Globally, 5% of new smear-positive cases treated under DOTS in 2006 defaulted, but this ranges from <1% to 13% in the world’s 22 high-burden countries. Default includes patients who have interrupted treatment but also patients who have died or transferred out and whose outcomes are unknown to the NTP treatment staff.
The true status of the “defaulting patient” must be ascertained: if defaulting is due to treatment interruption, and if it could be prevented, additional countries would be able to achieve the global TB control target of 85% treatment success. Treatment interruption can be prevented – or limited so that a patient does not default entirely from therapy (20). Promoting adherence through a patient-centred approach is prob-ably more effective in preventing treatment interruption than devoting resources to tracing patients who default.
Among the major factors that influence treatment interruption are comorbid condi-tions such as substance abuse or mental illness, access to treatment (distance, cost of transport) (21), time and wages lost, quality and speed of drug delivery, extent of knowledge about TB and the need to complete treatment, and flexibility for transfer to another facility.
As described in section 6.4, supervised treatment can help prevent interruptions.
When patients self-administer treatment, they often take drugs irregularly, and trac-ing is difficult and often unproductive; there is also a much longer delay between interruption of treatment and action by the health system.
Whenever the patient visits the health facility, the need for regular and complete intake of treatment should be reinforced and any problems that may cause inter-ruption should be identified. At registration, sufficient time should be set aside for meeting with the patient (and preferably also the patient’s family members or a desig-nated treatment supporter). This initial meeting provides an important opportunity to inform the patient about the duration of treatment. During the meeting, it is vital to record the patient’s address and other relevant addresses (e.g. partner or spouse, parents, place of work or study, or private doctor who may be consulted) as well as explain the need to consult ahead of time in case of a change of address. This maxi-mizes the likelihood of locating patients who interrupt treatment. Recording mobile telephone numbers for the patient and family has proved valuable in many settings.
Where resources permit, it is helpful for a health staff member to accompany the pa-tient to his or her residence. This allows verification of the papa-tient’s exact address and provides an opportunity to arrange for screening of household contacts, especially
children under 5 years of age and those of any age who may have TB symptoms or be living with HIV.
In the meeting with the patient at the end of the initial phase of treatment, the health worker should reassess his or her needs and enquire about plans (work, family, mov-ing to another location) that may affect the continuation phase of treatment (19). Any changes in the regimen should be discussed and all concerns should be addressed.
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