 Tuberculosis has plagued humanity for thousands of years. Dr. Robert Koch identified the bacterium that causes TB in 1882, but another 70 years would pass before this important discovery would lead to a cure. At its peak at the turn of the century, TB was the leading cause of death in the United States, killing one out of every four people. Popular remedies ranged from tonics laced with opium to sulfuric acid applied to the chest. For many years, patients were placed in sanatoria, where the only treatments available were rest and fresh air. Real progress in the fight against TB did not arrive until after World War II, when general public health conditions improved, and effective chemotherapies such as streptomycin and isoniazid were discovered. After decades of decline, TB was thought to have been conquered. As a result, TB programs lost funding in the 1970s and 1980s. But by the late 1980s, TB was on the rise again, with more than 26,000 cases reported in 1992. Several factors were behind the resurgence of TB. Chief among those was a change in social conditions that resulted in a number of people being homeless, people being crowded in shelters, in addition, the occurrence of HIV infection. And perhaps most important of all was the deterioration in the public health infrastructure and in the control programs that to that point had been quite successful in bringing tuberculosis to very low rates in this country. To regain control of the disease, Congress increased funding for TB programs in the early 1990s. These programs made tremendous strides, and annual TB cases fell 31% between 1992 and 1998. But while the overall incidence of TB in the U.S. is falling, rates of TB in certain groups remain alarmingly high. They tend to be the groups that are socially the most marginated, homeless persons, persons with substance abuse problems, HIV infected persons, persons from countries where there's a high prevalence of tuberculosis. Internationally, TB continues its deadly rampage. According to the World Health Organization, one third of the world's population is infected with the tuberculosis bacillus, with 7 to 8 million people developing the disease each year. TB accounts for more than one quarter of all preventable adult deaths in developing countries. We can expect that in the next 20 years, nearly 1 billion more people will become infected. 200 million people will develop the disease, and 70 million people will die from TB if global control is not strengthened. Multi-drug-resistant TB is now found on five continents. One of the most effective strategies against TB is Directly Observed Therapy, or DOT. That involves, as the name would imply, a healthcare worker directly observing the patient taking the medications. Another effective strategy is screening high-risk populations and increasing the number of people who receive treatment for latent infection. Despite recent gains in prevention and control, however, TB continues to be a major health threat. In order to win the war against TB, healthcare providers and public health workers need access to information, technical assistance, and training about TB control strategies. To provide these services, the Centers for Disease Control and Prevention established in 1993 three model centers, the Francis J. Curry National Tuberculosis Center in San Francisco, the Charles P. Felton National Tuberculosis Center at Harlem Hospital in New York City, and the New Jersey Medical School National Tuberculosis Center in Newark, New Jersey. Each year, the model centers train thousands of health providers and TB program staff to help them in the fight against tuberculosis. In 1995, the CDC's Division of TB Elimination produced five self-study modules on TB to provide basic information about TB to entry-level public health workers and others who serve persons with or at risk for TB. That year, the CDC also produced a satellite primer on tuberculosis, a national five-part satellite course based on the self-study modules that reach TB programs across the country. TB Frontmine continues this tradition of excellence. This three-part course is based on four new self-study modules developed by the CDC, covering Contact Investigation, Confidentiality, Surveillance and Case Management in Hospitals and Institutions, and Patient Adherence. TB Frontmine is brought to you by the Francis J. Curry National Tuberculosis Center in collaboration with the Division of Tuberculosis Elimination, National Center for HIV, STD and TB Prevention, Centers for Disease Control and Prevention, the Charles P. Felton National Tuberculosis Center at Harlem Hospital, the New Jersey Medical School National Tuberculosis Center, and the Public Health Training Network. Welcome to TB Frontmine. Satellite primer continued, Modules 6 through 9. I'm Dr. Gisela Schechter of the Francis J. Curry National Tuberculosis Center, and I'm moderating this three-part course. We're broadcasting live from San Francisco, California to over 7,000 of you who work on the frontlines of TB Control. We send special thanks to the site coordinators who are managing course logistics at nearly 1,000 downlink sites in all 50 states. As you know, this satellite course is based on four new self-study modules produced by the CDC's Division of TB Elimination. If you were unable to register for the course last December and would like to order the modules, we will provide ordering information at the end of today's program. Today, we present our third and final broadcast of TB Frontline. This two-hour session is based on module number 9, Patient Adherence to TB Treatment. I'd like to introduce our faculty members for this session. Carol Posick is Director of TB Control for the South Carolina Department of Health. Hello, Mrs. Posick. Hello. Dr. Masai Kawamura joins us again this week. She is Director of the TB Control Program right here in San Francisco. Welcome back, Dr. Kawamura. Thank you. Mrs. Posick and Dr. Kawamura will give presentations on various aspects of patient adherence. We will again apply the course content to a series of video dramatizations. We will conclude our broadcast with a question and answer period. TB Control staff from San Francisco will now ask the questions that we plan to address in today's broadcast. What are reasons that my patient might be non-adherent? How can I help patients overcome their barriers to adherence? What is DOT? What are its advantages and disadvantages? Who are candidates for DOT? What task does DOT involve? What are incentives and enablers? What progressive steps should be taken with the patient before resorting to involuntary confinement? For most of human history, tuberculosis was a major cause of death. It was not until after World War II that medical science finally uncovered effective treatments for TB. Despite the tremendous strides we have made against this disease in the last half century, we should not forget that adequate treatment is still not available to everyone in the world who needs it. Last year at the 30th World Conference on Lung Health in Madrid, Spain, his grace Archbishop Desmond Tutu, winner of the Nobel Peace Prize in 1984, delivered a moving inaugural address about the importance of ensuring that all persons with TB have access to complete and compassionate care. We share with you now some excerpts from the Archbishop's speech. I myself had tuberculosis when I was thirteen years of age and spent all of twenty months in hospital. I recovered from tuberculosis because I was able to exercise the right to proper treatment. It is more than fifty years since I had TB. I am cured. There is life after tuberculosis. My role here today is to speak out on behalf of tuberculosis patients who ask for one basic human right to be respected, the right to be treated for their illness. According to article 25 in the Declaration of Human Rights, I quote, Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing and medical care, and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. Closed quotation. The majority of tuberculosis patients throughout the world do not have the basic medical care that they need and deserve. Why? Because it is not free and they have no money to buy it, because it is not available in their community, because there is an unreliable supply of medication or a lack of health care workers to monitor their treatment, or because such strong social stigma attaches to tuberculosis in their community that they feel they should hide their illness. According to the latest data from the World Health Organization, more than 1.8 billion people, that is one third of the world's population, are infected with tuberculosis bacilli. Every year 9 million of those infected develop tuberculosis, and every year almost 2 million people die of this curable disease. Those are not numbers. We are talking about people of flesh and blood, such as you, such as I. Tuberculosis treatment must become an integral part of the health care that a country provides for its people. Tuberculosis has long been linked with social stigma and discrimination. We can change this by recognising tuberculosis as a curable disease, just like any other. If we do not take the rights of tuberculosis patients seriously, we reinforce the social stigma attached to the disease. We must respect their rights and commit ourselves to providing each patient with the appropriate means to treat his or her illness. A terrible result of inadequate treatment is that multi-drug resistant strains of tuberculosis can develop. Some multi-drug resistant tuberculosis has appeared in the last few years. Such cases are almost untreatable. We must do everything we can to make sure tuberculosis patients have a complete treatment. Even more so now by the threat of multi-drug resistant tuberculosis has become a dreadful reality. Every person with tuberculosis has the right to be treated for his or her disease. No one can deny that. So let us stop denying them this basic human right. TB can be cured. The scourge can be defeated. We are fortunate in the United States to have the resources to support a system of TB control services to ensure that all persons affected by TB have access to care. However, as we all know, access is only the beginning. TB disease is caused by tenacious bacteria that are not killed quickly, nor with a single drug. Finding ways to ensure that patients complete their full course of TB treatment is one of the most fundamental challenges facing any TB control program. Carol Pozik has grappled with this issue for over 17 years and she shares some of her experience with us now. Thank you. Today as I discuss the topic of adherence, I want to reinforce two of the most important outcomes of our goals in tuberculosis control. These are the completion of treatment for TB disease and latent TB infection. Getting the patient to adhere to treatment is the key to reaching these outcomes. Adherence is described as following the recommended course of treatment by taking all the prescribed medications for the entire length of time necessary. Tuberculosis is both preventable and curable and we know that this is only possible if the patient is adherent to treatment. What are some of the reasons for non-adherence? The patient may no longer feel sick after some treatment or as in the case of the treatment of latent TB infection, he hasn't felt sick at all. The patient may lack knowledge of tuberculosis infection or disease. He may not understand that his condition could worsen or that he could become a danger to others. The patient may have cultural beliefs that conflict with his understanding of the disease process and the reasons for taking medications until they're completed. There may be the inability to follow instructions to complete therapy due to mental or physical impairments. Some elderly may fall into this category, those who have disabilities or special needs. The patient may lack easy access to healthcare due to the clinic location, work schedules, lack of transportation or childcare. There may be language barriers between the patient and the healthcare worker which could cause misunderstanding about what is required of the patient in order to complete treatment. Lack of recognition of drug side effects and the ability to report them could also be damaging to the patient's health. The patient may lack motivation to complete therapy. He may have feelings of worthlessness causing him to not care about his health or the health of others around him. Also, there may be control issues between the caregiver and the patient which caused conflicts and thus a barrier to the completion of treatment. If the worker is too forceful on approach, the patient may rebel and hide from the worker or do such things as pretend to swallow medications, then spit them out when the worker is not looking. If the worker is too weak an approach, then the patient may take control of his own medication program and do as he wishes. This is, of course, not necessarily in his best interest or in the interest of the public's health. Sometimes it may be necessary to use another healthcare worker if the conflicts are interfering with treatment. Can we predict if the patient will take medications? It's not easy to do. Statistically, only about half of the time we may make an accurate prediction. A clue that might help us would be that a patient has failed on other medical regimens, such as taking prescribed medications or failing to follow physician's recommendations to stop smoking or lose weight in the face of serious health complications. It is extremely important to remember that anyone regardless of social class can be non-adherent. Many TB workers have been burned by these past experiences. Those who believe that reliable people, such as nurses, doctors, ministers, and parents would be compliant with taking or giving medication to others, have found out the hard way that this may not always be true. We are all human and sometimes fail. It is good to question patients directly about their medication-taking abilities during the assessment phase of working up the patient. Who is responsible for the completion of therapy? Many years ago in TB control programs, we used to say that the patient was totally responsible to take his medications. Often healthcare workers did not shoulder final responsibility to see that the patient followed through. Times have changed and now it is a shared responsibility. Patients today are less likely to fail on therapy because of the role of case management in tuberculosis control programs. A single health department case manager should be assigned primary responsibility for assessment and follow-up of the individual patient and the family unit. A major part of this assessment includes the family's level of knowledge about TB. By using open-ended questions and regularly reviewing this knowledge, the likelihood of successful completion of treatment is much greater. Communications is also an essential part of the success of the treatment plan. In order to communicate well with the patient, the worker must use simple, non-medical terms in an unhurried manner. Use an appropriate language level that the patient can understand. Limit the amount of information presented to the patient at one time. Not everything has to be done at the first visit. Discuss the most important topics first and last in the conversation. Repeat important information more than one time for reinforcement. Listen to feedback and answer all questions from the patient. Use recognizable examples and make the interaction a positive one. In addition to effectively communicating, education must be done in a way that is meaningful to the patient. Remember to provide information that is right for each patient's level of knowledge and awareness of the problem. Using scientific terms with the patient who has a fourth grade education may not impact his knowledge base. In fact, it may intimidate him and cause problems in the continuing relationship. Take into account specific needs of the patient at the time of the interview. For example, if the patient is concerned about his children becoming sick with tuberculosis, don't focus the conversation on sputum collection, but recognize the patient's fears and address them. Find ways to identify and deal with potential problems with adherence. The patient who is embarrassed and may not reveal his fears about taking pills for TB treatment and thus may try to avoid taking medications. Allow the patient to help make decisions and choose solutions to problems. By doing so, he will be more likely to be cooperative with the treatment plan. Throughout the process of treatment, make sure you document that the patient understands the information he receives. For those concepts which the patient does not understand, continual reinforcement must be given. In summary, the patient must understand his illness and the benefits of treatment or else he will not be committed to completion until cure. We'll hear more from Mrs. Pozik in a few minutes when she continues her presentation on adherence. But now, let's focus on a specific strategy that can radically improve adherence among TB patients. Directly Observed Therapy or DOT. As you know, DOT involves a healthcare worker or other responsible person watching the patient swallow each dose of his or her medication. When I first began working in the San Francisco TB Control Program over 20 years ago, we were already using rudimentary DOT. The San Francisco General Hospital TB wards had closed in 1973 and standard therapy became an all-oral outpatient regimen. But some patients with drug-resistant disease required daily or twice-weekly injectable drugs and so they came into our TB clinics regularly for treatment for many months. Homeless persons were also encouraged to come in for supervised treatment. The encouragement included a sandwich, two bus tokens and the real draw, a little pack of four cigarettes which our head nurse, Pat Eberhardt, would supply. It was actually very hard to give up that very effective incentive, but we did finally do that. In 1982, the CDC began to offer cooperative agreement funds for outreach workers dedicated to DOT and the use of DOT in San Francisco was expanded to a formalized clinic and field program. We sent our cameras out with two DOT workers from the San Francisco TB Control Program. Here then is a day in the life of one DOT team. When I come to work every day, the first thing I do is prepare sandwiches in the kitchen. We bring sandwiches, different juices. We have crackers, we have lollipops and instant noodle soup because some patients like different things. I feel that incentives really help. A lot of our patients are really economically poor. Most of them are on public assistance of some kind and some of them are homeless and things like that. Some of them don't even have any food to eat at all, so I think incentives like sandwiches and stuff like that is really helpful. Do we have to pick up sputum from anybody? No, we don't have to pick up the sputum today. On a typical day, we see about 16, 17 patients. Normally I'm out on the field about five, six hours. I always travel with a partner for the safety reasons. DOT is good because these patients need help. We're dealing with a lot of patients in high-risk categories. Some of them are not really reliable. A lot of them forget to take their medications. We make sure that someone's there to watch them take it. Now we're going to see about a 30-year-old female patient. She's a drug abuser and she's an uncle abuser and she's a homeless patient. She's facing a little bit of mental health problems. She keeps forgetting things. Right? Right inside. How are you doing? We're there, basically, not only watching them taking the meds, but to help them, to assure them that we're there, we care. Having a good rapport with the patients are very important because you've got to establish some kind of relationship, some kind of trust between the workers and the patients. Well, we've got just a little bit to see. Let that help them comply with taking the meds. It's a challenge, really, to deal day in, day out with some of these patients. We're talking at least six months of taking pills almost every day. And you combine that with patient factors like some persons who are homeless, persons who are using substances, persons who have mental problems. Just to give you an example, there are those other barriers. What really works is the tender loving care that the staff give to the patients. If they ask you a question, for instance, they'll say, gee, how long am I going to keep taking these medicines? And if you don't know, just say I don't know, and I will find out from the nurse, and then follow up. We've gone and recruited staff from the communities of the patients that we serve. So we can identify with our patients. All the incentives, enablers, they help. But it's this caring, caring, respectful attitude towards your patients. This needs to come across. Sometimes some questions come up. Why do you need to watch me taking medication? You guys don't trust me. You know, our answer to that question is not that we don't trust you. We are there to help you. Now we are going to see the 14-month-old baby who has TB on the neck. This baby is on DOT because his family has child care problems. We didn't know how we were going to give the meds to the baby. The mother suggested that we should mix medicine with the juice and suck it up in the syringe. It'll only take just a few seconds, and then it's done. My favorite part of doing DOT is to get to know the patients. I like it best when the patients are happy. The way they smile, the way they greet you, you know, they greet me. If they see you are happy doing it, they will feel happy. The volunteer information, talk about their family problems, talk about the fun things in the family, things like that, it makes me happy. You know, just make my day on that day. Masai, as director of the San Francisco program, we just saw a profile. Are there any comments you would like to add? There's one comment I'd like to make, and that is about Boone, who exemplifies that kind and respectful attitude that all healthcare workers need to have with their patients. It's really that respectful attitude that is universal, that goes beyond culture and any individual differences that connects with others. And it's that human connection that really helps the patient make it through and complete therapy. Thanks. Carol Pozik will now fully explore the topic of DOT as we continue with part two of her presentation. Who Should Get DOT? Discussions about directly observed therapy often center around the question of who should get DOT. The American Thoracic Society in the Centers for Disease Control say that everyone should be considered for DOT. As previously discussed, we have no way of knowing who will be compliant with therapy when we start a patient on medications. Some clinics have sufficient staffing to provide DOT for all their patients. This is called universal DOT and requires total staff commitment to buying into this concept. Universal DOT is done because staff then have confidence in knowing that all patients will complete treatment. They also find it easier to monitor for drug side effects for medical and social problems of the patient. Who is highest priority for DOT? There are two groups of patients who should have mandatory DOT. At highest priority are patients with drug resistant tuberculosis. Persons who have any resistance to tuberculosis medications should be put on DOT even if they are resistant to just one drug. The consequences of the spread of drug resistance can be disastrous. Staff who have treated drug resistant patients will tell you that it is very labor-intensive and frustrating. Treatment may often be daily and for much longer periods of time do the complex drug regimens required. Another group who must receive DOT are patients who are placed on intermittent therapy twice or three times a week. Missing one dose of intermittent treatment means that 50% for twice weekly or 30% for thrice weekly of the doses for a week have been missed. Therefore, all intermittent regimens must be strictly observed. If we had a crystal ball and could quickly know who would be compliant, it would make our jobs much easier. We don't have that. But we do know that there are certain groups of people who may be more at risk for not taking or managing their medications. The consequences of failure could be putting these persons at risk of personal health problems and others at risk of being infected with contagious tuberculosis. Some of these groups are as follows. Homeless or unstably housed persons may have difficulty taking care of their medications. That is, they might get lost or get wet or the medications might be subjected to undesirable temperatures. Taking their medications on schedule can also be a problem as there may not be something available to drink in order to take the medicine. Persons who abuse alcohol or illegal drugs often are unable to focus on taking their TB medications as a priority. Their priorities more than likely are focused on the substances that they abuse. It's not uncommon for alcoholics to avoid taking oral medications because their GI tract is disturbed from alcohol. Without DOT, the likelihood of compliance is slim. Some persons may be unable to take pills on their own due to mental or physical impairments. DOT provides them with the assistance that they need to be successful in the completion of treatment. For patients who are chronically depressed and at risk as a danger to themselves, medications in large quantities should never be left in the home. DOT will prevent the patient from having access to these medications and allow the health care worker to observe the patient's emotional status. Children and adolescents are generally a challenge when it comes to the ingestion of medications. Children may resist parents' attempts to give medicines by kicking, spinning, etc. After a while, the parent may give up and be reluctant to tell the health care worker of their personal failure to get medications into their child. Another person giving the medications to the child may be a God's end for the parent who has become frustrated with the process. Adolescents are another group of special concern. They must take their medicines because they can transmit disease to others as easily as adults. Most are social creatures and can be too involved with activities and friends to take their medicines. Parents may also have difficulty in getting adolescents to comply, so DOT is very helpful, particularly if it can be done at school. Persons who have previous histories of non-adherence should receive DOT. If they have not followed through with preventive treatment for latent TB infection, hypertension, diabetes, or other medical recommendations or regimens, they will probably not follow through with a long, multi-drug, tuberculosis treatment that is necessary for cure. It must be stressed that a group for whom it is mandatory to receive DOT are those who have failed on previous treatment for tuberculosis disease. This group is at highest risk for drug resistance and chances cannot be taken to have them take their own medications again. DOT must be given. DOT will be successful only if there is patient cooperation. Tremendous amounts of precious work time can be spent looking for patients who do not show up for appointments. Tailoring the DOT to the patient and his activities is a must. Determining a mutual place to meet for DOT is essential. Care must be taken to ensure confidentiality for the patient and safety for the staff and the patient. Caregivers must keep appointments made with all patients. They should never make the assumption that because the patient is homeless, he has nothing important to do. He may well have a part-time job or have some other important activities that he must take care of. Appointment keeping is important to most everyone. DOT is ideally given by a health department worker but in some instances it may be given by a responsible person and authority. Other healthcare workers are most desirable but in some instances the authority to give DOT can be delegated to landlords, bosses, clergy and etc. This must be carefully monitored to assure that the process is working. Family members should not be used to give DOT except in very rare circumstances. Emotional ties are too strong and when difficulties arise the patient who is resisting usually wins. Exceptionally close monitoring must be done in these rare instances. There are certain tasks which must be done at each DOT visit to assure medication safety in compliance with therapy. One of the most important tasks is checking for side effects. DOT is a great opportunity to observe the patient. Non-licensed workers must have professional nurse or physician backup if side effects are suspected. The medication should be withheld and the backup professional contacted immediately to take responsibility for professional assessment and further action. Verification of medication is extremely important. Each time DOT is delivered the healthcare worker should verify that the right drugs are delivered to the right patient. Policy should dictate that any discrepancies be reported to the supervisor immediately and the drugs withheld from the patient. Medication should never be left for the patient to take on his own. DOT is directly observed treatment and anything else is not DOT. When watching the patient take medications the worker should carefully observe the swallowing of pills. There are some patients who play games with the worker to see if they can avoid swallowing. All workers need to be aware that this might occur. Methods for documentation on the medical record by the worker must be in place. If the dose is not documented then in medical legal terms it was not given. Documenting therapy correctly is as important as watching the patient swallow the medications. Patient contracts may be useful in some circumstances. Contracts must clearly describe what is expected of the patient and the worker as well as the consequences of failing to keep the contract. Incentives can be given to increase the chances for success with contracts. The importance of the use of incentives and enablers in the tuberculosis control program cannot be stressed too heavily. Their success is well documented over the last 20 years by all kinds of healthcare workers. Incentives are small rewards given to patients to encourage them to either take their own medications or to keep their clinic or field DOT appointments. Enablers are those things that make it possible to make it easier for the patient to receive treatment by overcoming barriers such as transportation difficulties. Incentives should be carefully chosen according to a patient's needs or interests. The choice of an incentive for one patient may provide great motivation to comply but may not necessarily appeal to another patient. Getting to know the patient and his interests and needs is an incentive. The building of a positive relationship between the caregiver and the patient is very important to the completion of treatment. Incentives and enablers help with building that relationship. Some incentives that have been successfully used are food, beverages, clothing, automotive supplies, hobby and craft materials, toys, services such as laundering a patient's clothes, transportation, personal care items and anything special that will motivate the patient to comply. Enablers range from relatively simple items such as bus or subway tokens to more comprehensive services such as housing assistance or referrals to substance abuse treatment programs. Incentives and enablers may be obtained through local churches, charities, state or local American lung association affiliates, businesses, volunteers or through the personal outreach of health department staff. Your state or local health department TB control staff can assist you in finding sources of incentives and enablers for your patients. I highly recommend this strategy to assist you in achieving patient compliance. To quickly review my major points adherence is essential to TB control. Patients may be not adherent for many reasons. Adherence cannot be or be predicted. Completion of therapy is a shared responsibility. All patients should be considered for DOT. Patients who are high priority for DOT include drug resistant cases, patients on intermittent therapy, homeless patients, substance abusers, patients with mental and physical impairments, children and adolescents and patients with a history of non-adherence. DOT tasks include checking for side effects, verifying the medication, observing the swallowing of pills and documenting the visit. And finally, incentives and enablers can be powerful adherence tools. Thank you Carol. TB treatment regimens require patients to take many pills over many months. As we've learned, there is no magic bullet for helping patients to adhere to their treatment. Ensuring the completion of therapy requires a customized approach for each patient. With the concepts that Carol covered in her presentation, we have a series of dramatizations based on three real-life cases. As you watch the first case, think about the barriers to adherence that this patient faces. What strategies would you use to help the patient overcome these barriers? Teresa Rollins is one of three characters in our story who have been placed on DOT following a stay in the hospital for active TB. Teresa Rollins is a 65-year-old retired widow who suffers limited mobility due to her arthritis. Her support system consists mainly of her daughter and grandchildren who live a few blocks away and her friends from church. In this scene, Terry, a public health nurse from the county health department, has come to visit Mrs. Rollins at home to discuss her ongoing TB treatment regimen. We join them midway through their conversation. So, Mrs. Rollins, we've talked about how you've got TB, how it can spread to others, and what can happen if you don't take your medication. But let's talk about the good news right now, how you can get completely well. When you're in the hospital, you start to take four drugs. How are you feeling now? Oh, much better, much stronger, but it's not because of the pills. Really? Why do you think that is? Well, my prayer group has had a special blessing for me every day since I got sick. I'm like very supportive friends. As soon as I get stronger, I'm going back to church myself to light some candles. I hope you're feeling well enough to go back to church soon, also. And while you and your friends are calling on your spiritual powers to help make you better, it's very important to continue to take the TB medication for the entire six months. But six months is such a long time. It is a long time, and it will be an especially great Christmas present for you to complete your TB medication. So let's find a time for the health care worker to come by every day starting tomorrow, Monday through Friday, to help you take your medication. So many pills to swallow. They are a lot of pills to swallow, and that's why he's going to bring some juice to help you. That would be nice. What's a good time of day for the health care worker to come by? I don't know. Sometimes I forget things. And I go to church or out to the store. Well, let's see. Is there an activity that you do every day at the same time? I read my Bible after breakfast every morning. And about what time is that? About 8.30. 8.30? Would that be a good time for the health care worker to come by? We could try that. Okay. Well, let's set it up for 8.30. And maybe your daughter can help remind you as well. Well, my daughter hasn't come over since I got sick because I was afraid to make my grandchildren sick. I really miss them. Right now, because you're taking your TB medication every day, there's no danger to them. You don't need to worry as long as you're taking your TB medication every day. And keep praying. And that too. Maybe we can call your daughter right now and see if she can call you in the mornings to remind you about your appointment at 8.30. Okay. She's busy, but she always says she wants to help. Let's see if she's home. How many careers exist for Mrs. Rollins to take her TB medication? First of all, she lacks knowledge about tuberculosis. And so she has a fear that she's going to infect her daughter's family. She also is forgetful, and she admits that. And when you hear someone talking about being forgetful, you need to really think about what you need to do about that. She has limited support from her family and friends. And it sounds like, especially from the daughter who even though the daughter has not attempted to come over, you would wonder why she doesn't try. It seems like she could help some even by telephone. The lady has difficulty taking her medications. And that should be a clue to the worker to work extra hard to help her get a way to do that. And also she lacks physical mobility. And that's a very good reason for doing DOT. All right. How has the healthcare worker tried to reduce these potential barriers? Well, let me take the first two barriers which is the lack of knowledge and then the forgetfulness. In terms of the lack of knowledge, Mrs. Rollins thought she felt better because she had her friends praying for her. And she also did not have an idea how long she would be on medications. The healthcare worker was very skilled at acknowledging and respecting those beliefs, but at the same time interjecting the appropriate education materials for the patient. All right. Do you want to continue, girl? I'm not done with the forgetfulness. In terms of addressing the forgetfulness the healthcare worker linked the pill-taking to an important daily activity of reading her Bible. Also provided some memory cues for that, the Bible relating to the pill-taking. And what you could do is put a little calendar or reminder in the Bible so when she opens her Bible she can also remember. Of course an important strategy is DOT for the forgetful patient. Thanks. In terms of the ladies' mobility I just want to make the comment that we should always remember to not ask a patient to do something that they can't accomplish such coming into the clinic for DOT. I think that's an important thing that anyone that is providing care to a TB patient should remember. Patients feel very guilty when they can't do what the healthcare worker asks them to do. Also in this instance the worker was very thoughtful about trying to provide the right kind of juice or it could be a soft drink or it could be something like insure a nutritional supplement for the patient to take with their medication. And so all these things really help a patient and the worker gain a bond to get therapy completed. How about enlisting the family members? Family members can be very, very helpful in getting a patient to complete therapy. They also can be a problem in getting patients to complete therapy. I remember one elderly patient that we had whose sister was behind the scenes creating a disturbance in terms of discouraging our patient to take medicine. She told our patient that she once knew someone that had tuberculosis and they died from that medicine and she really should not take it. And so it was quite a while before we uncovered that information and when we did uncover the information we had to have a very serious talk with the sister and it did take some time for us to change that sister's opinion and unfortunately it took us a long time to get our patient to change her opinions about taking medicine period. It wasn't necessarily just what the sister was saying. We ultimately had to confine our patient because she was really breaking all the rules causing a lot of problems with getting therapy. She relapsed any number of things happened with this case. So family members are important in providing a support but they also can be a difficult situation. So they can be a help but they can also be a barrier. And for your forgetful patients or for elderly patients who maybe have difficulty hearing it's also very good to have that key relationship that family member there with them at every medical appointment when the healthcare workers counseling the patient so that they hear everything that the patient hears and that serves a good reminder it educates them at the same time and gets them to be more supportive in the right way. What should you do when a patient's beliefs differ from the facts about TB? Well you do what that healthcare worker did and that was listen. By listening I think you can gain key insights into the patient's beliefs not only the beliefs but what motivates them what fears they might have what obstacles you might have with them and their knowledge about TB disease. In her case what I liked about the scenario is that she actually used the prayer and her spiritual beliefs to support the TB treatment and that was very clever in her part. Whenever it's not harmful to treatment that alternative medicine or care should be incorporated to the treatment that's an acknowledgement of the patients and if you listen to them they're much more likely to actually listen to you. Are there some cultures that you think might have more of a tendency to have a problem with belief systems that are difficult to integrate with? Well that is true sometimes but I think any TB worker needs to take care not to think that that's the situation every time. We have plenty of people in the United States that have their own belief systems that we run into on a daily basis I think TB workers in the audience would certainly agree to that so it's not necessarily a person who comes from another country from another culture that may have these things we have plenty of our own who do. What effective communication techniques did the nurse use? One thing was to use simple terms not to go into great detail about the names of the medications she simply talked about TB pills or the red pill or the white pill often works so that the patient really can relate to what you're talking about. Also not to give too much information at one time it's a little bit like when you're a child who's five years old asked you where babies come from you don't want to go into great detail you just simply want to answer the question at the time and give just a straightforward answer and answer that question and over time not to overload a patient at any one visit for instance in an initial visit a patient may be very frightened about having tuberculosis they may have fears about death they may have fears about spreading the disease to many other people you want to capitalize on that and maybe that's the thing that you really need to educate the patient about but don't give them two hours worth of preventing tuberculosis and getting well just hit the high spots the ones that the patient is concerned about and allow two-way communication where the patient is able to ask their questions don't monopolize the conversation let the patient get their questions answered on that visit as we saw with our first patient Teresa Rollins patient education is an important first step in helping a patient establish a firm foundation for completion of therapy our next case involves a more challenging scenario in which substance abuse complicates the situation Lisa is one of three characters in our story who have been placed on DOT she is a 27 year old single woman who works odd jobs and has struggled with marginal housing and drinking when Lisa's DOT started her public health nurse had a long talk with her about TB the importance of finishing her treatment and what barriers to adherence she might anticipate at first Lisa seemed motivated by the incentive offered fast food coupons for each week with no missed doses things went well the first two weeks but during the last week Lisa has missed three scheduled doses Lisa couldn't be found in her usual single room occupancy hotel Terry finally tracks Lisa down at her sister's apartment Lisa it's really good to see you how's everything going I've been better sorry I haven't been around lately I've been concerned about you I went by the hotel and found out that you weren't renting the room anymore yeah I broke up with my boyfriend so I can't afford to rent that room by myself so I've been staying here at my sister's house that sounds really hard how's the drinking going well I've been feeling bad lately so you know yeah it's really hard break up with your boyfriend not have a place to live and if your TB gets worse you'll feel very bad then and I know you told me recently that you were really proud of yourself for being sober for four straight weeks it's just too much to deal with right now my sister's all mad at me because I'm drinking again the TB pills are the last thing on my mind plus I'm not coughing anymore you don't need them anyway you may not be coughing right now but you need to finish the full course of your TB treatment or else your TB will get much much worse and I'm sure that you don't want to go back into the hospital again things are hard right now but what do you think we can do to get you back on track well if I settle down and quit moving around for a while and if I get sober my sister will probably let me stay here well we can set up an appointment at the alcohol treatment center and you would go back and attend the sessions again I guess I could give it a shot I really like that one counselor I had before Ronnie but I don't know how I'd get from here to there every day anyway well I probably could get some bus passes for you and maybe if I used your sister's phone and call Ronnie right now we could make an appointment okay Ronnie thanks see you then bye bye alright you're all set it's your clock with Ronnie tomorrow now we have to get back on course with the TB medication schedule so you can cure your TB and we don't spread it to anybody like your sister so what's going to be a good time and place for us to meet do you want to come back here every day around noon noon is good and I brought today's dose with me and your favorite juice for helping to wash it down oh you think of everything yeah so I'll be back there tomorrow at noon and I'll bring bus passes with me for getting to the treatment center and there's just one more thing Lisa if you do move again or you go someplace else please call me anytime really let me know and I'm just happy to meet you at any place and I'm really glad that we're getting back on course me too thanks what barriers exist for Lisa to take her TB medication well Lisa illustrates a typical patient of ours that has a substance abuse problem whose life is very fragile relationships are fragile as you know she had housing problems as well she broke up with her boyfriend which led to losing her hotel room which led to drinking which led to of course not prioritizing TB as her treatment and so in addition to that she didn't have transportation to get to treatment how did the healthcare worker in this case reduce those potential barriers well first of all she did an assessment of the situation and she found that there were so many issues here that really needed to be resolved before they could get right down to the treatment problem she first recognized those problems and put them in proper perspective and realized that they needed to be solved in order for the completion of therapy it's a little bit like we used to say in public health that when you're counseling a mother about immunizations but her children are hungry she doesn't hear anything that you say and in this instance Lisa was listening to a lot of different messages in her own particular situation so she could not adequately respond it was good though she did recognize that she was chemically dependent and that she was having a barrier to getting stable housing she couldn't live with her sister until she got her act together and that was very important also the worker went ahead and lined her up with substance abuse treatment because the patient seemed ready I think those of us that work in TB control know that it is just fruitless to try to deal with the patient who is not ready to receive treatment and in this instance the worker recognized that she was and she moved ahead on that Is there any role for social workers for example? Absolutely I think that that's wonderful if your program has a social worker or has access to social workers many times in public health social workers are in the health department but they belong to maternal child health and I think that you can develop some linkages for instance with a maternal child health program that's got tuberculosis or a child I think that's very appropriate to ask frequently we don't ask but social work I can't say enough about what social work has meant in our program we often refer to tuberculosis as a social disease and it really is so many of our patients have issues that are not easily resolved by a busy outreach worker or by a busy nurse so if you do have access to social work please take advantage of it because it really is a boon to your patient's interest in yours too and they often have access to resources that you might not even be aware of How are incentives and enablers used to help Lisa? Well initially she got the fast food coupons which seemed to help but that was temporary and I think incentives are actually very good use of incentives I don't think the patient in initially but you know that's a temporary thing and what is really important is building the relationship with that patient and that's what really sees them through the end and when there are crises to address those you can again with incentives and enablers addressing the crises and so you're constantly assessing what might motivate the patient in terms of incentives and enablers in this case the health care worker did a good job and she was ready for alcohol treatment again linking her back up with that that's an enabler often times substance abuse treatment as we're saying earlier is not an incentive patients may not see that as an incentive and may not be ready for right How about transportation issues? Transportation can easily be resolved by either having someone bringing her to the substance abuse site or to the clinic that is absolutely necessary or just bus tokens, bus passes and that sort of thing We also have a saying in our program that if the patient can't come in you have to go out and I think that that we've learned that over the years that many people initially when we started DOT felt like the patient had to come into you but if your patient lives 20 miles away from the health department and there's no way to get to town so to speak in a rural setting then the health department is responsible for that completion of therapy on that patient and that means you do go out I like what you just said there the health department or the provider is responsible for the completion That's exactly right What are some positive factors in Lisa's situation that could contribute to her adherence? I think one thing the worker did she recognized that Lisa was motivated at this time and now she is ready and also she involved her in the decision making about what they were going to do to get her to complete therapy and to involve her in a drug treatment program So those issues I think at the very beginning were helpful also knowing that the patient was beginning to recognize where she had failed and that she needed to do these things or she was not going to do housing with her sister Another point I'd like to raise is that there are also differences between the substance use and she was ready and that's not often the kind of patient you have and the most difficult substance to deal with is crack cocaine cocaine addiction and methamphetamine use heroin you can often get around that problem by offering methadone very useful incentive in our program but with the crack and the speed use that's a much more difficult issue they often come in and they're high and it's very hard to connect in a meaningful way with these patients Along the methadone treatment program do you have any liaison with your methadone program in San Francisco? That has been a critical part link in our program I'm a time TB nurse working there at the methadone program to help screen their patients for tuberculosis and also monitor the patients that are on DOT and methadone I'd like to say something about our program in South Carolina because I think we've built it up over the years a good relationship with our alcohol and drug group in the state we have local alcohol and drug abuse commissions who have halfway houses and we've developed contracts with these halfway houses and for patients who are ready we get them out of their local environment where they drink with their buddies and move them to a town away which is an incentive for us to get their treatment done but it really is a good thing and it's very inexpensive they get their DOT treatment as well as their non-medical detox there we also have relationships with our patients when a patient really does need that service so it's important I'd like to now give out our toll free telephone number you can call toll free at 888-565-8673 or if you are outside of the United States you should call 415-8618543 and remember you can fax questions to our fax number 415-626-311 we now turn our attention to those occasional tough situations in TB control in which all the adherence strategies we've already discussed don't lead to the results we need this brings us to the topic of legal interventions such as court order DOT and involuntary confinement Dr. Kabomura will help us understand when restrictive measures should be considered and where they belong on the spectrum of adherence strategies thank you existing TB laws in many states have strengthened the backbone of tuberculosis control all over America these laws support us when our best efforts have failed to help our patients adhere to treatment in California legal orders for examination, isolation DOT and civil detention can be served to a patient who threatens the public's health yet legal remedies such as detention or involuntary confinement are measures of last resort after all lesser restrictive measures have failed remember having TB is not a crime legal remedies or strategies when humanely and skillfully applied should benefit both the patient and the public today I'd like to explore the progression of steps that can be taken when a patient is non-adherent and discuss how legal remedies fit into the spectrum let's begin with the patient's rights and due process generally speaking people do have the right to refuse medical treatment if they choose to however in the case of TB the public also has a right to be protected from infection laws may differ from state to state so it's important for you to know how TB in your state can be required to adhere to their treatment in my state California a contagious TB patient refusing treatment can be served in order of isolation or be detained in a hospital civil detention unit or correctional setting patients who are served detention orders must be informed of their right to appeal the process a court order review within 72 hours is mandatory if requested by the patient before going over the progressive steps let me define non-adherent behavior first it is taking medication erratically or inconsistently missing clinic appointments consistently failing to report for DOT or flat outright refusing medication before legal remedies are even considered the following steps should be taken when patients become non-adherent first healthcare workers should notify clinical and management staff second a team approach should be used whenever possible to problem solve and decide on which strategies might work best and finally DOT should be offered if the patient is currently self-administering so what should happen when a patient first demonstrates non-adherent behavior as a healthcare worker you must first ask yourself what failed one must determine the cause or make a behavioral diagnosis in order to address the issues directly the causes for non-adherence of the TV patient on DOT may fall into either provider or patient categories or sometimes both some examples of provider causes of non-adherence include the patient's lack of understanding of the disease potential side effects of the medication treatment and transmission sometimes there's just bad chemistry between the program staff and patient and from barriers of language, culture and negative stereotyping or attitudes another is the inappropriate use of enablers and incentives or the poor coordination of DOT with the patient an interesting cause is threatening legal mandates too early in treatment before a relationship of trust is built this can backfire on you and cause the patient to hide after missing a dose because of fear of confinement switching now to examples of patient causes of non-adherence active substance abuse with alcohol, crack cocaine heroin and speed is one of the more common causes or patients may be in denial despite what you tell them or they may have mental illness or disabilities depression, schizophrenia, dementia or they may have cultural and individual beliefs that lead to different inappropriate attitudes about TV like the laissez faire attitude TV is like the common cold in Asia so what's the big deal or alternative medicines are healthier and more effective the mistrust of authority from prior negative experience is yet another cause and the basic needs for shelter, food, child care and earning money may take precedence over treatment when addressing the problem of non-adherence one needs to individualize or customize the strategies to the patient to improve the treatment plan recognizing patterns of non-adherence is also important does non-adherence for example coincide with receiving bimonthly checks and binge drinking exhaust your list of tools such as making ongoing assessments of the patient's understanding and motivation and providing education throughout the patient's treatment reviewing the patterns of non-adherence with the patient and problem solving together by asking how can we make this work and another important resource may be getting the help of influential family members or friends or social service managers or in other words recruiting patient support from already established relationships giving positive reinforcement and encouragement throughout treatment is also essential or switching staff to create a better cultural match can often improve communication adjusting the incentives, enablers and getting social service support to address the patient's priorities for shelter food, clothing and earning a living accessing substance abuse treatment such as methadone maintenance or detox or other residential treatment programs making treatment contracts standard for patients placed on DOT can often prevent non-adherence and accessing mental health treatment I've just named a few tools here and I'm sure you can add to the list now, despite your best efforts for some adherence can collapse and legal remedies may be needed the most common reason in my program for using legal orders is the powerful disease of addiction and the patient's refusal to address it these patients are unable to adhere even if they desire cure and genuinely want to take their medication second to this is the inability to establish a relationship with the patient and overcome the patient's mistrust or denial let's now move to using legal remedies as adherence problems progress patients should be told orally what the consequences could be if non-adherence continues throughout the process documentation of the patient's non-adherence and the steps taken to address it is essential this is to protect both the patient's rights and to leave a paper trail for the TB program in case any of its actions are legally challenged in the future if voluntary DOT does not work a TB program supervisor may decide that the next step should be court-ordered DOT this is DOT that is administered to a patient by order of a public health official or court with appropriate authority this step may convince the patient of how important his or her adherence is when court-ordered DOT fails because of substance abuse then a court-ordered substance abuse treatment with DOT may be more appropriate to prevent the next and final step in voluntary confinement or isolation detention is a measure of last resort and is used to involuntary confine a patient until he or she is no longer a public health threat in California this decision is initially made by the health officer or designated TB controller after all lesser restrictive measures have been exhausted patients have the right to legal counsel and all cases are reviewed by the courts initially and every 90 days again this procedure may vary from state to state when deciding to confine a person one must consider the careful use of authority and balancing the patient's rights with the protection of the public's health when deciding one should be discerning and not morally judging the decision to confine someone for non-adherence must be an ethical one at times it may seem easier or more practical to detain or incarcerate the defiant difficult patient than to actually deal with the issues that led to the non-adherence one must ask is this person at real risk of infecting others either now or in the future some objective measures that you can use include the patient's opportunity to infect others for example, are there small children in the household or are they in and out of crowded settings such as homeless shelters or jails another objective measure is the extent of the disease when the patient became non-adherent that he or she have laryngeal TB cavities or positive sputum smear results or the presence of a cough after a patient is confined when should a person be released this decision is customized to the patient's circumstances and reasons for being confined release is usually determined by the local health officer or TB controller working with the courts it's also dependent on the likelihood of adhering to treatment after release and the non-contagious state to summarize, treating TB is a partnership whose responsibility is shared by both the patient and the health care providers understanding this relationship by both parties is essential to beating the disease and protecting the public's health in conclusion let's review some of the major points first, legal remedies must be used with respect and objectivity and as a last resort determine the cause of non-adherence third, customize strategies using the patient and your team's support third, exhaust the use of adherence tools such as reeducation using influential supportive individuals referrals to substance abuse treatment social or medical services and the use of enablers and incentives fourth, health departments must carefully document the process in detail patients should have legal counsel and finally patients' rights need to be balanced against the public's right to protection be familiar with the laws of your state I'd like to remind you that our toll-free phone number for questions is 888-565-8673 and again if you're calling from outside the U.S. you should call 415-8618543 and again our fax number 415-626-3110 Thank you Dr. Kawamura This is an area in TB control that is troubling to many health providers the balance between a patient's freedom of choice and the public's right to be protected from infectious disease is a delicate one Let's watch our final case study involving a patient named Ted As you hear Ted's story think about patients in your program who have posed similar adherence dilemmas for your staff How would you handle this situation? Ted is one of three characters in our story who has been placed on DOT He is a 37-year-old single man who has struggled with homelessness and crack cocaine addiction Ted was placed on daily DOT for smear positive TB When Ted's DOT started his public health nurse Terry had a long talk with him about TB the importance of finishing his treatment and what barriers to adherence he might anticipate Coupons for fast food and laundry service were offered to stay on track Ted missed four doses in the first eight days When Terry discussed the problem with Ted he expressed discomfort about the health care worker who delivered his meds thinking that the worker harbored negative thoughts about Ted's drug use To achieve a better match Terry assigned another health care worker to deliver his meds When Ted continued to miss doses Terry held another problem-solving discussion with him and reiterated her offer to refer him to substance abuse treatment Ted insists that he's not ready to quit smoking crack but he is now willing to let Terry help him secure more stable housing A room was arranged for Ted in a residential hotel but Ted continued to miss the majority of his DOT appointments Ted's health care team held a case conference to consider the next course of action Ted was invited but did not show up The team decides that the next best step is court ordered DOT Terry sets off to find Ted, deliver the order and explain the situation Ted, hi Remember me? Yes, it's Terry from TV Can I sit down for a minute? Yeah, yeah, I guess I'm in the doghouse with you guys What makes you say that? I haven't been around to take my TV minutes Well, nobody's mad at you I've always been worried about you and Randy says that you haven't been showing up at the hotel room for your DOT appointments It's been a bad time for me It's nothing personal We don't take it personally But you know how we've talked about how important it is for you to take your TV medicine not only for your sake but for the people around you Can we agree about that? Yeah, I know it's important So far we've tried several different things to help you take your medicine and remember we talked about the last steps that we might have to take if the other ideas didn't work You mean that legal stuff? Yeah, that legal stuff and now we're at a point where we have to get serious about things and that thing is court-ordered DOT and Dr. Jones has signed a court order here requiring you to take your TV medicine and that means that you have to show up every day from Monday through Friday for Randy to help give you your medicine So what happens if I miss a dose? You guys going to come and put me in jail? Well Ted, it is a possibility but it's our very last resort and we don't want to go there and if you take all of your pills every day and you miss one dose we won't have to detain you and you know, we're really not doing this to punish you but we want to make sure that you get well and you don't spur the TV to others So what else is getting in the way of getting this back on track? Those pills they hurt my stomach and Randy doesn't want to go where I hang out he probably thinks I'm a lost cause Terry assures Ted that no one thinks he is a lost cause and that Randy, the DOT worker will come to wherever Ted is If the pills bother Ted's stomach Terry will take him immediately to the clinic to consult the doctor about it So what else would turn this around Ted? Well I don't stay much at that hotel room anymore we've been hanging out in a different part of town Are we meeting the friends that you smell crack with? Yes and no, I don't want to quit yet Okay, really, that's fine and we don't have to talk about that right now but what do you think of the idea of getting you a hotel room closer to where you're hanging out with your friends then Randy could show up with your medicine at a time that's good for you and help you take the pills Ted certainly faces many barriers that interfere with taking his TB medication Several competing priorities get in the way, including his use of crack coat cane and his lack of stable housing and transportation He's also experiencing side effects from his TB medication Ted seems to lack motivation in any kind of support network How have Terry and other healthcare workers tried to address these barriers with Ted? Well they've tried all the incentives enablers food, coupons, housing they offered substance abuse treatment which he was not ready for they provided bus passes and the numerous counseling that she did with Ted and the sessions with the staff arranged for a counseling session with Ted to be there which of course he didn't show up for John This is a good place for social work again Also develop links with your alcohol and drug your I don't want to say facility but your formal organization in your community perhaps their counselors might be able to just do some intermediate counseling with Ted to get this rolling He really is in denial about his problem Right They did change the sites for DOT, they changed the healthcare worker and his complaint about how the medicines bothered his stomach may be real may be real and needs to be explored but may also be part of his resistance to take medication I like the way the healthcare worker asked what's getting in the way I think that's a very important way The thought occurred to me too that if he hasn't taken his medicine how's he having side effects the old story Ted is eventually given a court order DOT Do you think the health department was justified in taking this step to get Ted to comply? I think they did, they had tried everything and that's really what the health department ought to do There's nothing more embarrassing than going to court and have the judge saying well I don't see any evidence here that the health department did their part So documentation of these activities or in activities of the patients really important But in this instance they did do DOT they attempted it, they did provide incentives and enablers They counseled him and then they delivered an order which was their practice at that point they had come to a dead end with him and I think they did the right thing They also prepared him for that as well It sounded like he had been given a warning at some point that this was a possibility and the next step if you don't adhere Well, in this scenario the public health nurse who manages Ted's case delivered the court order to him Who's the best person to serve a patient with a court order? Nassai, do you want to start off? Well, I think in this situation the healthcare worker who does not provide the DOT is the ideal person and it's not clear from this scenario whether she did or not In our program the person who delivers the medication either the DOT field worker or the clinic nurse is not the one to deliver the order of treatment or DOT It's usually the disease control investigator who has spent time with the patient and knows the patient's situation and has done the contact investigation or sometimes it's actually me when it's called for How about in South Carolina? In South Carolina we do it a little bit differently we have our patients actually go to court and we're like you in that we exhaust all efforts of trying to get the patient to comply and what we do is take the patient to court there's a summons, the patient receives the summons generally from a process server or from a sheriff's deputy we do not and have never encouraged our staff to do it just as you don't have to deal with this patient a very long time and it really disrupts what patient nurse or worker relationship there is to have them be the heavy so we have a good guy bad guy kind of situation where we where our nurses tell the patient you know look I know you've had trouble taking this medicine and this is a difficult situation but we can't let you go on any longer like this and besides the people in Columbia that's us have found out about this and they're very concerned that you're not taking your medicine and this is out of my hands now I've tried to tell them you know that once in a while you take it but not always and so we do the good guy bad guy thing to eliminate the nurse if Ted does not adhere to his TB therapy after being served with court order DOT what options remain to get Ted to be adherent well Ted may need to be involuntarily confined and so you may need to obtain a warrant for his arrest and taken to court on this issue does that come up very often well for us in San Francisco where we have over 200 patients a year and a lot of substance using patients, homeless patients it actually doesn't come up too often it comes up maybe once a year so not often right and also even after they are confined and when you work with the judges I have or with the DA or the public defender and the patient don't forget the patient I visit them in the jail ward at the hospital I discuss the issues and how the substance use or the behavior has gotten in the way of treatment trying to separate that from the patient himself and saying that that's the reason why what can we do about this now and exploring with the patient and if the patient is willing to work with you say he is now more receptive to entering into a drug rehab program then the next step would be court ordered substance abuse treatment and not confinement well thank you Carol and Masai now the faculty would like to respond to your questions please call the toll free number that appears on your screen 888-565-8673 outside the US call 415-861-8543 or fax your question to 415-626-3110 please use a regular handset not a speakerphone and speak as far away from your television monitor as possible you can help us accommodate as many callers as possible by limiting yourself to one question our first call is from Conway South Carolina go ahead please Hi this is Deborah we were wondering what suggestions you would have for a toddler who absolutely refuses to take medication no matter what is tried because this child associates this with the nurse well one thing Deborah if you called me which you probably would we would talk about using suppositories this is something we have used in South Carolina for a number of years and in a child this age this has really been a boon to patient treatment there's not much written on the subject and I know that some people might object because of that but I would say that for the last 20 years we've had excellent success in children mainly under the age of two in giving the medications in suppositories and you can use multiple medications in suppositories and it works very effectively what we've done in San Francisco when that happens when there is already established a negative association is to change the person who delivers the medicine you also can disguise the medication in applesauce flavored applesauce is better I hear Nutella that chocolate European spread is a very good good one also the use of incentives after the toddler takes the medication giving them a little prize a Hershey's kiss you do whatever you need to do but once that negative association does occur it's very difficult to disassociate that our next question is from Tallahassee, Florida go ahead Tallahassee yes earlier today a comment was made about giving TB meds with insure and we've been taught that food supplements and and acids interfere with the absorption of some TB medications can you discuss that? I think I'm the one that brought that up we have used insure or sestical for probably 20 years in South Carolina and we use it very effectively on our patients who are debilitated who've had a lot of weight loss feel very badly and on our alcoholics who after a weekend don't want to see you on Monday morning to do DOT because they have gastritis we have never had a patient relapse I would say because of using the sestical or insure or any other nutritional products this is a practical thing that I'm saying I don't have any quote data to back that up but I have plenty of practical experience I think there's research to prove that there's decreased absorption of these medications however from a clinical standpoint it doesn't really make a difference and that's been our experience as well Our next question is from home of the CDC Atlanta, Georgia, go ahead Atlanta Hi, yes I was wondering should health departments consider DOT for latent TB infection? That's a good question and we do provide DOT for latent TB infection particularly for those who are at extremely high risk of developing disease for example our HIV homeless patient they're both likely not to adhere and also very likely to break down with TB in the setting of a shelter or after they get incarcerated etc so we would strongly advocate for DOT for that patient as well as small children or infants who are close contacts to active TB cases and converters Our next question is from Mayville, New York, go ahead Mayville Hi, my question really has to do with last week's presentation when using a relative or a community member or a non-health department employee as an interpreter is it necessary or advisable to have the patient and or the interpreter sign any kind of release of information or confidentiality agreement? Go ahead, Carol I have to be very frank, I don't have much experience with that I think certainly you might want to cover your tail but I would yield to these two ladies who have many more foreign born situations than I we're getting them but We have not had patients and the translators signed contracts however I think it's very important to counsel the translator about confidentiality and also translating accurately prior to the interview so often what happens is that you ask a quick question it becomes a very long discussion and you get a single word as the answer and that's not translating Our next question is from St. Paul, Minnesota Go ahead, St. Paul I got a question about enablers Do you typically provide enablers like bus fare for the entire course of a patient's treatment? If transportation is needed for the entire treatment we provide transportation bus tokens I think it's almost more important toward the end to keep people interested in coming in and sometimes when you take away an incentive that could have a negative impact Next we're going to answer a faxed question from Hartford, Connecticut How is DOT provided on weekends and holidays? I'll be interested to hear What do you do in San Francisco? It seems as though we do things differently from other programs and I think each program has their own style We provide DOT five days a week and depending on the patient and the behavior and the sense of adherence or not patients are given weekend doses Now if they take those weekend doses and miss the next week then they're not given weekend doses and then we add the doses on to the end of six months We do things a little bit differently For the treatment of disease we have a certain number of doses that we expect the patient to take We have determined that ahead of time if a patient is on daily therapy during the initiation phase of treatment then we expect that to be on a daily basis DOT is DOT as I said in my presentation Generally that's two to three week period of time so it's not a great big burden on staff to do that However, if we have a patient who is drug resistant I would say that if we do DOT on a patient who has drug resistance we are very strict about it and we do weekends holidays on those patients Patients who are on any other kind of weekend therapy we might not support weekend doses in the way that you might think We would have a patient take his own on the weekend but that's not DOT and we don't count those doses toward the total number of doses so that's how it goes So the therapy would be prolonged The therapy would be prolonged just as if they missed a dose of DOT Our next question is from Newark, New Jersey Go ahead, Newark Good afternoon, my name is Patrick Reed I'm calling from the National TB Center in Newark, New Jersey Here in Newark we have some rather unique situations in that many of the patients that we do DOT on live in very difficult terrain and along with that there is an element of danger affecting directly observed therapy Someone addressed the issue of public health representatives delivering DOT to patients who may live in dangerous situations and how they deal with fear and danger You say face that too here Right Healthcare workers must feel comfortable in going into that sort of setting and some do We always have two healthcare workers go out in the field together particularly in situations like that You often have to try and arrange for a place which the patient and the healthcare worker can agree upon that is safe for both of them As Boone said in the video because of the safety we go out in twos and I think that is helpful You can also ask the patient to meet you if a particular street I'm thinking of one right now in our community in a very bad drug infested area you might ask the patient and give them an incentive to come several blocks and meet you there as opposed to meeting you in that really bad area Next we have a fax from Frontera, California Are there any incentives you would recommend aside from counseling to enhance adherence for inmates in correctional facilities Now we have an outbreak going on in South Carolina This question came up at a staff conference a joint staff conference the other day between prison staff and our staff and we asked the question would incentives be of help to you in the prison and getting patients to complete their preventive treatment for those who are infected and the answer that we were given by our prison staff was we can't use them for the other inmates what you have to give to one you have to give to another and so this is a very difficult situation perhaps there are people who might want to comment to that but that was the answer that I was given Next we have a question from Raleigh, North Carolina Go ahead Raleigh How do you ensure that a patient has actually taken medication I know that some patients can be sort of tricky and pretend to follow it but you should periodically check their urine for the rifampin color, that orange color you could do drug levels which is costly and expensive if you think that they're palming their medicine or spitting them out you can actually check their mouths I didn't see you swallow the pills and could I just check your mouth that's a little bit uncomfortable and you need to do it in a confidential location but those are some of the things that you can do Our next question is from Battle Creek, Michigan Go ahead, Battle Creek This is Dr. Molida My question is on the substance abuse who continues to drink and take drugs the liver function is high liver function test results are quite high and this would seem to improve his liver function can you involuntarily confine this patient so that you can initiate the patient to hung up now and wait for your answer Legally, I don't think that you can confine this patient if the patient is adherent to your treatment However, there are other things that you can do you can give the patient an injectable agent or a regimen that has drugs that are not hepatotoxic if you must stop the regimen because of that issue you need to also strongly counsel about the issue of his liver dysfunction which is caused not just by the tuberculosis meds but by the drinking or substance abuse Now we have a fax from Chattanooga, Tennessee A 12 year old on treatment for LTBI is failing to take his INH approximately 25% of the time His mother denies the non-adherence and continues to allow the child to take the meds on his own How would you problem solve this situation? Well, I would say I feel that children are high priority for a directly observed preventive treatment of latent TB infection Young children particularly can develop TB meningitis and I think it certainly is best that if you're going to do supervised treatment you need to initiate it in the beginning and there are certain people for whom, as it was previously mentioned who are high risk who ought to have that My personal feeling is that children are in that group and there are a number of children who are going to buck their parents about taking medication and it just is that way that's the way it isn't life and to avoid that to do DOPT is really the best thing Alright Now we have a fax from Jacksonville, Florida is explaining the possibility of developing drug resistance an effective strategy for maintaining adherence What do you think? I think it's an effective strategy and I've used that when I've counseled my patients I think what's important if you're going to use that as a strategy is to use very simple terminology and not big words you might want to say for example that if you keep missing your pills the TB might come back and what comes back may be resistant to the medicines that you were taking and so the medicines may not work and so what's curable now may not be as curable in fact it may become incurable so this is your greatest chance is right now when you have the kind of TB that is easy to treat Our next call is from Philadelphia, Pennsylvania Go ahead Philadelphia My question is what suggestions do you have for the patient I'm sorry you can hear the overhead when we can identify what the problem is with the patient but we do not have a direct link to social services we don't have a social worker who works directly with our program I think the question was what do you do when you don't have a social worker in your program how do you address the patient's problems I think you can be very creative we didn't always have a social worker who used to arrange for housing you can get ideas from social workers working in other programs if you have one in your health department and then making links with key providers substance abuse treatment sites shelters hotels, etc for that you could also try and involve charities for food donations as well We have another call from Philadelphia Go ahead Philadelphia Hi this is Virginia calling from Philadelphia, Pennsylvania and you asked a few minutes ago to comment on the prison system someone in a different prison system suggested what is given to one then must be given to all so therefore it couldn't work in that other prison you were just mentioning but in Philadelphia I want to tell you that it is quite successful we do educate all correctional staff about the DOT program we do in and educate and have seminars with the inmates to teach them about this direct observed therapy program we offer incentives, the rewards of the food, coupons and transportation and we really feel as though it's been ongoing and successful so I just wanted to comment on that for Philadelphia Pennsylvania and Philadelphia prison system Thanks a lot and it does bring up that very important point is that you have to work with what you have locally and make the most of it the conditions will be different in different parts of the country next we have a fax from Denver, Colorado should the site of TB pulmonary or extra pulmonary impact the decision to provide DOT I would say that it would in terms of priorities none of us have the staff that we want I don't know of any program that has an abundance of staff to work and if you have to prioritize then of course your smear positive pulmonary cases would be first priority no question persons who have smear negative pulmonary tuberculosis would be next you don't want them to become smear positive and then your extra pulmonary cases of course would be the last situation in your prioritization except when you have laryngeal TB go for our final question from Austin, Texas go ahead Austin what should I do when my DOT client is going to be on vacation for a few weeks good question that's a very good question and I think you have to customize your approach to your patients your patient may be adherent or maybe not adherent they may be in the beginning of treatment still contagious or infectious or they may be at the end of their treatment when adherence is not as important and so if you have a difficult patient who wants to go on vacation and of course that's important to them you would really want to get information about how you can locate that patient wherever he's going you might even want to see their return ticket bus ticket or plane ticket but you're actually coming back and counsel them before they leave okay that concludes the time we have for our question and answer period we're sorry if we couldn't get to your call or facts following today's broadcast our faculty will be available for another half hour so to take some additional telephone questions from you use the same toll free telephone number that appeared on your screen earlier many questions were submitted by our audience during this three part course we will assemble a list of questions commonly asked questions and our responses to them and post them on our website before we close with some final housekeeping details TB Control staff from San Francisco will summarize the main points from today's program patients can stop taking their medicine for many reasons customize your strategies to fit the barriers that your patients face you can't be certain in advance who will be adherent to treatment use incentives and enablers to help patients stay adherent consider involuntary confinement only as a last resort after other strategies have been tried consider all patients for DOT DOT should be used for patients with drug resistance TB patients who are receiving intermittent therapy patients who are homeless or substance abuser and adolescents patients with the history of non-adherence patients who are mentally or physically impaired if you missed the registration deadline for this course or you were not able to attend all three broadcasts, take heart you can receive credit for reading the four self-study modules call the public health training network at 1-800-44-T-R-A-I-N train and ask for course number SS-3036 that was 1-800-41 train if you're not interested in receiving credits but simply want to order a set of the self-study modules call the CDC at 404-639-8135 Dr. Kenneth Castro Director of the Division of TB Elimination at the CDC will address you now with some closing thoughts Dr. Kenneth Castro Director of the Division of TB Elimination at the Centers for Disease Control and Prevention we hope you've enjoyed TB Frontline and have gained some useful tools to help you meet the daily challenges of TB control and elimination we've made tremendous strides in our fight against TB do in large part to the dedication and talents of thousands of you who work in TB in the last few years incidents of TB cases in the United States has steadily declined however despite these recent achievements there's still a lot of work that needs to be done to maintain our recent advances our shared goal is to achieve the eventual elimination of TB as you now return to your work we hope you leave this course with additional skills for meeting the daily challenges of TB prevention and control we hope that you will continue to use the print-based modules as an ongoing reference you can also access these modules on the World Wide Web we appreciate your participation in this course and encourage you to share the information you learn from the modules and the broadcast with your colleagues thank you this concludes our third and final session of TB Frontline thank you Carol and Masai for being here today we extend our appreciation to the state and big city TB controllers and the course liaisons that they designated to ensure that our course reached as many people as possible thanks to our 950 site coordinators and the thousands of you in our viewing audience for your participation to all of you working on the frontlines of TB control we salute your talents your energy and your dedication