Self-Study Modules on Tuberculosis
Module 9: Patient Adherence to Tuberculosis Treatment
Answers to Study Questions
9.1. What is adherence to treatment?
Adherence to treatment means that a patient is following
the recommended course of treatment by taking all the prescribed
medications for the entire length of time necessary.
9.2. Why is adherence to TB treatment important?
Adherence is important because TB is nearly always curable
if patients adhere to their TB treatment regimen.
9.3. What are four serious consequences that can result
when a patient with TB disease is nonadherent?
Nonadherence is the patient's inability or refusal to take TB
drugs as prescribed. When medical treatment is complicated or
lasts for a long time, as in the treatment for TB disease, patients
often do not take their medication as instructed. This behavior
is one of the biggest problems in TB control and can lead to serious
consequences. A nonadherent patient with TB disease may
- Remain sick longer or have more severe illness
- Spread TB to others
- Develop and spread drug-resistant TB
- Die as the result of interrupted treatment
9.4. Give eight reasons why a patient might be nonadherent.
There are many reasons why a person might have trouble completing
a regimen of TB drugs. Here are a few examples.
- Once patients no longer feel sick, they often
think it is all right to discontinue taking their TB drugs.
TB symptoms can improve dramatically during the initial phase
of treatment (the first 8 weeks). However, unless patients continue
treatment for at least 6 months, some tubercle bacilli may survive,
putting patients at risk for a relapse of TB disease and the
development of drug-resistant organisms.
- Patients sometimes do not fully understand the treatment regimen,
how to take their drugs, or the reasons for the long duration
of TB treatment. This lack of knowledge can
lead to an inability or lack of motivation to complete a regimen.
- Some patients have strong personal or cultural beliefs
about TB disease, how it should be treated, and who they can
turn to for help. When TB treatment conflicts with these beliefs,
patients can become fearful, anxious, or alienated from their
health care workers (a person who provides health care or health
services to patients, such as physicians, physician's assistants,
nurse practitioners, nurses, and outreach workers).
- Certain patients lack skills necessary for
following a health care worker's instructions and adhering to
a prescribed regimen. Elderly patients with limited mobility
or manual dexterity, patients with substance abuse or mental
health problems, and young children are particularly at risk
for problems with adherence.
- Lack of access to health care can also be
a significant barrier to successfully completing a TB regimen.
Special efforts must be made to reach and provide care to patients
without a permanent address or a means of transportation. Patients
with jobs may have work schedules that conflict with clinic
hours. Immigrants and refugees, as well as persons who inject
illicit drugs, may need reassurance that their TB disease and
treatment will be kept confidential and should not cause them
- Some patients, especially recent immigrants, may not be able
to find a health care worker who speaks their language. When
a patient speaks little or no English, this language
barrier can present significant problems for adherence,
as patient education and support services can have little effect.
Unless a good interpreter is found, such patients may be unable
to continue treatment.
- Some patients have poor relationships with health
care workers. When patients and health care workers
fail to establish a trusting relationship, this lack of relationship
can influence patient adherence. If a patient trusts or has
confidence in his or her health care worker, he or she is more
likely to follow instructions and advice and to cooperate with
the health care worker. Patients may also be more likely to
bring questions and concerns regarding adherence to the health
care worker's attention.
- Finally, some patients may have a lack of motivation
to adhere to a TB regimen. If patients have many competing priorities
in their lives such as substance abuse, homelessness, sickness
from other diseases (e.g., HIV), taking TB medication may not
be considered a priority by the patient.
9.5. Explain why a patient's adherence to a TB treatment
regimen is difficult to predict.
Each patient is unique and may have his or her own reasons for
nonadherence. One of the best predictors of adherence is a patient's
past adherence. If a patient was nonadherent in the past, it is
likely that he or she will encounter similar problems with the
current treatment regimen. However, it is important to keep in
mind that any patient can have problems with adherence. Barriers
are anything that can prevent a patient from being able to adhere
to a TB treatment regimen. Many health care workers think they
can tell which patients will be adherent, but research shows they
are correct only about half the time (that is, their predictions
are no better than flipping a coin). Although adherence is hard
to predict, the more the health care worker knows about the patient,
the better he or she will be able to understand and address the
9.6 Whose responsibility is it to ensure adherence?
Patients and health care workers are both responsible for ensuring
patients' adherence. Patients must decide every day or week whether
or not to take their medicine. What they decide often depends
on how much help they get from the health care workers they see.
9.7 Describe a case management system.
There are many strategies that may be used to ensure that patients
complete treatment. One strategy that may be used is case management.
There are three elements in a case management system:
- Assignment of primary responsibility for the patient
- Systematic regular review of patient progress
- Plan to address any barriers to adherence
A health department employee (case manager) is assigned primary
responsibility and is held accountable for ensuring
- Each patient is assessed and a treatment plan is established
- Each patient is educated about TB and its treatment
- Therapy is continuous
- Contacts are examined
9.8. To address the patient's specific needs, what kind
of things does the health care worker need to learn about the patient?
The health care worker will need to learn as much as possible
about the patient in order to assess potential adherence problems.
The health care worker will need to learn about the patient's
- Medical history and current health problems
- Knowledge, beliefs, and attitudes about TB
- Ability to take responsibility for following the TB treatment
- Resources (family, other social support, finances)
- Barriers to treatment
- History of adherence to previous TB regimens or other medication
9.9. How soon should the health care worker talk with the
patient to begin the assessment?
The health care worker or other program staff should visit the
patient to begin the assessment as soon as possible. If the health
care worker is assigned to work with a hospitalized TB patient,
he or she should visit before the patient leaves the hospital.
If the patient leaves the hospital before the health care worker
can get there, he or she should visit the patient at home as soon
as possible. During the first meeting, the health care worker
should learn at the very least the names of the patient's close
contacts so a contact investigation can begin. The information
the health care worker finds out in these meetings is confidential;
he or she should follow the agency's or clinic's rules for keeping
patient information confidential.
9.10. What is an open-ended question and what can it help
the health care worker learn about a patient?
An open-ended question is one that cannot be answered with a
simple "yes" or "no." Open-ended questions are designed to elicit
the patient's knowledge, feelings, and beliefs by beginning with
words like "What," "Why," "Who," "When," and "How" that demand
an explanation. In addition, phrases that begin with "Tell me
about" or "Explain to me" may be helpful in eliciting information
from the patient. Such questions are used when a health care worker
needs to explore complex issues that do not have a finite or predetermined
set of responses.
9.11. In the list below there are close-ended and open-ended
questions. Mark an X for each open-ended question that the health
care worker can ask the patient to find out his or her ideas and
feelings about TB.
X What is TB?
Do you think TB can be cured?
X How is TB spread?
Do you have difficulty taking medicine?
X What are some of the difficulties you have taking medicine?
X Why do you think you need to take medicine?
Is TB curable?
X How is TB cured?
9.12. Why is it important to assess the patient's knowledge,
beliefs, and attitudes regarding TB and adherence to TB medicine?
Assessing TB patients' knowledge, beliefs, and attitudes regarding
TB and adherence to TB medicine may help the health care worker
better understand the patient's views and suggest areas in which
the patient needs education. They may also give the health care
worker some idea of the patient's ability to adhere to a treatment
regimen. For example, asking a patient what problems the illness
has caused him or her can help the health care worker assess the
strength of family and social support; potential job-related problems;
and, to some extent, the problem-solving skills of the patient.
Throughout treatment, the health care worker should ask the patient
about his or her concerns about TB and success with adherence
to the regimen. Whenever possible, the health care worker should
adapt such questions according to the patient's age, family situation,
education level, and cultural background. Remember that the more
the health care worker is aware of the patient's ideas and concerns
about TB and its treatment, the better prepared the health care
worker will be to anticipate and resolve problems that can arise.
9.13. List eight effective communication techniques that
can help the health care worker to present new information to patients.
Use simple, nonmedical terms in explanations,
and be specific about the behaviors that are
expected. For example, it is much more helpful to say, "This pill
will help you get better," than to say, "This drug, isoniazid,
is a bactericidal agent that is highly active against Mycobacterium
tuberculosis." Using words that are familiar to patients
can make the information relevant to them.
Use the appropriate language level. Written
information should match the patient's reading level. Persons
with a limited education may only be able to understand very basic
materials. Highly educated patients may prefer more detailed information.
If a patient does not read or write, health care workers should
give instructions orally and leave visual cues or reminders, such
as a snapshot of each medication, with the time the patient should
take it written in large numbers.
Limit the amount of information given at any one time.
If too much information is given, the patient may not remember
any of it. To avoid overwhelming the patient, the topics to be
discussed should be organized in the order of their importance.
In the first session, the most essential topics (such as the names
of exposed contacts) should be discussed, in case the patient
does not return for follow-up care.
Discuss the most important topics first and last.
People remember information presented at the beginning and at
the end of a session more easily than they do the information
presented in the middle. Health care workers should tell the patient
what is expected of him or her before they explain test results,
the expected outcome of a procedure, or treatment. For example,
early in the first session the health care worker might say, "To
get well, you must take four of these capsules every day." This
information should be reviewed before leaving the patient.
Repeat important information. Some data indicate
that people need to hear new information several times before
they will remember it. Health care workers should repeat key messages
throughout the session, have the patient repeat the information,
then in later sessions review previously presented material first.
The topic can be introduced by saying, "As we discussed last time..."
Listen to feedback and questions. Communication
with the patient should always be two-way. This means that the
health care worker should listen to feedback and questions from
the patient to be sure they received and understood the message.
The health care worker should use open-ended questions to assess
the patient's knowledge and beliefs.
Use concrete examples to make information easy
to remember. This is especially important for patients who are
not on DOT. For example, visual descriptions of pills can be helpful.
The health care worker could say, "Take two Rifamate capsules
in the morning when you get out of bed. These are the big red
pills in the little brown bottle." If there is something patients
do every morning, such as brushing their teeth, a picture or note
placed on the mirror near the toothbrush can serve as a reminder.
Make the interaction with the patient a positive experience.
It's not only what is said and done, but how
it is said or done, that will help the patient adhere to treatment.
The health care worker should be encouraging and supportive. The
health care worker's warm, concerned, and respectful attitude
toward the patient will make the experience more pleasant for
both and will render the treatment more effective.
9.14. If the health care worker uses an interpreter, what
are four problems the health care worker may encounter?
The health care worker and the patient can have serious problems
understanding each other if they do not speak the same language.
If an interpreter is used, the health care worker can still have
problems getting accurate, unbiased information and protecting
the patient's confidentiality. For example,
- Interpreters may not state accurately what the health care
worker and the patient have said
- Interpreters sometimes add their own ideas of what has been
- The patient may be uncomfortable talking about personal information
that he does not want a third person, the interpreter, to know
- Interpreters may have difficulty finding equivalent words
or translating medical terms into the patient's language
It is best to use trained medical interpreters whenever possible.
If a trained interpreter is not available, other persons who are
sometimes used as interpreters are other health care workers who
speak the patient's language, the patient's family members, or
people from the patient's community. If an interpreter is unavailable
when the health care worker makes a home visit, the health care
worker should call back to the office or clinic if see if someone
there could translate for them over the telephone. If family members
must be used to interpret, children should not be used;
they will hear personal information and may be asked to translate
things that the family feels children should not discuss, and
this can be upsetting.
9.15 List at least six guidelines for working with an interpreter
that can help the health care worker make the best of the interview.
After the health care worker has identified an interpreter, he
or she should follow these guidelines to make the best use of
- Ask for the patient's permission to use an interpreter
- Plan the interview and decide what key points to talk about
with the patient
- Meet with the interpreter before the interview to talk about
the goals for the interview, to give instructions and guidance,
and to make sure the interpreter is comfortable with the questions
and topics that will be discussed
- Remind the interpreter that all information in the interview
- Ask the interpreter to refrain from adding his or her own
- Address the patient directly, not the interpreter
- Ask the interpreter to explain questions or answers that are
- Keep the messages simple and factual; use short phrases and
focus on one topic at a time
- Give the interpreter time to translate each phrase before
continuing; do not interrupt the interpreter
- Ask the interpreter to translate the patient's and the health
care worker's own words as exactly as possible
- Give the patient time to answer questions
9.16 What is DOT?
A component of case management that helps to ensure that patients
adhere to treatment is directly observed therapy (DOT). DOT is
the most effective strategy for making sure patients take their
medicines. DOT means that a health care worker or other designated
individual watches the patient swallow every dose of the prescribed
drugs. DOT should be considered for all patients because it is
difficult to reliably predict which patients will be adherent.
Even patients who intend to take their medicine might have trouble
remembering to take their pills every time. All DOT visits should
be documented. In many health departments, DOT is the standard
9.17 Who should be considered for DOT?
All patients should be considered for DOT. However, there are
certain groups of patients for whom DOT is often the best option,
regardless of local treatment completion rates. These groups include
- Patients with drug-resistant TB
- Patients receiving intermittent therapy
- Persons at high risk for nonadherence, such as
- Homeless or unstably housed persons
- Persons who abuse alcohol or illicit drugs
- Persons who are unable to take pills on their own due
to mental, emotional, or physical disabilities
- Children and adolescents
- Persons with a history of nonadherence
9.18 List and explain four tasks that are part of the DOT
Delivering DOT means that the health care worker should
- Check for side effects. At each visit, before
the drugs are given, the health care worker should ask if the
patient is having any adverse side effects. Patients being treated
for TB should be educated about symptoms indicating adverse
reactions to the drugs they are taking, whether minor or serious.
If the patient has symptoms of serious adverse reactions, a
new drug supply should not be given; the patient should stop
taking medication immediately. The supervisor should be told
that the drugs were not given, and the prescribing clinician
should be notified about the adverse reaction. The health care
worker should arrange for the patient to see the clinician as
soon as possible.
- Verify the medication. Each time DOT is delivered,
the health care worker should verify that the right drugs are
delivered to the right patient, and that he or she has the correct
amount of medication. If this cannot be confirmed, the drugs
should not be given to the patient. The supervisor should be
asked for clarification.
- Watch the patient take the pills. Medication
should not be left for the patient to take on his or her own.
The health care worker or the patient should get a glass of
water or other beverage before the patient is given the pills.
The health care worker should watch the patient continuously
from the time each pill is given to the time he or she swallows
- Document the visit. The health care worker
should document each visit with the patient and indicate whether
or not the medication was given. If not given, the reason and
follow-up plans should be included. It is important to correct
any interruption in treatment as soon as possible.
9.19 Name at least five places where DOT can be given.
DOT can be given anywhere the patient and health care worker
agree upon, provided the time and location are convenient and
safe. Clinic-based DOT is delivered in a TB clinic
or comparable health care facility (Figure 9.3). For some patients,
DOT must not interfere with the patient's work schedule, so DOT
can be provided in a nonclinical setting or during nonbusiness
hours. When a patient cannot easily get to the TB clinic, the
health care worker must go to the patient. DOT delivered in a
setting outside of the TB clinic or health care facility is called
field-based DOT (Figure 9.4 and Figure 9.5).
Field DOT can be given at almost any site:
- The patient's home
- The patient's workplace
- A public park or other agreed-upon public location
- A school
- A restaurant
Sometimes staff at other health care settings, such as outpatient
treatment centers, can be asked to give DOT to a patient who can
get to the alternative health care setting more easily than the
9.20 What are four advantages of DOT?
When used as a collaborative effort with the patient, DOT has
many advantages over self-administered therapy:
Often patients who have successfully completed DOT are willing to
describe their experience or share it with new patients. If this
can be arranged, former patients may help encourage new patients
to participate in the DOT program.
- It ensures that the patient completes an adequate regimen
- It lets the health care worker monitor the patient regularly
for side effects and response to therapy
- It helps the health care worker solve problems that might
- By ensuring the patient takes every dose of medicine, it helps
the patient become noninfectious sooner
- Often patients who have successfully completed DOT are willing
to describe their experience or share it with new patients.
If this can be arranged, former patients may help encourage
new patients to participate in the DOT program.
9.21 What are incentives and enablers, and what are their
Just offering a DOT program is not enough. Patients must agree
to participate in taking their medicine and stick with it. Incentives
and enablers may help them do this. Incentives
are small rewards given to patients to encourage them to either
take their own medicines or keep their clinic or field DOT appointments.
Enablers are those things that make it possible
or easier for the patients to receive treatment by overcoming
barriers such as transportation difficulties. Incentives and enablers
are widely used in facilities providing TB services; they help
patients stay with and complete treatment.
9.22 How does a health care worker determine which incentives
and enablers to use for each patient?
Incentives and enablers should be chosen according to the patients'
special needs and interests, or the patients may not care if they
receive them. For example, if the health care worker knows that
transportation is a problem, he or she could offer bus tokens,
bus fare, or taxi fare. If transportation is not a problem, then
he or she should offer something that is needed. Learning as much
as possible about patients will help to identify their needs and
interests and better motivate them to complete treatment. The
best time to begin using incentives is after a good relationship
has been established with a patient. Enablers, however, may be
vital to the initiation of treatment and should be provided as
soon as treatment starts.
9.23 What are some sources of incentives and enablers?
Programs can obtain incentives and enablers from many different
sources. Possible resources for obtaining incentives and enablers
- The state or local American Lung Association chapter
- Community organizations, such as church groups
- Businesses that can donate items such as food or food coupons
- Volunteers who can contribute goods and services, such as
baked goods or childcare
- TB program staff who are willing to devote extra time and
9.24 What are five ways the health care worker can help
parents improve adherence in children?
The health care worker should do everything that can be done
to make sure that parents support their children's TB treatment,
- Educate parents of children and adolescents
with TB disease. By assessing their knowledge and beliefs about
TB, the health care worker can address concerns and needs, correct
misconceptions, and help parents understand their child's disease.
If both the patient and his or her parents are knowledgeable
about TB, the patient is more likely to successfully complete
- Warn parents about the possible problems
their children might have during TB treatment. Children may
resist taking medications, may have adverse reactions to the
medications, and may have problems swallowing pills and capsules
(the common form of TB medications). When parents know in advance
about problems that can come up during their child's treatment,
they can cope with and help solve problems as they arise.
- Give DOT to children with TB when parents'
or caregivers' compliance with giving medications as prescribed
cannot be ensured.
- Use incentives and enablers, such as coloring
books and toys, to encourage a child to take medicine. Giving
incentives to parents and caregivers should be considered, too;
this will encourage and reward their participation.
- Give TB drugs in easy-to-take preparations.
Rifampin can be made into a liquid suspension. Isoniazid can
also be prepared as a suspension, although its stability varies.
The health care worker can discuss the use of liquid medications
with the patient's clinician. Isoniazid and pyrazinamide pills
can be crushed and given with small amounts of food.
9.25 Why are adolescents at high risk for nonadherence?
Although adolescents can be responsible for taking their own
medications, they are also frequently nonadherent. They may be
embarrassed about having to take TB medications because they are
concerned about what their friends think. Also, they may not feel
threatened by TB and may not take the condition seriously. For
these reasons, adolescents are a high priority group for DOT.
9.26 If a health care worker conducts a behavioral diagnosis,
what methods can the health care worker use to help a patient whose
adherence problem is:
Get help from family or friends, simplify the regimen or
use combination pills, link pill taking with other activities,
provide special pill dispensers and memory cues, or use DOT.
- Lack of motivation?
Point out the dangers of nonadherence and benefits of therapy,
increase the frequency of visits, provide incentives and set
short-term goals, use DOT
- A complex regimen?
Simplify the regimen, associate the regimen with other activities,
use combined capsules, or use DOT.
- Poor relationship with the health care worker?
Develop communication skills, be accessible throughout care,
work on attitudes about patients and DOT, change health care
workers, provide social services
9.27. Describe how cultural, religious, or other personal
beliefs can affect the treatment for TB.
Sometimes cultural, religious, or other personal beliefs affect
a patient's TB treatment. It is important for the health care
worker to sincerely respect the beliefs of the patient. Sometimes
patients seek medical advice from folk healers or alternative
practitioners. The health care worker may encounter patients who
use folk remedies along with their prescribed medications. For
example, in some Asian cultures, TB medicines are considered "hot"
and need to be countered with something "cold," such as green
Take the time to learn about the patient's cultural beliefs.
If the patient thinks that the health care worker does not respect
his or her beliefs, it could cause the patient to distrust the
health care worker. If the patient comes from a background that
includes the use of alternative medicine or folk medicine, find
out if there are barriers to the acceptance of conventional medical
practices. A discussion about the patient's beliefs and health
practices may help the health care worker to individualize treatment
so that it is acceptable to the patient.
When folk or alternative practices are safe, health care workers
should consider including them in the treatment plan. For example,
some people believe in the healing power of prayer. These persons
may be more willing to take medications after saying a brief prayer,
so accepting their belief in prayer is an important aspect of
treatment. If a patient is taking an herbal remedy, the health
care worker should check with the patient's physician or pharmacist
to be sure it will not cause side effects or interact adversely
with the patient's TB drugs. He or she should ask patients who
have concerns about nutrition supplements or interactions with
TB drugs to discuss this with their clinician.
While it is important to respect the patient's beliefs, it is
just as important for the health care worker to clearly present
the rationale for taking TB drugs for a full course of treatment.
The health care worker can do a great deal to help the patient
adhere and incorporate his or her beliefs into the treatment,
but it is crucial that both come to an agreement about taking
9.28. Name eight specific things the health care worker
can do to form an effective partnership with his or her patient.
Patients make independent decisions every day about whether they
will take medication or show up for DOT. The health care worker
must recognize the important role of the patient in making decisions
about treatment. For this reason, the health care worker should
develop a partnership with the patient. Effective partnerships
call for specific behaviors from the health care worker:
- Listen and try to understand the patient's knowledge, beliefs,
and feelings about TB disease and treatment
- Be open minded about the patient's beliefs and cultural expectations
- Recognize and address the patient's fears about the illness
- Understand and fulfill the patient's expectations about treatment,
- Communicate clearly so that the patient can understand the
- Avoid criticizing the patient's adherence behavior; suggest
behavior changes respectfully
- Treat the patient with dignity and respect
- Be consistent in what is done and told to the patient
9.29. Who can provide support to a patient and help the
patient remember to take medications?
The support of family, friends, and health care workers can be
important to patients trying to complete treatment. The health
care worker should ask his or her patients to identify persons
who support their TB treatment and can help them remember to take
medications or keep their DOT appointments. Such persons might
- Family members
- Social workers
9.30. What are two things the health care worker can do
to tailor the regimen to the patient's lifestyle?
To improve adherence, the medication regimen should be tailored
to the patient. If possible, the regimen should be simplified
and changed within acceptable therapeutic limits to match the
patient's lifestyle. For example, the patient's physician can
- An intermittent regimen for a patient whose
schedule doesn't permit daily DOT appointments
- A combined pill, which is a fixed-dose combination
capsule or tablet that may enhance patient adherence, for patients
with difficulty swallowing. In the United States, the Food and
Drug Administration has licensed fixed-dose combinations of
isoniazid and rifampin (Rifamate) and of isoniazid, rifampin,
and pyrazinamide (Rifater).
Patients who are not on DOT sometimes find it useful to monitor
their pill-taking by checking off doses on a daily calendar. A
calendar can help patients remember the days they need to take
medicine and engage them in determining their own schedule. A
weekly pill box may also help patients monitor their pill-taking.
9.31 What is a formal adherence agreement?
For some patients, a formal adherence agreement
-- a written understanding between the health care worker and
a patient -- may be useful. A sample adherence agreement is presented
in Figure 9.7. A patient should dictate or write down the activities
he or she agrees to carry out (such as taking medicine as prescribed),
in return for specific services, activities, or incentives from
the health care worker. For some patients, this written commitment
increases the likelihood of adherence. The patient should be asked
to sign the agreement next to the health care worker's signature
and be given a copy to keep. The health care worker should review
the agreement with his or her patient periodically to assess how
well both are doing and to make changes as needed.
9.32. What three methods can be used to help patients keep
There are three methods to help patients keep their appointments:
- Remind patient of appointment
- Contact no-shows and make another appointment
- Use other alternatives for patients who repeatedly break appointments
Examples of Methods to Help Patients Keep Appointments
Remind patient of appointment
Contact the no-shows and
make another appointment
Use other alternatives
for patients who repeatedly break appointments
Send a post card
- Call the patient by phone (opportunity to counsel)
- Give an appointment card
Hold a conference with all members of the health
Possibly include the patient in the conference
Consider legal alternatives
9.33. Give four examples of nonadherent behavior.
The Advisory Council for the Elimination of Tuberculosis (ACET)
defines nonadherent behavior as an inability or unwillingness
to follow a prescribed treatment regimen. Examples of nonadherent
- Taking medication inconsistently
- Missing clinic appointments
- Consistently failing to report for DOT
- Refusing medications
9.34. Describe the progressive interventions that should
be attempted before a court orders involuntary confinement.
ACET recommends that before a court orders involuntary confinement,
state and local TB control programs should have a treatment plan
that goes step-by-step from voluntary participation to involuntary
confinement as a last resort. The plan should begin with learning
the possible reasons for nonadherence and addressing the identified
problems using methods such as DOT, incentives, and enablers.
The patient should be told orally and in writing of the importance
of adhering to treatment, the consequences of failing to do so,
and the legal actions that will have to be taken if the patient
refuses to take medication. If the patient does not adhere to
DOT voluntarily, the next step may be court-ordered DOT, which
is DOT that is administered to a patient by order of a public
health official or a court with the appropriate authority. It
is used when patients have been nonadherent despite the best efforts
of TB program staff. Court-ordered DOT can be successful in convincing
a patient that his or her TB treatment is an important public
TB control programs should not begin procedures for confining
patients to a treatment facility until after the patient has shown
that he or she is unable or unwilling to follow a treatment regimen
implemented outside such a facility. Involuntary confinement or
isolation for inpatient treatment should be viewed as the last
step. However, when a patient with infectious TB refuses treatment
and voluntary isolation, emergency detention to isolate the person
is appropriate. Confinement can be either in a hospital or in
some other institution with TB isolation facilities.
9.35. List the criteria for deciding if a patient should
When deciding whether to legally confine a TB patient to protect
the public, local health officials must decide whether the person
is at real risk of infecting others (now or in the future). To
determine this risk, these factors are considered:
- Laboratory results (acid-fast bacilli smears and cultures)
- Clinical signs and symptoms of infectious TB
- An abnormal chest radiograph, especially if cavities are present
- A history of nonadherence (not caused by factors outside patient's
- The opportunity to infect others
An order to confine a patient should require that he or she be
isolated until no longer a public health threat. This decision
should be based on
- The patient becoming asymptomatic, with documentation of at
least three negative sputum smears taken on different days
- The local health officer's decision that the person has completed
therapy according to the most recent American Thoracic Society/CDC
The patient should be ordered to receive treatment in a proper
facility until cured, unless it is certain that the person will
voluntarily complete therapy at home once noninfectious. If the
patient refuses the ordered treatment, the health officer should
have the authority to extend the confinement order as needed.