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Module 9: Patient Adherence to Tuberculosis Treatment
Answers to Study Questions

9.1. What is adherence to treatment?

Adherence to treatment means that a patient is following the recommended course of treatment by taking all the prescribed medications for the entire length of time necessary.

9.2. Why is adherence to TB treatment important?

Adherence is important because TB is nearly always curable if patients adhere to their TB treatment regimen.

9.3. What are four serious consequences that can result when a patient with TB disease is nonadherent?

 

Nonadherence is the patient's inability or refusal to take TB drugs as prescribed. When medical treatment is complicated or lasts for a long time, as in the treatment for TB disease, patients often do not take their medication as instructed. This behavior is one of the biggest problems in TB control and can lead to serious consequences. A nonadherent patient with TB disease may

  • Remain sick longer or have more severe illness
  • Spread TB to others
  • Develop and spread drug-resistant TB
  • Die as the result of interrupted treatment

9.4. Give eight reasons why a patient might be nonadherent.

 

There are many reasons why a person might have trouble completing a regimen of TB drugs. Here are a few examples.

  • Once patients no longer feel sick, they often think it is all right to discontinue taking their TB drugs. TB symptoms can improve dramatically during the initial phase of treatment (the first 8 weeks). However, unless patients continue treatment for at least 6 months, some tubercle bacilli may survive, putting patients at risk for a relapse of TB disease and the development of drug-resistant organisms.

  • Patients sometimes do not fully understand the treatment regimen, how to take their drugs, or the reasons for the long duration of TB treatment. This lack of knowledge can lead to an inability or lack of motivation to complete a regimen.

  • Some patients have strong personal or cultural beliefs about TB disease, how it should be treated, and who they can turn to for help. When TB treatment conflicts with these beliefs, patients can become fearful, anxious, or alienated from their health care workers (a person who provides health care or health services to patients, such as physicians, physician's assistants, nurse practitioners, nurses, and outreach workers).

  • Certain patients lack skills necessary for following a health care worker's instructions and adhering to a prescribed regimen. Elderly patients with limited mobility or manual dexterity, patients with substance abuse or mental health problems, and young children are particularly at risk for problems with adherence.

  • Lack of access to health care can also be a significant barrier to successfully completing a TB regimen. Special efforts must be made to reach and provide care to patients without a permanent address or a means of transportation. Patients with jobs may have work schedules that conflict with clinic hours. Immigrants and refugees, as well as persons who inject illicit drugs, may need reassurance that their TB disease and treatment will be kept confidential and should not cause them legal problems.

  • Some patients, especially recent immigrants, may not be able to find a health care worker who speaks their language. When a patient speaks little or no English, this language barrier can present significant problems for adherence, as patient education and support services can have little effect. Unless a good interpreter is found, such patients may be unable to continue treatment.

  • Some patients have poor relationships with health care workers. When patients and health care workers fail to establish a trusting relationship, this lack of relationship can influence patient adherence. If a patient trusts or has confidence in his or her health care worker, he or she is more likely to follow instructions and advice and to cooperate with the health care worker. Patients may also be more likely to bring questions and concerns regarding adherence to the health care worker's attention.

  • Finally, some patients may have a lack of motivation to adhere to a TB regimen. If patients have many competing priorities in their lives such as substance abuse, homelessness, sickness from other diseases (e.g., HIV), taking TB medication may not be considered a priority by the patient.

9.5. Explain why a patient's adherence to a TB treatment regimen is difficult to predict.

Each patient is unique and may have his or her own reasons for nonadherence. One of the best predictors of adherence is a patient's past adherence. If a patient was nonadherent in the past, it is likely that he or she will encounter similar problems with the current treatment regimen. However, it is important to keep in mind that any patient can have problems with adherence. Barriers are anything that can prevent a patient from being able to adhere to a TB treatment regimen. Many health care workers think they can tell which patients will be adherent, but research shows they are correct only about half the time (that is, their predictions are no better than flipping a coin). Although adherence is hard to predict, the more the health care worker knows about the patient, the better he or she will be able to understand and address the patient's problems.

9.6 Whose responsibility is it to ensure adherence?

Patients and health care workers are both responsible for ensuring patients' adherence. Patients must decide every day or week whether or not to take their medicine. What they decide often depends on how much help they get from the health care workers they see.

9.7 Describe a case management system.

There are many strategies that may be used to ensure that patients complete treatment. One strategy that may be used is case management. There are three elements in a case management system:

  • Assignment of primary responsibility for the patient
  • Systematic regular review of patient progress
  • Plan to address any barriers to adherence

A health department employee (case manager) is assigned primary responsibility and is held accountable for ensuring

  • Each patient is assessed and a treatment plan is established
  • Each patient is educated about TB and its treatment
  • Therapy is continuous
  • Contacts are examined

9.8. To address the patient's specific needs, what kind of things does the health care worker need to learn about the patient?

The health care worker will need to learn as much as possible about the patient in order to assess potential adherence problems. The health care worker will need to learn about the patient's

  • Medical history and current health problems
  • Knowledge, beliefs, and attitudes about TB
  • Ability to take responsibility for following the TB treatment plan
  • Resources (family, other social support, finances)
  • Barriers to treatment
  • History of adherence to previous TB regimens or other medication

9.9. How soon should the health care worker talk with the patient to begin the assessment?

The health care worker or other program staff should visit the patient to begin the assessment as soon as possible. If the health care worker is assigned to work with a hospitalized TB patient, he or she should visit before the patient leaves the hospital. If the patient leaves the hospital before the health care worker can get there, he or she should visit the patient at home as soon as possible. During the first meeting, the health care worker should learn at the very least the names of the patient's close contacts so a contact investigation can begin. The information the health care worker finds out in these meetings is confidential; he or she should follow the agency's or clinic's rules for keeping patient information confidential.

9.10. What is an open-ended question and what can it help the health care worker learn about a patient?

An open-ended question is one that cannot be answered with a simple "yes" or "no." Open-ended questions are designed to elicit the patient's knowledge, feelings, and beliefs by beginning with words like "What," "Why," "Who," "When," and "How" that demand an explanation. In addition, phrases that begin with "Tell me about" or "Explain to me" may be helpful in eliciting information from the patient. Such questions are used when a health care worker needs to explore complex issues that do not have a finite or predetermined set of responses.

9.11. In the list below there are close-ended and open-ended questions. Mark an X for each open-ended question that the health care worker can ask the patient to find out his or her ideas and feelings about TB.

X What is TB?

   Do you think TB can be cured?

X How is TB spread?

   Do you have difficulty taking medicine?

X What are some of the difficulties you have taking medicine?

X Why do you think you need to take medicine?

   Is TB curable?

X How is TB cured?

9.12. Why is it important to assess the patient's knowledge, beliefs, and attitudes regarding TB and adherence to TB medicine?

Assessing TB patients' knowledge, beliefs, and attitudes regarding TB and adherence to TB medicine may help the health care worker better understand the patient's views and suggest areas in which the patient needs education. They may also give the health care worker some idea of the patient's ability to adhere to a treatment regimen. For example, asking a patient what problems the illness has caused him or her can help the health care worker assess the strength of family and social support; potential job-related problems; and, to some extent, the problem-solving skills of the patient.

Throughout treatment, the health care worker should ask the patient about his or her concerns about TB and success with adherence to the regimen. Whenever possible, the health care worker should adapt such questions according to the patient's age, family situation, education level, and cultural background. Remember that the more the health care worker is aware of the patient's ideas and concerns about TB and its treatment, the better prepared the health care worker will be to anticipate and resolve problems that can arise.

9.13. List eight effective communication techniques that can help the health care worker to present new information to patients.

Use simple, nonmedical terms in explanations, and be specific about the behaviors that are expected. For example, it is much more helpful to say, "This pill will help you get better," than to say, "This drug, isoniazid, is a bactericidal agent that is highly active against Mycobacterium tuberculosis." Using words that are familiar to patients can make the information relevant to them.

Use the appropriate language level. Written information should match the patient's reading level. Persons with a limited education may only be able to understand very basic materials. Highly educated patients may prefer more detailed information. If a patient does not read or write, health care workers should give instructions orally and leave visual cues or reminders, such as a snapshot of each medication, with the time the patient should take it written in large numbers.

Limit the amount of information given at any one time. If too much information is given, the patient may not remember any of it. To avoid overwhelming the patient, the topics to be discussed should be organized in the order of their importance. In the first session, the most essential topics (such as the names of exposed contacts) should be discussed, in case the patient does not return for follow-up care.

Discuss the most important topics first and last. People remember information presented at the beginning and at the end of a session more easily than they do the information presented in the middle. Health care workers should tell the patient what is expected of him or her before they explain test results, the expected outcome of a procedure, or treatment. For example, early in the first session the health care worker might say, "To get well, you must take four of these capsules every day." This information should be reviewed before leaving the patient.

Repeat important information. Some data indicate that people need to hear new information several times before they will remember it. Health care workers should repeat key messages throughout the session, have the patient repeat the information, then in later sessions review previously presented material first. The topic can be introduced by saying, "As we discussed last time..."

Listen to feedback and questions. Communication with the patient should always be two-way. This means that the health care worker should listen to feedback and questions from the patient to be sure they received and understood the message. The health care worker should use open-ended questions to assess the patient's knowledge and beliefs.

Use concrete examples to make information easy to remember. This is especially important for patients who are not on DOT. For example, visual descriptions of pills can be helpful. The health care worker could say, "Take two Rifamate capsules in the morning when you get out of bed. These are the big red pills in the little brown bottle." If there is something patients do every morning, such as brushing their teeth, a picture or note placed on the mirror near the toothbrush can serve as a reminder.

Make the interaction with the patient a positive experience. It's not only what is said and done, but how it is said or done, that will help the patient adhere to treatment. The health care worker should be encouraging and supportive. The health care worker's warm, concerned, and respectful attitude toward the patient will make the experience more pleasant for both and will render the treatment more effective.

9.14. If the health care worker uses an interpreter, what are four problems the health care worker may encounter?

The health care worker and the patient can have serious problems understanding each other if they do not speak the same language. If an interpreter is used, the health care worker can still have problems getting accurate, unbiased information and protecting the patient's confidentiality. For example,

  • Interpreters may not state accurately what the health care worker and the patient have said
  • Interpreters sometimes add their own ideas of what has been said
  • The patient may be uncomfortable talking about personal information that he does not want a third person, the interpreter, to know
  • Interpreters may have difficulty finding equivalent words or translating medical terms into the patient's language

It is best to use trained medical interpreters whenever possible. If a trained interpreter is not available, other persons who are sometimes used as interpreters are other health care workers who speak the patient's language, the patient's family members, or people from the patient's community. If an interpreter is unavailable when the health care worker makes a home visit, the health care worker should call back to the office or clinic if see if someone there could translate for them over the telephone. If family members must be used to interpret, children should not be used; they will hear personal information and may be asked to translate things that the family feels children should not discuss, and this can be upsetting.

9.15 List at least six guidelines for working with an interpreter that can help the health care worker make the best of the interview.

After the health care worker has identified an interpreter, he or she should follow these guidelines to make the best use of the interview:

  • Ask for the patient's permission to use an interpreter
  • Plan the interview and decide what key points to talk about with the patient
  • Meet with the interpreter before the interview to talk about the goals for the interview, to give instructions and guidance, and to make sure the interpreter is comfortable with the questions and topics that will be discussed
  • Remind the interpreter that all information in the interview is confidential
  • Ask the interpreter to refrain from adding his or her own comments
  • Address the patient directly, not the interpreter
  • Ask the interpreter to explain questions or answers that are not clear
  • Keep the messages simple and factual; use short phrases and focus on one topic at a time
  • Give the interpreter time to translate each phrase before continuing; do not interrupt the interpreter
  • Ask the interpreter to translate the patient's and the health care worker's own words as exactly as possible
  • Give the patient time to answer questions

9.16 What is DOT?

A component of case management that helps to ensure that patients adhere to treatment is directly observed therapy (DOT). DOT is the most effective strategy for making sure patients take their medicines. DOT means that a health care worker or other designated individual watches the patient swallow every dose of the prescribed drugs. DOT should be considered for all patients because it is difficult to reliably predict which patients will be adherent. Even patients who intend to take their medicine might have trouble remembering to take their pills every time. All DOT visits should be documented. In many health departments, DOT is the standard of care.

9.17 Who should be considered for DOT?

All patients should be considered for DOT. However, there are certain groups of patients for whom DOT is often the best option, regardless of local treatment completion rates. These groups include

  • Patients with drug-resistant TB
  • Patients receiving intermittent therapy
  • Persons at high risk for nonadherence, such as
    • Homeless or unstably housed persons
    • Persons who abuse alcohol or illicit drugs
    • Persons who are unable to take pills on their own due to mental, emotional, or physical disabilities
    • Children and adolescents
    • Persons with a history of nonadherence

9.18 List and explain four tasks that are part of the DOT encounter.

Delivering DOT means that the health care worker should

  • Check for side effects. At each visit, before the drugs are given, the health care worker should ask if the patient is having any adverse side effects. Patients being treated for TB should be educated about symptoms indicating adverse reactions to the drugs they are taking, whether minor or serious. If the patient has symptoms of serious adverse reactions, a new drug supply should not be given; the patient should stop taking medication immediately. The supervisor should be told that the drugs were not given, and the prescribing clinician should be notified about the adverse reaction. The health care worker should arrange for the patient to see the clinician as soon as possible.

  • Verify the medication. Each time DOT is delivered, the health care worker should verify that the right drugs are delivered to the right patient, and that he or she has the correct amount of medication. If this cannot be confirmed, the drugs should not be given to the patient. The supervisor should be asked for clarification.

  • Watch the patient take the pills. Medication should not be left for the patient to take on his or her own. The health care worker or the patient should get a glass of water or other beverage before the patient is given the pills. The health care worker should watch the patient continuously from the time each pill is given to the time he or she swallows it.

  • Document the visit. The health care worker should document each visit with the patient and indicate whether or not the medication was given. If not given, the reason and follow-up plans should be included. It is important to correct any interruption in treatment as soon as possible.

9.19 Name at least five places where DOT can be given.

DOT can be given anywhere the patient and health care worker agree upon, provided the time and location are convenient and safe. Clinic-based DOT is delivered in a TB clinic or comparable health care facility (Figure 9.3). For some patients, DOT must not interfere with the patient's work schedule, so DOT can be provided in a nonclinical setting or during nonbusiness hours. When a patient cannot easily get to the TB clinic, the health care worker must go to the patient. DOT delivered in a setting outside of the TB clinic or health care facility is called field-based DOT (Figure 9.4 and Figure 9.5). Field DOT can be given at almost any site:

  • The patient's home
  • The patient's workplace
  • A public park or other agreed-upon public location
  • A school
  • A restaurant

Sometimes staff at other health care settings, such as outpatient treatment centers, can be asked to give DOT to a patient who can get to the alternative health care setting more easily than the TB clinic.

9.20 What are four advantages of DOT?

When used as a collaborative effort with the patient, DOT has many advantages over self-administered therapy:

  • It ensures that the patient completes an adequate regimen
  • It lets the health care worker monitor the patient regularly for side effects and response to therapy
  • It helps the health care worker solve problems that might interrupt treatment
  • By ensuring the patient takes every dose of medicine, it helps the patient become noninfectious sooner
  • Often patients who have successfully completed DOT are willing to describe their experience or share it with new patients. If this can be arranged, former patients may help encourage new patients to participate in the DOT program.
Often patients who have successfully completed DOT are willing to describe their experience or share it with new patients. If this can be arranged, former patients may help encourage new patients to participate in the DOT program.

9.21 What are incentives and enablers, and what are their purposes?

Just offering a DOT program is not enough. Patients must agree to participate in taking their medicine and stick with it. Incentives and enablers may help them do this. Incentives are small rewards given to patients to encourage them to either take their own medicines or keep their clinic or field DOT appointments. Enablers are those things that make it possible or easier for the patients to receive treatment by overcoming barriers such as transportation difficulties. Incentives and enablers are widely used in facilities providing TB services; they help patients stay with and complete treatment.

9.22 How does a health care worker determine which incentives and enablers to use for each patient?

Incentives and enablers should be chosen according to the patients' special needs and interests, or the patients may not care if they receive them. For example, if the health care worker knows that transportation is a problem, he or she could offer bus tokens, bus fare, or taxi fare. If transportation is not a problem, then he or she should offer something that is needed. Learning as much as possible about patients will help to identify their needs and interests and better motivate them to complete treatment. The best time to begin using incentives is after a good relationship has been established with a patient. Enablers, however, may be vital to the initiation of treatment and should be provided as soon as treatment starts.

9.23 What are some sources of incentives and enablers?

Programs can obtain incentives and enablers from many different sources. Possible resources for obtaining incentives and enablers include

  • The state or local American Lung Association chapter
  • Community organizations, such as church groups
  • Businesses that can donate items such as food or food coupons
  • Volunteers who can contribute goods and services, such as baked goods or childcare
  • TB program staff who are willing to devote extra time and attention

9.24 What are five ways the health care worker can help parents improve adherence in children?

The health care worker should do everything that can be done to make sure that parents support their children's TB treatment, including

  • Educate parents of children and adolescents with TB disease. By assessing their knowledge and beliefs about TB, the health care worker can address concerns and needs, correct misconceptions, and help parents understand their child's disease. If both the patient and his or her parents are knowledgeable about TB, the patient is more likely to successfully complete a regimen.

  • Warn parents about the possible problems their children might have during TB treatment. Children may resist taking medications, may have adverse reactions to the medications, and may have problems swallowing pills and capsules (the common form of TB medications). When parents know in advance about problems that can come up during their child's treatment, they can cope with and help solve problems as they arise.

  • Give DOT to children with TB when parents' or caregivers' compliance with giving medications as prescribed cannot be ensured.

  • Use incentives and enablers, such as coloring books and toys, to encourage a child to take medicine. Giving incentives to parents and caregivers should be considered, too; this will encourage and reward their participation.

  • Give TB drugs in easy-to-take preparations. Rifampin can be made into a liquid suspension. Isoniazid can also be prepared as a suspension, although its stability varies. The health care worker can discuss the use of liquid medications with the patient's clinician. Isoniazid and pyrazinamide pills can be crushed and given with small amounts of food.

9.25 Why are adolescents at high risk for nonadherence?

Although adolescents can be responsible for taking their own medications, they are also frequently nonadherent. They may be embarrassed about having to take TB medications because they are concerned about what their friends think. Also, they may not feel threatened by TB and may not take the condition seriously. For these reasons, adolescents are a high priority group for DOT.

9.26 If a health care worker conducts a behavioral diagnosis, what methods can the health care worker use to help a patient whose adherence problem is:

  1. Forgetfulness?

    Get help from family or friends, simplify the regimen or use combination pills, link pill taking with other activities, provide special pill dispensers and memory cues, or use DOT.

  2. Lack of motivation?

    Point out the dangers of nonadherence and benefits of therapy, increase the frequency of visits, provide incentives and set short-term goals, use DOT

  3. A complex regimen?

    Simplify the regimen, associate the regimen with other activities, use combined capsules, or use DOT.

  4. Poor relationship with the health care worker?

    Develop communication skills, be accessible throughout care, work on attitudes about patients and DOT, change health care workers, provide social services

9.27. Describe how cultural, religious, or other personal beliefs can affect the treatment for TB.

Sometimes cultural, religious, or other personal beliefs affect a patient's TB treatment. It is important for the health care worker to sincerely respect the beliefs of the patient. Sometimes patients seek medical advice from folk healers or alternative practitioners. The health care worker may encounter patients who use folk remedies along with their prescribed medications. For example, in some Asian cultures, TB medicines are considered "hot" and need to be countered with something "cold," such as green leafy vegetables.

Take the time to learn about the patient's cultural beliefs. If the patient thinks that the health care worker does not respect his or her beliefs, it could cause the patient to distrust the health care worker. If the patient comes from a background that includes the use of alternative medicine or folk medicine, find out if there are barriers to the acceptance of conventional medical practices. A discussion about the patient's beliefs and health practices may help the health care worker to individualize treatment so that it is acceptable to the patient.

When folk or alternative practices are safe, health care workers should consider including them in the treatment plan. For example, some people believe in the healing power of prayer. These persons may be more willing to take medications after saying a brief prayer, so accepting their belief in prayer is an important aspect of treatment. If a patient is taking an herbal remedy, the health care worker should check with the patient's physician or pharmacist to be sure it will not cause side effects or interact adversely with the patient's TB drugs. He or she should ask patients who have concerns about nutrition supplements or interactions with TB drugs to discuss this with their clinician.

While it is important to respect the patient's beliefs, it is just as important for the health care worker to clearly present the rationale for taking TB drugs for a full course of treatment. The health care worker can do a great deal to help the patient adhere and incorporate his or her beliefs into the treatment, but it is crucial that both come to an agreement about taking TB medication.

9.28. Name eight specific things the health care worker can do to form an effective partnership with his or her patient.

Patients make independent decisions every day about whether they will take medication or show up for DOT. The health care worker must recognize the important role of the patient in making decisions about treatment. For this reason, the health care worker should develop a partnership with the patient. Effective partnerships call for specific behaviors from the health care worker:

  • Listen and try to understand the patient's knowledge, beliefs, and feelings about TB disease and treatment
  • Be open minded about the patient's beliefs and cultural expectations
  • Recognize and address the patient's fears about the illness
  • Understand and fulfill the patient's expectations about treatment, when possible
  • Communicate clearly so that the patient can understand the messages
  • Avoid criticizing the patient's adherence behavior; suggest behavior changes respectfully
  • Treat the patient with dignity and respect
  • Be consistent in what is done and told to the patient

9.29. Who can provide support to a patient and help the patient remember to take medications?

The support of family, friends, and health care workers can be important to patients trying to complete treatment. The health care worker should ask his or her patients to identify persons who support their TB treatment and can help them remember to take medications or keep their DOT appointments. Such persons might include

  • Family members
  • Friends
  • Teachers
  • Social workers
  • Landlords
  • Clergy
  • Neighbors

9.30. What are two things the health care worker can do to tailor the regimen to the patient's lifestyle?

To improve adherence, the medication regimen should be tailored to the patient. If possible, the regimen should be simplified and changed within acceptable therapeutic limits to match the patient's lifestyle. For example, the patient's physician can prescribe

  • An intermittent regimen for a patient whose schedule doesn't permit daily DOT appointments
  • A combined pill, which is a fixed-dose combination capsule or tablet that may enhance patient adherence, for patients with difficulty swallowing. In the United States, the Food and Drug Administration has licensed fixed-dose combinations of isoniazid and rifampin (Rifamate) and of isoniazid, rifampin, and pyrazinamide (Rifater).

Patients who are not on DOT sometimes find it useful to monitor their pill-taking by checking off doses on a daily calendar. A calendar can help patients remember the days they need to take medicine and engage them in determining their own schedule. A weekly pill box may also help patients monitor their pill-taking.

9.31 What is a formal adherence agreement?

For some patients, a formal adherence agreement -- a written understanding between the health care worker and a patient -- may be useful. A sample adherence agreement is presented in Figure 9.7. A patient should dictate or write down the activities he or she agrees to carry out (such as taking medicine as prescribed), in return for specific services, activities, or incentives from the health care worker. For some patients, this written commitment increases the likelihood of adherence. The patient should be asked to sign the agreement next to the health care worker's signature and be given a copy to keep. The health care worker should review the agreement with his or her patient periodically to assess how well both are doing and to make changes as needed.

9.32. What three methods can be used to help patients keep their appointments?

There are three methods to help patients keep their appointments:

  • Remind patient of appointment
  • Contact no-shows and make another appointment
  • Use other alternatives for patients who repeatedly break appointments

Examples of Methods to Help Patients Keep Appointments

Remind patient of appointment Contact the no-shows and make another appointment Use other alternatives for patients who repeatedly break appointments
  • Send a post card
  • Call the patient by phone (opportunity to counsel)
  • Give an appointment card
  • Call the same day as the appointment

  • Visit the patient at home
  • Hold a conference with all members of the health care team

  • Possibly include the patient in the conference

  • Consider legal alternatives

  • 9.33. Give four examples of nonadherent behavior.

    The Advisory Council for the Elimination of Tuberculosis (ACET) defines nonadherent behavior as an inability or unwillingness to follow a prescribed treatment regimen. Examples of nonadherent behavior include

    • Taking medication inconsistently
    • Missing clinic appointments
    • Consistently failing to report for DOT
    • Refusing medications

    9.34. Describe the progressive interventions that should be attempted before a court orders involuntary confinement.

    ACET recommends that before a court orders involuntary confinement, state and local TB control programs should have a treatment plan that goes step-by-step from voluntary participation to involuntary confinement as a last resort. The plan should begin with learning the possible reasons for nonadherence and addressing the identified problems using methods such as DOT, incentives, and enablers. The patient should be told orally and in writing of the importance of adhering to treatment, the consequences of failing to do so, and the legal actions that will have to be taken if the patient refuses to take medication. If the patient does not adhere to DOT voluntarily, the next step may be court-ordered DOT, which is DOT that is administered to a patient by order of a public health official or a court with the appropriate authority. It is used when patients have been nonadherent despite the best efforts of TB program staff. Court-ordered DOT can be successful in convincing a patient that his or her TB treatment is an important public health priority.

    TB control programs should not begin procedures for confining patients to a treatment facility until after the patient has shown that he or she is unable or unwilling to follow a treatment regimen implemented outside such a facility. Involuntary confinement or isolation for inpatient treatment should be viewed as the last step. However, when a patient with infectious TB refuses treatment and voluntary isolation, emergency detention to isolate the person is appropriate. Confinement can be either in a hospital or in some other institution with TB isolation facilities.

    9.35. List the criteria for deciding if a patient should be confined.

    When deciding whether to legally confine a TB patient to protect the public, local health officials must decide whether the person is at real risk of infecting others (now or in the future). To determine this risk, these factors are considered:

    • Laboratory results (acid-fast bacilli smears and cultures)
    • Clinical signs and symptoms of infectious TB
    • An abnormal chest radiograph, especially if cavities are present
    • A history of nonadherence (not caused by factors outside patient's control)
    • The opportunity to infect others

    An order to confine a patient should require that he or she be isolated until no longer a public health threat. This decision should be based on

    • The patient becoming asymptomatic, with documentation of at least three negative sputum smears taken on different days
    • The local health officer's decision that the person has completed therapy according to the most recent American Thoracic Society/CDC treatment recommendations

    The patient should be ordered to receive treatment in a proper facility until cured, unless it is certain that the person will voluntarily complete therapy at home once noninfectious. If the patient refuses the ordered treatment, the health officer should have the authority to extend the confinement order as needed.

     
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