petition said.

It stated that while the patient “is permitted to leave her home for medical care, it appears that she did not alert the ER staff that she had tuberculosis (as evidenced by the fact that the staff thought she had lung cancer) thereby putting the staff at risk, as well as those she encountered in the ER.”

It noted the patient also tested positive for COVID-19, “which also strongly suggests that she is not isolating as per this court’s order.”

Any identifiable information about the wreck and location of subsequent medical treatment are not included in the filing to preserve patient privacy.

Previous orders had stated failure to comply with the court’s isolation orders could result in further measures, left unspecified.

In an order issued Jan. 20, the court stated that failure to comply “may result in a finding of contempt whereby the court orders further measures, up to and including electronic home monitoring and detention in Pierce County Jail or other lawful orders the court may issue, in accord with the applicable code.”

Standard protocol vs. ongoing case

Denise Stinson, communicable disease control program manager for the health department, is listed as the department’s representing health officer in the case filings.

In a June 15, 2022, TB presentation to the Tacoma-Pierce County Board of Health, Stinson said that active case management was crucial in reducing risks of drug-resistant TB strains.

“People can develop drug resistance if they don’t take their medicines every day correctly. And that’s why we really are very involved with TB care as a public health department,” she said.

She noted that the cost of treating drug-resistant TB can run $100,000 or more.

“That’s why we very carefully manage our patients,” she told the board. If patients are lax in medication adherence, “you can develop resistance. And then we have a real problem when this happens.”

Pierce County each year sees on average around 20 TB patients, with outreach workers assigned for directly observed therapy five days a week, Stinson told the board.

Directly observed therapy is when a health worker watches the patient take the prescribed TB medication. The observation can be in-person or via video, a process that’s made easier now with smartphones, she noted.

“Once the patient’s stabilized, we’re able to put them on a video system, if they want to do that,” she said. “And a lot of patients really love this because they can take their medicine anytime. They don’t have to wait on the worker to come and watch them.”

The patients record themselves taking the medicine “and then they send the video to us later,” she explained.

Given all of the department’s official TB case management procedures, much remains unclear about exactly how the ongoing court-ordered isolation got so off track.

The News Tribune contacted the patient’s appointed attorney, Sarah Tofflemire, asking whether factors such as a possible language barrier or any neurological issues such as dementia were factors in the prolonged case. Clerk entries in the case list a foreign language interpreter present at proceedings.

“Since this is both a confidential case and an ongoing matter, I cannot provide any further comment,” Tofflemire wrote.

Turner told The News Tribune on Friday that while he could not comment on specifics about the woman, “it’s a matter of standard practice that we address any challenges that the person might have in taking the medication to make it as easy as possible for them to do that.

“Of course, if there are language issues, we will provide interpreters to make sure that’s not a challenge when we work with any TB case,” he said.

He added the public’s risk to potential exposure was “very, very low.”

“TB is something that’s not passed very easily between people. They have to be in enclosed settings for extended periods of time,” he said. “So we make that assessment and where appropriate, we then facilitate testing for people and then offer treatment if needed.”

As for the woman, he said the department has spent “hundreds of hours” on the case “to make sure no stone is unturned,” in persuading her to comply.

“We’re not there yet, but we hope to continue to make progress.”