Knowledge - Tuberculosis treatment: managing non-adherence

TB conjures up images of Victorian workhouses and inner-city Edwardian slums: a disease of poverty that has no place in 21st-century Britain. Yet the number of cases of TB has risen in the UK from 5,086 cases in 1987 to 6,723 in 2004 with the bulk of new notifications occurring in inner-city areas (Health Protection Agency, 2006).

Most people who develop TB belong to minority ethnic groups and were born abroad (National Collaborating Centre for Chronic Conditions, 2006). The Department of Health has responded with its TB action plan (DH, 2004) and the National Collaborating Centre for Chronic Conditions (2006) has issued guidelines on behalf of NICE on the treatment and management of this disease.

TB can be cured but patients must complete a full course of medication, which normally lasts six months. This comprises a combination of antibiotics, which need to be taken together to prevent the development of drug resistance (Pratt et al, 2005).

A key challenge for health professionals is to ensure that people in the community are protected from the risk of cross-infection when patients with TB choose not to adhere to their drug regimen. The question for health professionals is how far they can and should go in forcing patients to conform to treatment (Coker, 1999).

In New York in the early 1990s, there was a dramatic rise in the incidence of TB and in particular of multidrug-resistant TB (Frieden et al, 1993). The city's authorities responded with a series of strategies including directly observed therapy (DOT) and incentives such as cash and food coupons to encourage compliance. They also detained a number of people for compulsory treatment, some of whom did not have infectious TB (Coker, 1999).

In England and Wales, sections 37 and 38 of the Public Health Act 1984 allow authorities to admit people to hospital against their will and detain them if they are thought to pose a risk of spreading infection in the community. However, once detained a patient cannot be forced to take treatment. In practice obtaining the warrant and detaining someone in hospital is complicated and the act is rarely used (Coker, 2000).

The effective treatment of TB requires the patient to be compliant with the medication prescribed. However, the term 'compliance' has fallen out of favour as it is considered to be associated with concepts of enforcement and the patient being passive while the health professional has an authoritative role.

Increasingly health professionals are using the principles of concordance. This involves discussion and agreement between the patient and prescriber so that the patient can make an informed decision about her or his health and about taking a particular course of treatment (Mullen, 1997). However,while prescribers strive to achieve concordance with patients, a combination of strategies encompassing the principles of compliance and concordance needs to be applied pragmatically in the management of TB (Boxes 1 and 2).

Understanding and improving adherence to therapy

Patients with TB belong to a variety of cultures and have many different backgrounds. They all have an assortment of problems and needs. However, patients experience similar problems that can be anticipated, such as side-effects from medicines and running out of tablets.

Simple measures can help, such as providing the patient with information about the side-effects before starting treatment and reinforcing this information during subsequent consultations. Most of the disincentives to take TB treatments are associated with troublesome side-effects of medication, although a small percentage of patients will develop serious adverse reactions, such as hepatotoxicity. As a lot of patients seem to have difficulty with their treatment in the first few weeks, it is advisable to monitor them frequently at this stage. A contact number to call for medication advice encourages people to telephone with problems rather than stop their treatment.

Most patients who develop TB in this country were not born here and some have difficulty accepting that they need treatment. For example, some patients may not think they are ill if they have a tuberculous neck gland with no symptoms. Some patients have never heard of TB and do not understand how infection occurs. In some cultures, TB is considered a stigma and health professionals must be sensitive to this cultural notion.

Many patients with TB have considerable social problems, as those with the disease are more likely to belong to disadvantaged social groups (National Collaborating Centre for Chronic Conditions, 2006). Some will be unable to turn their attention to taking tablets until at least some of their problems have been resolved. Patients may also have concerns about taking time off work or studies to attend clinics and outpatient appointments (Box 1).

Referring patients to social services, housing departments and immigration services, as well as writing letters on their behalf, can relieve some of these pressures. Other strategies include arranging transport for clinic appointments, assigning link workers to people who do not speak English and following up patients who do not attend appointments.

Remembering to take tablets every day can be difficult and an assessment at the beginning of treatment and during follow-up appointments should consider whether a patient is able to take their drugs without supervision. Strategies such as DOT, where medicines are administered under supervision three times a week, can be adopted. However, this has a huge impact on the workload of health professionals and can also be difficult for the patient as she or he has to take up to 16 tablets at one time. There are often more side-effects when treatment is given in this way and an alternative solution is to visit the patient once a week and use a dosette box.

Preventing resistance

Preventing the development of drug-resistant TB is essential. Resistance can occur when treatment is interrupted or taken haphazardly. It may also occur if treatment is prescribed or dispensed incorrectly and in particular if only one drug is taken.

The drugs used to treat tuberculosis can be confusing for health professionals who are unfamiliar with them. For example, Rifadin, Rifinah, Rifater all have similar-sounding names but different ingredients. For this reason patients with the infection should be managed by those with expertise in this area to limit mistakes in prescribing (National Collaborating Centre for Chronic Conditions, 2006).

TB teams need to take charge of the medication by checking the number of tablets dispensed and ensuring that further supplies are issued in good time. This makes it easier to ascertain the number of tablets that have been taken by patients whose therapy is being monitored with a pill count.

There are occasions when a patient refuses to follow advice. As the worst-case scenario is a patient with multidrug-resistant TB refusing treatment, it is better to withdraw treatment before the TB becomes resistant and inform the patient and GP of this decision. However, this is an unusual situation and one that should be avoided.

Conclusion

The majority of people in the UK who have TB should be cured. However, adherence to treatment is largely dependent on adequate staffing levels to ensure that the specialist support that patients with TB require is provided.

References

Carter, S. et al (2005) A Question of Choice - Compliance in Medicine-Taking: A Preliminary Review. London: The Medicines Partnership.

Coker, R.J. (2000) The law, human rights, and the detention of individuals with tuberculosis in England and Wales. Journal of Public Health Medicine; 22: 3, 263-267.

Coker, R.J. (1999) Carrots, sticks and tuberculosis. Thorax; 54: 2, 95-97.

Cox, K. et al (2004)A Systematic Review of Communication Between Patients and Healthcare Professionals About Medicine Taking and Prescribing.London: The Medicines Partnership.

Department of Health (2004) Stopping Tuberculosis in England: An Action Plan from the Chief Medical Officer.London: Department of Health.

Frieden, T.R. et al (1993) The emergence of drug-resistant tuberculosis in New York City. New England Journal of Medicine; 325: 8, 521-526.

Health Protection Agency (2006) Tuberculosis.www.hpa.org.uk/infections/topics_az/tb/menu.htm

Mullen, P.D. (1997) Compliance becomes concordance. British Medical Journal; 314: 691.

National Collaborating Centre for Chronic Conditions (2006) Tuberculosis: Clinical Diagnosis and Management of Tuberculosis, and Measures for its Prevention and Control. London: Royal College of Physicians.

Pratt, R.J. et al (2005) Tuberculosis.London: Hodder Education.

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