 Good morning Tracy. Hey, Dr. Rogers. How's Alex doing today? I'd say you've got one anxious gentleman on your hands doctor. I take it our patients ready to be discharged. Have a good morning Tracy. You too. Good morning, Alex. Ah, Dr. Rogers. I like this room much better than the other one. You have good news, no? Yes, I do. Looks like you're going home today. Excellent. Since I have been here, I'm beginning to feel much better. Well, it's good to hear. Looks like the medication you've been taking for the last two weeks has done its job. Your TB is no longer considered infectious. That's why you were moved out of isolation down into this room. Very good. When do I go? Ah, well, hold on a moment. There's more. In order for us to completely cure your TB disease, you're gonna have to take your medication for the next six months. Six months? But Dr. Rogers, you told me yourself I am no longer infectious. Well, that's true. You are no longer infectious, but TB is a lot more complicated than that. You remember when you came in here two weeks ago? Yes. Now, what did you tell me? I told you that I had come from Russia 18 months earlier and that I had never felt this sick before. I mean, what kind of sickness did you feel? Oh, I had cough, I have fever, I felt weak, I was weight. I had very bad chest pains and I sweat very badly at night. And those, my friend, are the classic symptoms of tuberculosis. But I am feeling much better now. Well, I know you are, but just because you're no longer infectious does not mean that the TB disease is gone. No. Remember when I told you about TB? I remember little. Good. Then you remember, TB is spread by tiny germs that float in the air and these germs are spread when someone with TB coughs or sneezes or even talks. Of course. Continue, please. Thank you. So if you're in the room with somebody who has TB and that person happens to cough, it's possible that you could breathe the TB germs into your lungs and become infected. So what is the difference between infection and disease? Well, that's a good question. I think in your case you probably became infected with the TB germs while you were still living in Russia. TB germs can live inside of you without making you sick, but at that point you are considered infected. But how can these germs live inside me without making me sick? Alex, your immune system fights these germs and traps them. But sometimes the germs get free and begin to multiply. This is what happened to you after you were living here in the U.S. for a while. I see. Now it's these free germs that cause the TB disease. They can attack your lungs or other parts of your body and once you have the TB disease, if you don't get proper medical treatment, you can die. Dr. Rogers, I am very, very grateful to you for making me better. Alex, there's no need for that. But what you can do is take your medication for the next six months, as well as visit the health clinic once a month so we can monitor the effects of the medication. I see. Excuse me, hi. I'm Michelle Vega from the County Health Department. I'm here to see a patient of yours by the name of Alexander Volkov. Sure. Mr. Volkov is in room 315. That's right down the hall and on your left-hand side. Great. Thank you. Sure. But Dr. Rogers, I am a very busy man. I don't know if I will be able to remember to do all of these things that I must do all by myself. That's why I've asked somebody from the County Health Department to stop by this afternoon. Hello. How's my timing? Couldn't be better. Alexander Volkov, I'd like you to meet Michelle Vega. Hello. It's a pleasure to meet you, Mr. Volkov. Oh, please, call me Alex. All right, Alex. Alex, Michelle stopped by today to talk to you about directly observed therapy. That's designed to help you take your medicine over the next six months. Okay. Well, Alex, I am going to finish preparing your discharge papers while Michelle explains what directly observed therapy is. Good to see you again, Michelle. It's great to see you too. Bye-bye. Well, Alex, you must be very excited about going home today. Oh, very much so. I need to get back to work if I want to be able to keep my job. Oh, where's that? I work at the baggage in the airport. Oh, I imagine there's quite a bit of heavy lifting involved. Yes, there is. It is important to stay healthy. Well, as long as you take your medication, you should be fine. And that's why I'm here. To help me with my medication? Yeah, sort of. It's like Dr. Rogers said. I'm from the county health department. I'm what's called a DOT worker. A DOT stands for directly observed therapy. And I'm here to make sure that you get through your treatment from start to finish. Oh, so what is this therapy? DOT means that I'll be responsible for watching you take your medication. So you mean I am like a child and cannot be trusted? Oh, no, of course not. I can't tell you how important it is, Alex, that you take all of your medications at the right time. You're going to be taking several medications all at the same time during the course of the treatment for UTV. Anyone, including myself, would have a difficult time remembering which medication to take at the right time over a six-month period. We do DOT treatment with all of our patients. Continue? I'm not only here to help you take your medication. I'm also here to make sure that the medicine is working the way that it's supposed to, along with checking to see that you don't have any bad reactions along the way. I'm also here to answer any questions that you might have about the medicine. And this continues for six months? I'll need to see you five times a week for the next two weeks, and you'll have to take your medication on your own over the weekend. If everything goes well, we'll meet two or three times a week after that, per Dr. Rogers' decision. Did Dr. Rogers tell you about going to the clinic once a month? Yes. Great. Any other questions? So, you are like coach? Exactly. Okay, so what do we do next? Well, we need to find a time and place where we can meet five times a week. You are welcome to come to my apartment if you like. Thank you. Why don't you tell me your address? I live at 78 Dean Street, apartment number one. Great. Now all we need to do is find a time. You said that you worked at the airport. What shift do you work? I work a second shift, four p.m. to midnight. Okay, how about a morning meeting then? Okay, not too early. I sometimes like to sleep in. How's 11 a.m. sound? Okay. Perfect. Well, since you're being discharged today, I will see you at 11 a.m. sharp. It was a pleasure meeting you, Alex. Okay. Wow, I haven't been to this part of town in a long time. But since I checked out the city map, I know exactly where I'm going. Let's see. I'm still a few minutes away. Just enough time to check out the neighborhood. This area looks quite open. Not too many trees or shrubs for hiding places. A decent amount of visible space. Several exits to and from the street. Hmm, not too many people around. All right, Michelle, you dress comfortably but appropriately. No chains, no dangling earrings or high-heeled shoes. Make sure to put just a few dollars in your wallet instead of your purse. And you have county ID. Check. Yes? Good morning, Alex. It's Michelle Vega. It's 11 o'clock already. 11 o'clock on the nose. In that case, please come in. Thank you. Can I offer you a cup of coffee? Oh, no, thank you. I've already had two cups this morning. Okay, very good. Well, let's go in the kitchen. Sure. So how did you sleep last night, Alex? Oh, I sleep like long. My bed is much more comfortable than a hospital bed. Oh, I'm sure it is. Alex, could you please get your medication? Here it is. You'll be taking these four drugs every day for the next two weeks. So all we need now is a glass of water. Sure. For this, I think I need a big glass of water. So did Dr. Rogers go over the medication with you? Yes, but the names were very confusing. Isosomething, reefer, I don't know. All I know is I take four drugs, yes? Yes, that's right. And let me help you with those names again. But you were right on track. Isonizid, rifampin, pyrazinamide, and afambutol. Okay, very good. Now, while you're taking these drugs, it's very important that you let me know if you begin having any bad reactions. Like what? For example, if you begin to have no appetite or you begin feeling very tired or very weak or you begin to have an upset stomach or you see any rashes or see any bruising or the whites of your eyes or your skin begins to turn yellow, you need to stop taking the medication immediately. Okay. Hold on. There are a few less serious side effects that won't stop you from taking the medication, but we'd like to know if any of these happen. If you have any muscle or joint aches. I'd like it if you could let me know, okay? Sounds like cure is worse than disease, no? The rifampin will cause body fluids to turn an orange color and your tears and your urine will start to look a little different. But that's normal. But those other things that I mentioned, they only happen if you're having a bad reaction to the medication. And this is something we need to monitor, okay? Okay. What's the label you're taking on? Oh, this is my medication log. It helps me keep track of how much medication you've swallowed and when. Like calendar, no? Oh, yes, it is like a calendar. As I said before, you'll be taking these pills every day for the next two weeks. And if everything goes well, two to three times a week after that, per doctor's decision. And your trip to the clinic once a month, right? Mm-hmm. So how do you plan on getting there? Oh, I take the bus, maybe friend will drive me. I don't know, I figure something out. What about this? When it's your time to visit the clinic, I'll give you tokens for the bus and I'll give you a coupon for the diner across the street from the clinic. They make the best cup of coffee there and you wouldn't believe the apple pie, deal? It's deal. So we're continuing our contact investigation at the Mission Shelter down on Chestnut Street. Anything turn up? Several converters but no cases. I'm still pretty new to all of this. Can you tell me again, what's a contact investigation and converter? Sure. A contact is a person who lives or works with an infectious person or shares air with an infectious person through a common ventilation system, thus the term contact investigation. Now obviously when we're dealing with a place like a homeless shelter, this becomes a real concern. I'm sorry, I'm late, everyone. I was meeting with a new patient down on Dean Street. I'm all glad you could join us, Michelle. I'm just bringing Melissa up to date on the situation at the Mission Shelter down on Chestnut. Okay. And I was about to tell her what a converter is but why don't you tell her? Sure. A converter is a contact who we know had a negative skin test but who is now testing positive. That is to say they converted from negative to positive. Now we run an ongoing targeted testing program at the shelter and we keep good records of most of the regulars who are there. So if we discover a higher rate of positives within those contacts, we can usually expand our investigation to the next circle. Those who have come into close contact with the patients but less frequently than those who live and work there. As far as the shelter is concerned, we're still dealing with the men who actually live there. Way, Michelle. Nice definition of converter. I'm not so sure. I like that smile. Mr. Sean Allen is an exam one. He's a resident of the shelter. He's skin test positive and the doctor has determined that he is not diseased but he is recently infected which makes him a good candidate for treatment for latent TB infection and he's all yours. But what about my lunch? It will still be there when you get back, I think. Mr. Allen, I'm Michelle Vega from the County Health Department. Hey. I'm here to talk to you about your tuberculosis skin test, what it means and how you'll need to be treated. Okay, I guess. This guy, Jerry, lives at the shelter that I do and told me that he got TB and now we have to all come and get checked for it. They told me that since I live in the same place that I gotta come here and get some tests. That's why you're here, right? Can you wait to tell me I got TB? Well, you don't have what's called active TB but your tuberculosis skin test shows that you have been infected with a germ that causes TB. You became infected when you were exposed to someone who has active TB. So what you have right now is the infection and not active TB. Well, if I'm infected, then I got it, right? Not exactly. A person can be infected with a bacteria that causes tuberculosis disease but not have active tuberculosis. A lot of people are infected with a germ that causes tuberculosis. And then some of those people do go on to develop active tuberculosis. What you have is the infection, not active tuberculosis. Do you see the difference? Yeah. So what you're saying is I don't have TB. Good. So I can leave. It's Tuesday. They always serve beef barley soup on Tuesday and I like beef barley soup. Wait, Mr. Allen, before you go, just another minute, okay? Just because you aren't feeling the symptoms of the TB infection doesn't mean you're not infected. You are. And if you don't take the medication to get rid of the tuberculosis infection, you can get active tuberculosis. Okay, well, give me the medicine I need to take and I'll take it. Because it's Tuesday, beef barley soup. I gotta go. Mr. Allen, treating TB infection takes a long time. You'll need to take medicine twice a week for nine months. Damn! Woman, you crazy, nine months? You just told me I don't have TB. Why I gotta take medicine for nine months? Don't you see, I can't be taking medicine every week like that. I got a reputation. People think I'm sick. That could cause me serious problems. You should see what they do to Jerry. Nah. Can't do that. Sorry. No one needs to know that you're taking the medication, Mr. Allen. And it's very important that you take the medicine twice a week for nine months and come to the clinic for regular checkups once a month. If you don't take the medication, the bacteria can remain in your lungs. And if that happens, you're in danger of getting active TB. And if that happens, everyone will know. Well, I don't think that anyway if I'm taking pills. Listen, I'm here to help you stay healthy. What if we make some sort of an arrangement to meet away from the shelter? Like where? There's a really pretty park a couple of blocks away from the shelter. There's a couple of picnic benches across from the pond. We could meet there. What do you say? What time? Let's say 10 a.m. You can take your medication and you can go back to the shelter and no one has to know. So I don't have to keep any medicine on me and you'll meet me at the park each time. Why would you do that? Because it's part of my job. So what do you say? Okay, let's give it a shot. As long as no one finds out. Great. Tomorrow morning at 10 a.m. before you leave I want to give you this pamphlet on TV infection. You can read it whenever you get the chance. Checked out the park for safety. Picked a public spot where we're not too isolated. You dress comfortably but appropriately. Just a few dollars in your wallet along with your ID. I'd say you're good to go. Hey, Mr. Allen, you're here bright and early. Couldn't sleep last night. I was a little nervous about today. You could call me Shawn. Okay, Shawn. Well, I can understand the nervous part. Starting anything new can be a bit unnerving. Right. It's got a lookin' answer. Sure. I've got an idea. I'm going to explain to you about directly observed therapy. What it is and about your medication. But no one likes to hear a story on an empty stomach. So I brought along a little snack. You're gonna be kidding me. It can't be. Yes, it is. Beef barley soup. You like this stuff, too? Oh, it's one of my favorites. All right. In directly observed therapy, I'm responsible for watching you take all your medications each time. So you take your medications, I'll write it down in my log, and I'll explain the rest as we eat our soup, okay? Tuberculosis is caused by tiny germs that float in the air. If you're next to someone with TB and they happen to cough, sneeze, or even talk, it's possible that you could breathe some of the germs into your lungs. TB germs can live in a person's body without making them sick. This is called latent TB infection and needs to be treated in order to prevent the person from developing the disease. Approximately one out of every 10 people who are infected with TB develop TB disease. Symptoms include fever, general weakness, weight loss, chest pains, and a chronic cough. Directly observed therapy, DOT, requires a health professional to watch a TB patient swallow all of their medication. This leads to a reduction in treatment failure, relapse, and drug resistance. Personal safety is a critical element in successfully administering DOT. Establish a consistent meeting location with the TB patient. Examine the location for unusual street activities, escape routes, lighting, and places where people can conceal themselves, like trees, shrubs, and in alleyways. Wear comfortable but appropriate clothing. Do not wear glittering jewelry or high-heeled shoes. Carry a very small amount of money on your person and keep it in a wallet, not a purse. And make sure to have proper ID with you at all times. Directly observed therapy requires a commitment by the DOT worker as well as the patient. Finishing the entire treatment is absolutely necessary. As a DOT worker, you'll need to facilitate the treatment, avoid possible roadblocks, and empathize with your client. These are the building blocks, the tools, if you will, that you'll need to use in order to increase your chances for successful outcomes when administering DOT. Good luck!