Improving Patient Adherence to Tuberculosis Treatment
As a general rule, people in our society have the right to refuse
to follow health advice. However, persons with infectious TB may
lose the right to refuse such advice — that is, instructions to
complete prescribed TB treatment — if health officials believe these
persons are putting the public at risk for infection. Patients who
are unwilling or unable to adhere to treatment may be required to
do so by law. Since state governments have legal jurisdiction over
TB control activities such as treatment protocols for nonadherent
patients, refer to the laws in your state for those provisions.
The Advisory Council for the Elimination of Tuberculosis (ACET)
defines nonadherent behavior as the inability or unwillingness to
follow a prescribed treatment regimen (34).
Examples of nonadherent behavior are
- failing to report for DOT
- refusing medications
- taking medication inconsistently
- missing clinic appointments
Notify the appropriate health official when patients are nonadherent.
The health official or designated representative should determine
the reasons for the nonadherence and begin the appropriate interventions.
Although legal remedies for nonadherence are available in some
areas, they should be used only when less restrictive measures have
failed. When legal remedies are used, measures should be taken to
ensure that the rights of the patient are protected. Patients subjected
to these proceedings should be represented by legal counsel.
The legal remedies commonly used by public health officials to
address treatment nonadherence are court-ordered DOT and involuntary
isolation, hospitalization, and confinement.
Commitment is defined as the confinement of a person who has infectious
TB or who is not infectious but has not adhered to prescribed treatment.
The purpose of commitment is to prevent the development of drug-resistant
organisms or to ensure that a person receives a complete course
ACET recommends that before committing patients to involuntary
confinement, state TB control programs should adopt a step-by-step
treatment plan that progresses from voluntary participation to involuntary
confinement (34). The plan should begin with an assessment of the
potential reasons for nonadherence and procedures for addressing
the identified obstacles which include the use of DOT, incentives,
If the patient does not adhere to DOT voluntarily, the next step
may be DOT that is ordered by a public health official or a court.
TB control programs should not initiate procedures for confining
patients to a treatment facility until after the patient has demonstrated
an inability or unwillingness to follow the treatment regimen.
Involuntary commitment or isolation for inpatient treatment should
be viewed as a last resort. However, when a patient with infectious
TB refuses treatment and voluntary isolation, emergency detention
to isolate the person is appropriate.
When determining whether the legal commitment of a person with
TB is necessary to protect the public, local health officials should
determine whether the person is at substantial risk of infecting
others (now or in the future). To determine this risk, assess the
patient's situation by considering these factors:
- Clinical evidence such as laboratory results (acid-fast bacilli
sputum smears and sputum cultures)
- clinical signs and symptoms of infectious TB
- abnormal (cavitary) chest x-ray
History of nonadherence for reasons not related to treatment
or delivery system failure
Risk of infecting others
The commitment order should require the isolation of the person
with infectious TB until the patient is determined to be noninfectious.
This decision should be based either on laboratory results demonstrating
that the person is smear negative and asymptomatic or on the local
health officer's determination that the person has completed a course
of therapy consistent with the most recent recommendations of the
American Thoracic Society and CDC (35).
The patient should also be ordered to receive treatment in a hospital
or other appropriate facility until cured, unless the person's voluntary
completion of the ordered therapy can be ensured. If the patient
refuses to consent to the ordered treatment, the health officer
should have the authority to extend the commitment order as necessary.
When asked for a recommendation for improving patient adherence
to TB treatment, an experienced public health nurse from Arkansas
said, "What we do is whatever it takes!" These words seem
to summarize all the preceding strategies and to embody a philosophy
that no longer accepts nonadherence as inevitable and tolerable.
Doing whatever it takes to ensure the completion of adequate therapy
is a challenge, but one that must be successfully met if this curable
and preventable disease is to be controlled.