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Communicable Diseases Module: 15. Follow-up of Patients on Anti-Tuberculosis Treatment and Defaulter Tracing

Study Session 15  Follow-up of Patients on Anti-Tuberculosis Treatment and Defaulter Tracing

Introduction

In this study session you will learn about the follow-up of patients put on anti-tuberculosis drugs during the intensive and continuation phases of treatment. You will also read about what to do when people with TB default (i.e. stop their medication in the course of treatment) and how to trace them. TB treatment is a long process and it is critical to maintain contact with patients throughout treatment to ensure successful outcomes. However, sometimes circumstances interfere with maintaining contact, so that these patients stop their medication or take their drugs irregularly, often resulting in development of drug resistance by the TB bacteria in the patient’s body. This study session will describe how to maintain contact with patients, even in difficult circumstances, and thus improve the chances that they will complete treatment and be cured of their illness.

Learning Outcomes for Study Session 15

When you have studied this session, you should be able to:

15.1  Define and use correctly all of the key words printed in bold. (SAQ 15.1)

15.2  Describe how tuberculosis patients are monitored during the intensive and continuation phase of treatment with anti-tuberculosis drugs. (SAQ 15.1)

15.3  Describe the arrangements for medical referrals and transfer of tuberculosis patients to ensure that people with TB continue treatment. (SAQ 15.1)

15.4  Describe how you can trace those people with TB who default from tuberculosis treatment, and how you should try to resolve this problem. (SAQ 15.2)

15.5  Define the possible anti-tuberculosis treatment outcomes. (SAQ 15.3)

15.1  Monitoring of TB patients during treatment

Monitoring is the regular observation and recording of activities and results taking place in a programme.

In the first part of this study session you will learn how to follow patients throughout the course of anti-TB treatment by checking the results of sputum examinations and hence monitor their clinical response to treatment. For patients who interrupt their medication, we will also talk about possible reasons for them doing so and how such problems can be resolved.

Like any medical activity, TB programmes need continuous monitoring. To achieve this, patients need to be followed very strictly and the outcome of treatment needs to be clearly defined. As a health worker, your role is very important in ensuring patients are taking their drugs properly. This is called adherence to treatment. Part of your responsibility is to tell your patients very clearly not to interrupt their treatment and to look for side-effects of drugs of the type described in Study Session 14 and to seek help accordingly.

15.2  Refilling of medication and adherence to treatment

It is important for you to monitor all individuals with TB during treatment, both adults and children — checking that they are taking their medication properly during the intensive phase of treatment, and that they are periodically collecting their drugs during the continuation phase — this is called refilling their drugs.

Monitoring with sputum examination is readily available only for patients with sputum smear-positive pulmonary tuberculosis and these are usually adults and older children. Routine monitoring of treatment response by chest X-ray (recall from Study Session 14) is unnecessary and wasteful of resources because it is not readily available and also costly to the patient. But if patients with smear-negative TB and extra-pulmonary TB do not show clinical improvement (their symptoms do not improve and there is no weight gain), or if patients get worse during or after anti-TB drug treatment, you must refer such patients to a hospital for further evaluation. For such patients, it is essential that you monitor clinical symptoms and keep monitoring their weight over time.

  • How is the monitoring that you do different in the intensive and continuation phases?

  • In the intensive phase, monitoring drug taking involves directly observed therapy; in the continuation phase, you need to check that patients are refilling their anti-TB drugs from the health centre or hospital.

How can you ensure that patients are adhering to their treatment regimen? In all your interactions with patients, you need to be strong-minded and clear in your instruction, but also polite, considerate and respectful. Always treat the patient with dignity and give the patient every opportunity to voice concerns and to regularly ask questions.

Behaving in this way will help create a relationship of trust and confidence between you as the DOTS provider and the TB patient, which will help bring about the patient’s adherence to treatment. Also, adherence is all the more likely if the patient and his or her family members learn from you the basic information about TB, including what is necessary for effective treatment and cure.

15.2.1  Monitoring of patients with sputum smear-positive pulmonary TB

As you have learnt in Study Session 13, sputum examination is required for diagnosis for all persons suspected of TB who are able to produce sputum; this test is also essential for follow-up of smear-positive TB individuals, as we will now discuss. Table 15.1 shows the required schedule of sputum examination for a smear-positive TB patient during treatment. You must refer the patient for testing at the times on this schedule.

Table 15.1  Monitoring of patients with sputum smear-positive pulmonary TB.
When to refer patients for sputum smear examination8 month treatment regimen6 month treatment regimen
At time of diagnosisAll persons suspected of having TB and producing sputumAll persons suspected of having TB and producing sputum
At end of intensive phase (end of two months)Smear-positive TB patient at diagnosis needs sputum examination at end of two monthsSmear-positive TB patient at diagnosis needs sputum examination at end of two months
In continuation phaseSmear-positive TB patient at diagnosis needs sputum examination at month fiveSmear-positive TB patient at diagnosis needs sputum examination at month five
At end of treatmentSmear-positive TB patient at diagnosis needs sputum examination at month eightSmear-positive TB patient at diagnosis needs sputum examination at month six
  • Most patients improve their symptoms within the two months of the intensive phase of drug treatment and as a result some patients assume that they are cured. Should such patients stop taking their drugs if they feel better?

  • No — it is essential that they continue taking drugs up until the end of the continuation phase, in other words that they fully adhere to the treatment.

Sputum smears at the end of the intensive phase

The majority of patients will have a negative sputum smear at the end of the intensive phase. If the sputum smear is still positive at this time, intensive phase treatment with the same four drugs 1 (RHZE) should be continued for four more weeks. When the sputum smear is checked again after this extra period, it is unlikely still to be positive. The continuation phase should be continued even if the sputum smear after the extra four weeks of intensive phase treatment is still positive.

Sputum smears in continuation phase

In eight month treatments, a positive smear at five months (or any time after five months) means treatment failure. In six month treatments, a positive sputum smear at five months (or any time after five months) means treatment failure. The patient treatment category changes to Category II (you should recall what this means from Table 14.2 in Study Session 14), and the re-treatment regimen described in Study Session 14 begins.

Sputum smears on completion of treatment

If a patient has a negative sputum result at the end of treatment and one additional result at the end of two months, or at five months, that is also negative — the patient is defined as cured.

15.3  Referral of people suspected of being infected with TB and TB cases

You know from Study Sessions 13 and 14 that a very important role for you is referring people suspected of having TB — specifically those with a cough for two or more weeks — to a health institution for TB diagnosis. Referrals can come about in other ways. Sometimes a doctor may diagnose TB and then refer the patient with the drugs to your health facility to continue their treatment under your supervision. Those patients need registration at your level and continued follow-up needs to be put into place.

If a patient is very sick or has major treatment side-effects (recall Study Session 14), it may be necessary to refer the patient to a doctor or to a hospital for care of the acute problem. However, sometimes such a patient then believes that, because of the treatment received at the hospital, there is no need to come to you for regular TB treatment and he or she may then discontinue treatment. When a referral of this type comes about, discuss the situation with the patient and their family and emphasise the need to return to your health facility to continue treatment after discharge from the doctor or hospital.

15.3.1  Coordinating transfers when a patient is moving

Figure 15.1  A health worker discusses the needs of a TB patient who is about to move to another area.

If a registered patient plans to move out of the area permanently, find out when and where the patient is moving and identify an appropriate treatment facility in the new area. In your discussions with the patient in the period before the move, stress the need to continue treatment and the importance of reporting to the new health facility (Figure 15.1). Make sure that the patient understands that to be cured, he or she must continue taking all of the required drugs for the entire time required. If necessary, provide self-administered doses for several days until the patient has reached their new home.

If you do not receive confirmation from the receiving health facility, contact the facility to ask whether the patient has reported for treatment. If not, tell the facility where to locate the patient. Ask the District TB Coordinator whether there is any new information about the patient. If the transfer is never confirmed (i.e. the patient never reports to the new facility), the patient’s treatment outcome will be recorded as a ‘transfer out (transfer TB patient to other health facility)’. If the transfer is confirmed, at the appropriate time, ask the new health facility where the patient was referred about his or her treatment outcome, so that you can record it on the patient’s registration.

It is important that you are in contact with the District TB Coordinator — this is the person who controls and coordinates TB activity at district level. If the patient originates from your district, it is your district’s responsibility to find the treatment outcome for the patient.

So, remember that it is the responsibility of the originating health facility (in other words, the first one involved) to find out about the treatment outcome for a patient who transfers out, but you can help the process. When you receive a patient from another health facility, make a note that this is a transferred-in patient to remind you to report the treatment outcome to the originating health facility. When any patient completes treatment, check to see whether the patient has been transferred in. If so, contact the originating health facility and report the treatment outcome.

15.3.2  Arrangements for patients who travel

If a patient will be travelling or absent for longer than two weeks, identify a health facility in the area where the patient’s treatment can be followed.

During their regular treatment visits, ask patients to inform you if they have plans to travel, so that arrangements can be made to continue treatment without interruption. If a patient is to travel out of the area, or will be unable to have directly observed treatment for one or more days, provide instructions and drugs for a short period of self-administration; if necessary, you may provide drugs for up to two weeks.

If the patient’s drugs are not pre-packaged, prepare a separate packet of drugs for each day that the patient will be absent (Figure 15.2). Give the patient careful instructions, in your conversation with him/her and in writing, about how to take the drugs. Point out the number and colour of the drugs in each day’s packet and tell the patient to take the drugs at the same time each day, take the pills with water and take all of the drugs for the day together.

Figure 15.2  Anti-TB drugs are being sorted into separate packages for a patient who is about to travel to another district (Photo: courtesy of the World Lung Foundation/Gary Hampton).

Ask questions such as ‘how do you take the medication?’ and ‘do you divide the dose?’ to make sure that the patient understands when and how to take the drugs. On the patient’s registration, record the days when you observed treatment and then draw a line through the days on which the patient will take self-administered drugs.

15.4  Tracing patients who missed doses and defaulters

What about patients who miss doses and those (called defaulters) who discontinue their treatment during the course?

15.4.1  Conducting home visits for patients who miss a dose

Give the patient the missed doses one day at a time. Do not give an extra dose on any days.

If a patient misses a dose of anti-tuberculosis medication during intensive treatment for more than 24 hours, find the patient by making a home visit within the next couple of days. Use the address on the patient’s TB registration to find the patient. When you go on the home visit, take the patient’s drugs with you. If the patient is not at home, ask the family or neighbours where the patient is and see if you can find out why treatment was missed. If necessary, visit the contact person listed on the patient’s TB registration.

When the patient is found, talk to the patient and the family about the problem that caused the interruption in treatment. Ask direct questions such as: ‘Why did you miss your appointment?’ and ‘Will this problem happen again?’ When you have found the cause of the problem, try to help the patient to solve it with the help of the information given in Table 15.2.

Table 15.2  Some examples of possible causes and solutions for missed doses of anti-TB medication.

Examples of possible

causes of missed doses

Possible solutions
Coming to the health facility is inconvenient. Identify a convenient community TB treatment supporter.
Patient dislikes coming to the health facility because of the long queue.Make arrangements so that TB patients do not have to wait in a queue. For example, let them enter through a back or side door.
Supervisor at work kept the patient late.
  • Offer to talk with the supervisor and explain the importance of the treatment, or
  • Identify a community TB treatment supporter at work.
Patient had troublesome side-effects.
  • Give appropriate advice for side effects, or
  • Refer the patient for further evaluation.
Patient had difficulty swallowing because of pain (due to oral ulceration, common in AIDS patients).Give appropriate advice and refer patient as necessary for further evaluation.
Patient cannot leave small children at home and is tired of bringing them to the health facility.
  • Suggest that a family member or neighbour watch the children.
  • Remind family members/neighbours that the patient must continue treatment to protect their health, and particularly the health of the children.
  • If possible, identify a community TB treatment supporter closer to the patient’s home.
The patient may simply need to be forced to comply and be reminded of the reasons not to interrupt treatment.

Remind the patient of the need to take all of the recommended drugs together, for the recommended time, to be cured. Even after beginning to feel better, the patient must continue taking the drugs for the entire period of treatment.

Motivate the patient with statements such as the following:

  • TB can be cured if you keep coming for the medicine, and then you will not have to worry about it any more.
  • You only have 10 more doses to take every day. After that, you will come less often.
  • These are the safest, most effective drugs available to treat TB anywhere in the world.
  • Almost all patients who take their medicines as recommended are cured.
  • If you keep taking your medicine, you will not spread TB to your family.

15.4.2  Home visits for patients who fail to collect drugs for self-administration

Suppose a patient on a self-administered continuation regimen fails to collect the drug supply on the appointment day. What should you do? If a patient does not come for the drugs within a week, visit the patient’s home to find the patient, deliver the drugs and determine the problem. Try to solve any problems after discussion with the patient, as outlined in Table 15.2.

15.4.3  Tracing patients who interrupt treatment

If you cannot locate a ‘defaulter’ patient who has interrupted treatment at the home address recorded on the TB unit register form, try to find the patient through the contact person listed on the card. Seek information and leave messages with neighbours and relatives or at the patient’s workplace. Try to find out whether the patient is just temporarily missing or has permanently moved. If the patient has moved, try to find out the new location and notify the District TB Coordinator. In this way the patient may eventually be transferred to the care of another health facility.

If a patient is found and resumes treatment within a month, the same treatment should be continued and should be prolonged to make-up for the missed doses. If treatment is interrupted for between one and two months, the patient will need a new sputum examination before the appropriate treatment can be determined. If treatment is interrupted for two months or more, the patient has defaulted. The treatment outcome ‘default’ should be entered on the TB unit register form. If the patient returns, he or she will need to be re-assessed to determine the appropriate treatment.

15.5  Treatment outcomes

As you know, treatment is completed when the patient has taken the correct number of doses of the continuation-phase drugs. If the patient has missed some doses along the way, the duration of the treatment extends until all the doses in the patient’s drug box are taken, which will be some days or weeks longer. Some patients do not complete treatment, either because they die during treatment or more likely they stop coming for treatment and cannot be located. When each patient completes treatment or stops coming for treatment, record that patient’s outcome on the TB treatment registration form.

Possible treatment outcomes are defined as follows:

Cured

An intensively smear-positive patient who is sputum smear-negative at completion, or one month prior to the completion of treatment, and on at least one previous occasion (usually at the end of the second or fifth month).

Treatment completed

A patient who completed treatment but for whom smear results are not available at month seven or one month prior to the completion of treatment.

Treatment failure

A patient who remains or becomes again smear-positive at the end of month five or later during treatment. The same outcome would apply to a patient who was sputum smear-negative at the beginning of treatment and smear-positive at the end of the intensive phase.

Died

A patient who dies for any reason during the course of treatment.

Defaulter

A patient who has been on treatment for at least four weeks and whose treatment was interrupted for eight or more consecutive weeks.

Transfer out

A patient who started treatment and was transferred to another reporting unit and for whom the treatment outcome is not known at the time of evaluation of treatment results.

Treatment success

The total number of patients who are declared ‘cured’ and those who have ‘completed’ treatment.

At the end of treatment of tuberculosis with anti-TB drugs the outcome for the treated patient should be documented and reported to the District Health Office. You will no doubt be very pleased with ‘cures’ and you should achieve some satisfaction that as a HEP you have contributed to making such a difference to a person. In fact, for all the TB patients that come into your care, you are in a position to make an important contribution to improving their well-being and increasing the chances of success.

Summary of Study Session 15

In Study Session 15, you have learned that:

  1. Patients on anti-TB drugs must be monitored throughout the course of treatment for adherence and potential side-effects.
  2. Sputum examination during follow-up is important for smear-positive TB patients and looking for symptom improvement is essential for other forms of TB.
  3. When a TB patient is referred to a hospital or clinician for special care, inform the patient and the receiving clinician that the patient is expected to return to the original health facility for continuing TB treatment after referral care is completed.
  4. When a patient moves and transfers to a new treatment facility, follow-up to ensure that the transfer is successfully completed.
  5. It is the originating (first) health facility’s responsibility to find out the treatment outcome for a patient who transfers out.
  6. The outcome ‘transfer out’ is used only if the patient was transferred and another outcome cannot be determined.
  7. If TB patients must travel, drugs may be provided for up to two weeks of self-administration (if the patient will be absent for more than two weeks, a transfer should be arranged).
  8. If a TB patient misses a dose for more than 24 hours, make a home visit within the next 24–48 hours, give patients the missed dose only, finding out reasons for missed treatment.
  9. If a TB patient on a self-administered regimen fails to refill the drug supply within a week of the scheduled day, use a home visit to find the patient, deliver the drugs and determine the problem.
  10. If a TB patient interrupts treatment, make every effort to find the patient through family, neighbours and the contact person listed on the TB registration form.

Self-Assessment Questions (SAQs) for Study Session 15

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 15.1 (tests Learning Outcomes 15.1, 15.2 and 15.3)

For each of the following statements, decide if it is true or false. In each case explain your reasoning.

A  Monitoring of TB treatment is the regular observation and recording of activities taking place during treatment of patients with anti-TB drugs.

B  Smear-positive patients do not require sputum examination at five months into treatment.

C  After a temporary referral to a clinician or hospital, a patient should return to the original health facility to continue treatment for TB.

D  When a TB patient transfers to a new facility, that facility should notify the original health facility that the patient has reported for treatment.

Answer

A is true; when you monitor TB treatment you observe and record all treatment activities and this in turn helps to monitor the TB programme at national level.

B is false; at the fifth month a sputum examination is required for all TB patients with initial smear-positive results.

C is true; it is the responsibility of the original health facility to conduct subsequent follow-up once the patient is discharged from hospital.

D is true; it is the responsibility of the new facility to inform the original health facility that the transferred patient has reported for treatment.

SAQ 15.2 (tests Learning Outcome 15.4)

Suppose a known TB patient has been on anti-TB drugs for six weeks and they interrupt treatment for two weeks. What would you do for this patient and what advice would you give him/her for the future?

Answer

If a patient interrupts anti-TB treatment for less than one month the appropriate action is to trace the patient, solve the cause of the interruption and advise to continue treatment and prolong it to compensate for missed doses. Then you should advise the patient not to interrupt treatment again. Mention that if he or she continues interruption, the chances of cure will be lessened, as the patient may develop drug-resistant TB.

SAQ 15.3 (tests Learning Outcome 15.5)

For each of the following scenarios, write down the appropriate treatment outcome:

  • a.A TB patient who developed severe skin rash is referred from your health facility to the health centre health officer. The patient never returns to the health facility. The rash went away, but the health officer has not seen the patient for two months.
  • b.A TB patient plans to move and transfer to another health facility. You send the patient with a TB referral/transfer form. The receiving health facility never confirms that the patient has reported.
  • c.A TB patient on treatment transferred to a new health facility, but you do not receive written confirmation. Later you contact the new health facility and find that the patient has reported there for treatment. At the appropriate time you contact the health facility again and find that the patient has been cured.
Answer
  • a.Defaulter
  • b.Transfer out
  • c.Cure.