 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, you know, because some patients like, you know, different things. I feel that incentives really help. A lot of our patients are really economically poor, you know. Most of them are on public assistance of some kind, and some of them are homeless and things like that. So, you know, 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, no sputum today. No, we don't have to pick up a 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 the medications. We make sure that someone's there to watch them take it. Now we're going to see a 30, about 40-year-old female patient. She's a drug abuser, and she's an uncle abuser, and she's a homeless patient. She's, you know, facing a little bit of mental health problems. She keeps forgetting things. Right? Right in shy. How are you three, sir? We're there, basically, to 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 know, you've got to establish some kind of relationship, some kind of trust between the workers and the patients. Well, we've got 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 be 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 and ablers, they help, but it's this 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. Our answers 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 have 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 he's done. My favorite part of doing DOT is to get to know the patients. I like it best when the patients are happy. I like 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. It just makes my day on that day. 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. Mrs. 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 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. They sound 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, but you know the good news is that it'll take you up to Christmas and this will be an especially great Christmas present for you to complete your TB medication. So let's find a time for the healthcare 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 shoes to help you. That would be nice. What's a good time of day for the healthcare worker to come by? I don't know. Sometimes I forget things. What if I forget they're coming 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. Would that be a good time for the healthcare worker to come by? You 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 I'd 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. Great. Confidentiality means that you want to protect the patient from other people knowing information that they shouldn't know, especially the medical information about TB. Confidentiality is important because there are certain rights that patients have and one of them is a right to privacy. We have patients that actually still lose their jobs because of tuberculosis. There's still a lot of stigma to TB. We recently had a patient who was sprayed with Lysol and thrown out of the house. So if we did not maintain confidentiality, we would probably not get the cooperation of our patients. I think it's very important that the patient be able to trust you. If that is undermined, you may find that your patient is no longer adhering to treatment and the key to success for cure is the completion of therapy. You have to rely on the patient to tell you who is he spending time with, who may have infected him. And without that bond that you develop between yourself and the patient, that makes it very difficult. Often people will test us to make sure that we do keep confidentiality. Someone will call and say, well, we know that there is a case of tuberculosis at the fishing pole plant and I want you to tell me who that is. I think I might have been exposed to that person. And often I feel like that probably is the person themselves calling to test us about whether we'll give out that information and we just won't do it. It's especially difficult to protect a patient's confidentiality especially in school investigations and in workplace investigations because rumors start to fly. People get very anxious and become very demanding. Sometimes we'll go out to do a screening and we'll include the patient and we'll screen the patient, the index patient, as if they've never been screened before and we may give them a saline solution instead of the PPD solution. So there won't be any reaction and they won't be targeted by other people in the office who know who look or other people in the shelter who know to look for a positive reaction. We had a situation in a large workplace where there were 500 workers and the person with tuberculosis did not want her name revealed to anyone and we were faced with having to test all 500 people even though we knew she probably didn't have any kind of contact with all those people. I protect the privacy of my own patients by first of all letting the patient know what information I'm going to tell anyone that is about the patient and certainly if I'm going to give the name of the patient to anyone I will let the patient know and discuss it with the patient so that the patient feels okay about it. It's a challenge in a very small busy clinic so I attempt to have any paperwork with patients' names on it unavailable to other people who don't need to see it. And if you're leaving the patient an appointment or a message card it really should be in a plain envelope that doesn't have anything associated with TB control on it. If you're calling the patient you shouldn't say, you know, I'm the nurse from the TB clinic calling to this patient. If you don't educate the patients about when confidentiality will be broken and for what reasons you're going to run into problems with therapy. We're very, very careful because we want to protect all rights of the patient but if it's impossible the rights of the public and the public health certainly supersede this. When the patient is unwilling or unable to assist you in the contact investigation then I think it is appropriate to break confidentiality especially if the patient is very contagious, is smear positive and is putting the public at risk. For example, we had a patient that was homeless and substance abusing. He wasn't working with us, he wasn't coming in for his therapy and he was still contagious and he disappeared for a while. So at a certain point when we couldn't find him after searching for him our TB controller decided that we had to alert the shelters that he was frequenting that he was a case of tuberculosis and not to let him have admittance to the shelters. In Spanish, confiar means to have faith and I feel that that gets to the key of the issue that confidentiality is not some kind of puritanical not talking about things but rather having the faith and trust of a person who's sick. People are putting their lives in our hands as healthcare providers and with that faith in us we need to honor that trust as an integral part of what we do. Hey, Charlie's not home right now. Oh, God, we had an appointment at 9. Did you see him leave? Yeah, he took off a while ago. I've seen you around here before I just saw you pull up in the city and county car. Who are you? Well, I work with public health. Did Charlie say when he was coming back? No idea. Is Charlie sick? Well, no, hon. He's doing a lot better now. Better? What is Charlie sick with? It must be pretty bad if the healthy farmers come over here all the time. Is it AIDS or Ebola? No, it's nothing serious like that. Serious? Is it contagious? You know, Charlie's not infectious. He stopped coughing. Coughing? You mean he has TB? Hon, you know, I really, really can't say, okay? I just can't. Hey, George. The guy downstairs has TB. Hey, Charlie's not home right now. Oh, really? Okay, thanks. Yeah, he took off a while ago. Who are you? I have seen you around here with the city and county car. Yeah, that's a county car. Is Charlie behind on his taxes? Oh, you know, I hope not, but look, did Charlie tell you when he was coming back? No, I'm not his social secretary. What is in that bag? What is this, neighborhood watch? No, but we tell each other when suspicious characters are knocking on the door. Well, look, when you see Charlie, would you let him know that Candy came by and that I'll stop back by again this afternoon? Well, why should I tell him this is all about? Oh, Charlie'll know. Thanks for your help. Do you want to leave that bag with me or make sure that he gets it? No, that's okay, but thanks. Bye. So be sure to call us if you have any more problems with. Excuse me, just one second. Hi, this is Marie. Oh, yes, please put him through. Excuse me, just one second. Hi, this is Marie. Yes, I've been waiting on the Jones chart. Oh, you faxed it this morning. Great, great. It's been such a madhouse around here. I haven't had a chance to check the fax machine. It's right in the hallway. If you hold on, I'll check. I'll be right back, okay? Yes, yes, it was in the fax. Thank you. Yes. Oh, you want to leave a message for Dr. Peters regarding the Jones chart? No. Oh, regarding Wilma? Fredrickson. Okay. Abnormal, chest x-ray. Smear. Positive. Call. Regarding interactions with protease inhibitors. Okay. I'll make sure Dr. Peters gets the message. Thank you. Okay. I'm sorry. Okay. So, again, if you have any more problems, be sure to call us. Okay? Take care of her. So, be sure to call me if you're having any problems with her. Excuse me. Hi, this is Marie speaking. Yes, put them through. This call is urgent, so I'll take a quick message and I'll get right off. Okay? Hi, this is Marie. Yes, you've faxed it this morning. Great, thank you. The next machine is in the clerk's office and he processes each incoming fax, so we'll be able to confirm that. Okay. Oh, okay. You wanted to leave a message for Dr. Peters? Okay. Can you spell that? Okay. All right. I'll be sure Dr. Peters gets the message. Thank you for calling. I'm so sorry about that. Okay. So, if you have any more problems, give us a call. I'll see you next month. Is this my skin test? It sure is. Hi, my name is Patrick Fian. I'm with the Davis County Health Department. Why don't you come in and sit down? Okay, but I hope this doesn't take long. I've got a ton of work to do. No, no, no. It shouldn't take much time at all. I'm just going to ask you a few questions and I'll give you a quick skin test. You'll be on your way. So, first of all, what's your name, please? My name is Alexis Martinez. Listen, I can save us some time. I don't have TB if that's what you're wondering. And I never hang around the legal department. The legal department? We all know that that's where TB started. So, since I never go over to legal. The thing is, you might have shared airspace with her somewhere else in the building. Her? You mean Jennifer? Actually, no. I don't mean anyone. We're screening everybody who spent time on the second floor in November. So, just tell me this. Have you been coughing lately? No. Jennifer coughs, but I thought that's because she smokes. She's it, right? I'm not supposed to say, actually. I just know that your name is on a list as a second-floor employee. So, I'm just going to have to finish asking these questions and give you your skin test so we can determine if you're infected. Okay, whatever. Man, poor Jennifer. I should warn everyone in accounting. Hi, is this where I'm supposed to get my skin test? It sure is. Hi, I'm Patrick Fian. I'm with the Davis County Health Department. Would you mind getting the door for me, please? Mind and sit down. Okay, but I hope this doesn't take long. I've got a ton of work. No, no, no. It won't take long at all. I just have a few questions to ask you and we'll do a quick skin test. You'll be on your way, okay? So, first, what's your name? My name's Alexis Martinez. Listen, I can save us some time. I don't have TB if that's what you're wondering. And I never hang around the legal department. No TB. Great. And that's why I'm here today, to confirm that. But this isn't about any particular department. Now, as that letter from the company president said, you may have been exposed to an active case of TB here at work and we want you to stay well. So, I'm going to ask you a few questions about how you've been feeling lately and I'll place a skin test on your forearm. Now, on Thursday, I'll be back to look at the test and depending on the reaction, we'll be able to tell if you've ever been infected with a TB germ. Yeah, but who's been spreading TB? It's somebody in legal, right? Bob or Jennifer? Well, as much as I appreciate your curiosity, the identity of the patient is going to be confidential. I'm sure if the situation were reversed, you'd want us to protect your identity, too. And we would do that. Everybody knows it's either Bob or Jennifer. And we have a right to know who's spreading the disease. I mean, we're concerned about him or her. You don't have anything to worry about. The person with TB is going to be just fine. Today, we want to make sure you're okay. So, have you been coughing lately? No. Bob had a cough last month. Oh, wait a second. I can only interview one person at a time. So, he's not the one? Well, people cough for different reasons. Let's just focus on you right now, okay? Have you had any fevers or night sweats? 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, Terry, 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? Oh, 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, so I really don't need them anyway. You may not be coughing right now, but you need to finish the full course 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. Do you think that you would go back and attend the sessions again? 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 use your sister's phone and call Ronnie right now, we can make an appointment. Okay. Okay, Ronnie, thanks. See you then. Bye-bye. All right, you're all set for three o'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 here 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. 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 help him stay on track. Ted missed four doses in the first eight days. When Terry discussed the problem with Ted, he expressed his comfort about the health care worker who delivered his meds, saying 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. The 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. Do you remember me? Yeah, 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. We've just 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. 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, but we're still not there. 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. We're 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, Monday through Friday, for Randy to help give you your medicine. So what happens if I miss a dose? Are 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 spread 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. We meaning 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 your 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.